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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1000
} | Medical Text: Unit No: [**Numeric Identifier 63918**]
Admission Date: [**2129-7-6**]
Discharge Date: [**2129-7-8**]
Date of Birth: [**2129-7-6**]
Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: [**Known lastname 951**] [**Known lastname 44856**] is the former 2.92
kilogram product of a 35 [**5-17**] week gestation pregnancy born to
a 32-year-old GII now PII woman. Prenatal screens: Blood type
O positive, antibody negative, rubella immune, hepatitis B
surface antigen negative, RPR nonreactive, group beta strep
status unknown. The mother presented to the [**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) 63919**] labor, rupture of membranes occurred
just prior to delivery. The delivery was by cesarean section
due to breech presentation. There was no maternal fever noted
prior to delivery and the mother was not treated with
antibiotics. Apgar scores were 7 at 1 minute and 8 at 5
minutes. He required blow-by oxygen in the delivery room. He
was admitted to the neonatal intensive care unit for
treatment of respiratory distress.
PHYSICAL EXAMINATION: Upon admission to the neonatal
intensive care unit: Weight 2.92 kilograms, 75th percentile,
length 51 cm, greater than 90th percentile. Head
circumference 34.5 cm, 90th percentile. General: Ruddy, pink,
appropriate for gestational age infant breathing comfortably
in room air. Head, eyes, ears, nose, and throat: Anterior
fontanelle soft and flat, sutures overriding, posterior
fontanelle small. Red reflex present bilaterally. Palate
intact. Normal facies. Respiratory: Initial grunting and
retractions resolved. Breath sounds clear and equal.
Cardiovascular: S1, S2, normal. No murmur. Abdomen: Soft, no
organomegaly. GU: Normal male. Testes down bilaterally.
Neuro: Good tone, symmetrical exam with good cry, good Moro.
Musculoskeletal: Hips stable.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
1. RESPIRATORY: [**Known lastname 951**] was initially on blow-by oxygen but
weaned to room air within an hour after admission to the
neonatal intensive care unit. Respiratory distress noted
at admission also resolved. At the time of discharge, he
is breathing comfortably in room air with a respiratory
rate of 30-50 breaths per minute. He had 2 isolated oxygen
desaturations, 1 with crying and 1 with feeding, none have
been observed for 12 hours prior to discharge.
2. CARDIOVASCULAR: [**Known lastname 951**] has remained normotensive with
normal blood pressures. No murmurs have been noted.
3. FLUIDS, ELECTROLYTES, AND NUTRITION: Initial blood sugar
was 42 and [**Known lastname 951**] received a dextrose bolus and started on
a continuous infusion. Enteral feeds were started on day
of life #1 and the IV fluids were gradually weaned. At the
time of transfer, he has been off of intravenous fluids
for greater than 36 hours and maintaining blood sugars of
58-80. He is breast feeding or taking Enfamil 20 ad lib on
a q.4 h. schedule. Serum electrolytes were checked on day
of life #1 and were within normal limits.
4. INFECTIOUS DISEASE: Due to the unknown etiology of the
respiratory distress, unknown group B strep status of the
mother, [**Name (NI) 951**] was evaluated for sepsis upon admission to
the neonatal intensive care unit. A complete blood count
had a white blood cell count of 14,800 with a normal
differential. A blood culture was obtained prior to
starting intravenous antibiotics. The blood culture was no
growth at 48 hours and the ampicillin and gentamicin were
discontinued.
5. GASTROINTESTINAL: Serum bilirubin were checked on day of
life #1 and #2. Peak bilirubin thus far on day of life #2
is 9.6 total/0.3 mg per deciliter direct. The baby does
have clinical jaundice. A bilirubin for the morning of
[**2129-7-9**] has been ordered.
6. HEMATOLOGICAL: Hematocrit at birth was 56.8%.
7. NEUROLOGICAL: [**Known lastname 951**] has maintained a normal neurological
exam and there were no concerns at the time of discharge.
8. SENSORY: Hearing screening has not yet been performed.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Transfer to the 6 [**Hospital Ward Name 1826**] nursery
for continuing care.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 19267**] [**Location (un) 63920**] Pediatric
group- [**Last Name (NamePattern1) 63921**]-[**Location (un) 17566**], [**Numeric Identifier 63922**]. Phone number: [**Telephone/Fax (1) 63923**].
While in the newborn nursery, the baby will receive care by
Dr. [**First Name8 (NamePattern2) 5279**] [**Last Name (NamePattern1) 43699**] of [**Hospital **] Pediatrics.
CARE AND RECOMMENDATIONS:
1. At the time of discharge, feeding ad lib, breast feeding
or Enfamil 20.
2. No medications.
3. Car seat position screening is recommended prior to
discharge.
4. State newborn screens due to be sent on day of life #3,
[**2129-7-9**].
5. No immunizations administered thus far.
6. Immunizations recommended: 1) Synagis RSV prophylaxis
should be considered from [**Month (only) **] through [**Month (only) 958**] for
infants who meet any of the following 3 criteria: 1) Born
at less than 32 weeks. 2) Born between 32-35 weeks with 2
of the following: Daycare during RSV season, a smoker in
the household, neuromuscular disease, airway
abnormalities, or school-age siblings; or thirdly with
chronic lung disease.
Influenzae immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the first 24 months of the child's life
immunization against Influenzae is recommended for household
contacts and out of home caregivers.
DISCHARGE DIAGNOSIS:
1. Prematurity at 35 6/7 weeks gestation.
2. Transitional respiratory distress.
3. Suspicion for sepsis, ruled out.
4. Status post breech presentation in utero.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD
Dictated By:[**Last Name (NamePattern4) 56030**]
MEDQUIST36
D: [**2129-7-8**] 15:52:08
T: [**2129-7-8**] 17:12:55
Job#: [**Job Number 63924**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1001
} | Medical Text: Admission Date: [**2119-9-16**] Discharge Date: [**2119-9-19**]
Date of Birth: [**2051-4-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
elevated INR
Major Surgical or Invasive Procedure:
None
History of Present Illness:
68 F with ESRD on HD, CHF with EF 15%, CAD s/p CABG, Afib on
coumadin, admit from ED with significantly elevated INR now s/p
4 units FFP. Patient reports being in her usual state of health
with exception of mild diarrhea starting yesterday. Patient
reports daughter gave her a medication for this. On [**9-14**], INR
checked and noted to be 8.6. During HD today, INR rechecked and
greater than assay. Initial BP 81/36, post BP 93/50 (range
73-93). Hgb 9.2. Other than diarrhea, patient has been feeling
well. No abdominal pain, fever, chest pain, bloody stools,
epistaxis, hematemesis or other e/o bleeding; no dyspnea, though
feels "wheezy" following FFP, feels like she got too much fluid.
No dysuria though has had "dark urine".
.
In ED, vitals 98.4, HR 72, BP initially 76/40, R20, 100% on 4L.
Started on 4 units FFP, received 5 vit D SQ and 5 IV. Hct 32 (at
baseline). 3pm labs pending. Likely to dialysis tomorrow. Ace
and B-blocker have been held.
.
Hospital course: s/p 4 U FFP. Hct stable w/o source of bleed. BP
now in 90s.
Past Medical History:
1. CHF with EF of 15% s/p BiV pacer on coumadin, recently
admitted for CHF exacerbation in [**7-23**]
2. ESRD - on HD since [**2119-8-1**], *EDW 64.4 kg*
3. CAD s/p MI & CABG x 2 ([**2108**] and revised in [**2118**])
4. DMII x 4yrs on insulin
5. s/p L AKA
6. Hypothyroidism
7. a-fib on coumadin
8. home oxygen (needed at night when sleeping)
Social History:
Lives at home with daughter. Remote smoking history less than
2-3yrs total, pt has not smoked in over 30yrs. There is no
history of alcohol abuse or IVDU.
Family History:
non-contributory
Physical Exam:
Vitals: T 97 (afeb), BP 105/55 (80-100/40-50), HR 78 (paced), R
16, 100% 2L. wt 69 kg; I/O 170/anuric
General: Pleasant female, NAD
HEENT: NC/AT, PERRL, sclera anicteric, MM slightly dry
Neck: Supple, no adenopathy. L EJ in place
Chest: +bilateral rhonchi with few wheezes, no crackles
appreciated
Heart: RRR S1 S2, [**3-22**] SM at LUSB
Abdomen: soft, NTND, no HSM, +BS
Extrem: s/p L AKA, RLE without edema.
Neuro: alert, appropriate, MAE.
Pertinent Results:
Labs:
[**2119-9-16**] 03:00PM BLOOD WBC-4.4# RBC-3.49* Hgb-10.0* Hct-32.5*
MCV-93 MCH-28.7 MCHC-30.9* RDW-20.8* Plt Ct-158
[**2119-9-19**] 07:15AM BLOOD WBC-5.0 RBC-3.21* Hgb-9.1* Hct-31.7*
MCV-99* MCH-28.4 MCHC-28.8* RDW-21.4* Plt Ct-189
[**2119-9-16**] 03:00PM BLOOD Glucose-104 UreaN-14 Creat-1.4* Na-139
K-7.4* Cl-100 HCO3-34* AnGap-12
[**2119-9-19**] 07:15AM BLOOD Glucose-148* UreaN-37* Creat-1.9* Na-141
K-4.2 Cl-101 HCO3-34* AnGap-10
[**2119-9-17**] 04:42AM BLOOD Albumin-2.8* Calcium-8.1* Phos-3.5 Mg-1.6
[**2119-9-19**] 07:15AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.1
[**2119-9-17**] 04:42AM BLOOD ALT-16 AST-32 LD(LDH)-242 AlkPhos-234*
TotBili-0.3
[**2119-9-17**] 04:42AM BLOOD TSH-5.2*
[**2119-9-18**] 01:10PM BLOOD Free T4-1.3
[**2119-9-16**] 03:00PM BLOOD Vanco-13.2
[**2119-9-16**] 04:23PM BLOOD Lactate-1.2
.
INR
[**2119-9-16**] 04:15PM BLOOD PT-150* PTT-150* INR(PT)->22.8*
[**2119-9-19**] 04:00PM BLOOD PT-17.7* INR(PT)-1.6*
.
[**2119-9-16**] Blood cx- no growth
.
CXR [**2119-9-16**]:
IMPRESSION:
Persistent small bilateral pleural effusions. Marked interval
improvement in right-sided pleural effusion. Support lines as
described. No pneumothorax. Increased airspace opacity involving
both lungs may simply reflect low lung volumes, but mild
pulmonary edema is not excluded.
Brief Hospital Course:
ASSESSMENT AND PLAN: 68 F with ESRD on HD, CHF, Afib on
coumadin; admit to MICU with supratherapeutic INR now s/p 4
units FFP and IV vit K.
.
# Elevated INR. The patient had an elevated INR which was
greater than assay at one point early on in her admission. Of
note, the patient took a bowel regimen for constipation and
reports significant diarrhea prior to admission. The patient
was not taking excess coumadin doses. In addition the patient
was on vancomycin for a previous HD catheter infection which
could have contributed to the increased INR. The patient had no
signs of bleeding at the time of admission or during her
hospitalization. Her INR normalized with giving IV vit K and 4
units of FFP. The patient was restarted on coumadin prior to
discharge. She was discharged on 4mg of coumadin daily with a
follow up INR check at hemodialysis.
.
# Hypotension. The patient became hypotensive with SBPs in the
70s in ED and at HD. She was admitted to the MICU for
monitoring and her home BP medications were stopped. She had a
negative blood cx and a negative CXR. She was receiving
vancomycin with HD for a previous line infection. Her SBP on
the day of discharge ranged from 100-110s and she was not
restarted on her BP meds prior to discharge.
.
#Hypothyroidism: She had and elevated TSH at 5.2 and a normal
free T4. Her dose of levothyroxine was increased from 125 to
150mcg daily.
.
# Systolic CHF: The patient has systolic CHF with an EF of 15%.
She received 4 units FFP plus additional IVF while in the MICU.
She did not require early HD as she was not volume overloaded.
Her carvedilol and ACEI were held due to her hypotension and not
restarted prior to discharge.
.
# Diabetes type II: The patient was continued on her home Lantus
and ISS.
.
# ESRD on HD: The patient received HD while at the hospital as
per her normal schedule. She finished her doses of vancomycin
for her previous line infection.
.
# CAD. The patient has a history of CAD and CABG x2 with CHF.
She was continued on ASA while in the hospital. The patient was
not able to tell me the name of her new PCP so [**Name Initial (PRE) **] could not find
out why she was no longer on a statin. I did confirm her
medications with her pharmacy and she was not receiving a
statin. Her ACE and beta-blocker were held due to her
hypotension. These medications should be restarted as an
out-patient after follow up with her PCP.
.
#Lesions on back of calf and bleeding of R big toe secondary to
nail clipping. The lesion of the back of her calf is surrounded
by erythematous tissue suggesting adequate blood flow to heal
the lesion.
.
Left phantom limb pain. The patient felt her ultram was not
helping her. She uses a lidocaine patch on her left leg which
provides some relief. I started gabapentin which the patient
requested to be discharged on.
.
# Full code: discussed with patient
[**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) 3315**] PGY-1, [**MD Number(1) 78445**]
Medications on Admission:
Carvedilol 3.125 mg daily
Lantus 12 units at HS
Senna 1 tab [**Hospital1 **]
Humalog sliding scale
ASA 325 mg daily
lorazepam 0.5 mg HS prn
albuterol neb QID prn wheeze
lisinopril 5 mg daily
Percocet 5-325, 1-2 tabs QID prn pain
tramadol 50 mg Q6H prn
colace 100 [**Hospital1 **]
levothyroxine 125 daily
warfarin 5 mg daily
Flovent MDI [**Hospital1 **]
vanco with HD
zolpidem 5mg qHS
Bisocodyl 5mg 1-2 tabs daily
enulose 90ml, 15ml q4hrs
vicadin 5 tabs 5/500 q4hrs
lidoderm patch 5% 1 daily PRN limb pain
Discharge Medications:
1. Sevelamer HCl 400 PO TID W/MEALS
2. Levothyroxine 150 mcg PO once a day.
3. Aspirin 325 mg PO DAILY
4. Docusate Sodium 100 mg PO BID: PRN as needed for
constipation.
5. Senna 8.6 mg PO BID:PRN as needed for constipation.
6. Acetaminophen 500 mg Two Tablet PO q6hrs: PRN pain as needed
for pain.
7. Zolpidem 5 mg PO HS (at bedtime) as needed for insomnia.
8. Bisacodyl 5 mg Tablet Sig: 1-2 Tablets PO once a day as
needed for constipation.
9. Lactulose 10 gram/15 mL Solution Fifteen ml PO every four (4)
hours as needed for severe constipation.
10. Lorazepam 0.5 mg PO qHS as needed for anxiety.
11. Lidocaine 5 %(700 mg/patch) One Adhesive Patch DAILY
12. Oxycodone 5 mg PO every four (4) hours as needed for pain.
13. Guaifenesin 600 mg Tablet PO twice a day as needed for
cough.
14. insulin glargine continue home dose of 12units subcut qHS
15. humalog continue previous home sliding scale
16. Warfarin 4 mg PO once a day.
17. Fluticasone 110 mcg/Actuation Aerosol Two Puff Inhalation
[**Hospital1 **]
18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) One Inhalation
every six (6) hours as needed for wheeze.
19. Gabapentin 300 mg One Capsule PO Q24H as needed for limb
pain.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary
1. Supratherapeutic INR
2. Hypotension
3. End Stage Renal Disease on hemodialysis
.
Secondary
1. Chronic Congestive Heart Failure with EF 15%
2. Coronary artery disease s/p myocardial infarction
3. Left above the knee amputation
4. Hypothyroidism
5. Atrial fib
Discharge Condition:
Blood pressure stable and INR no longer supratherapeutic
Discharge Instructions:
You were admitted with a supratherapeutic INR and with decreased
blood pressure. Your supratherapeutic INR was treated with
fresh frozen plasma and vitamin K. Your blood pressures have
improved and you have been put back on coumadin with a goal INR
of [**3-19**].
.
The doses of the following medications were changed:
-warfarin
-levothyroxine
.
The following medications were discontinued:
-carvedilol
-lisinopril
-dextromethorphan-guaifenesin
.
The following meds were started:
gabapentin
.
Adhere to 2 gm sodium diet
Fluid Restriction to 2L
.
Please return to the hospital if you develop dizziness,
difficulty breathing, chest pain, blood in stool, vomiting
blood, blood in urine, any sign of bleeding, or any new medical
condition.
.
Please check INR with dialysis
Followup Instructions:
Please follow up with your PCP [**Name Initial (PRE) 176**] 1-2 weeks and discuss
restarting your blood pressure medications.
Completed by:[**2119-9-29**]
ICD9 Codes: 5856, 4280, 4589, 2449, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1002
} | Medical Text: Admission Date: [**2119-12-6**] Discharge Date: [**2119-12-12**]
Date of Birth: [**2065-11-1**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / daptomycin
Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms [**Known lastname 24166**] is a 54 y/o F with hx of long-standing T1DM,
long-standing tobacco abuse (recently quit) and chronic
osteomyelitis of the foot who came to the ED after calling EMS
for experiencing acute-onset shortness of breath while lying in
bed at home. She denied chest pain or palpitations. She was
found by EMS to be hypoxic to 70s on room air, with increased
work of breathing and tachycardia to the 110s. She was given
nebulizers en route to the ED, without significant improvement.
In the ED, initial VS were: 99.2 120 216/80 32 92% with neb.
Exam notable for respiratory distress with accessory muscle use
and decreased breath sounds bilaterally with expiratory wheeze.
Labs revealed anemia slightly below baseline, normal WBC count,
hyperglycemia > 600, hyponatremia, mild anion gap metabolic
acidosis, normal cardiac biomarkers, and BNP 2500. ECG
demonstrated sinus tachycardia @ 141 bpm with lateral ST
depressions. CXR showed vascular prominence and cephalization
of the vessels, with LLL consolidation. The pt was given
increasing amounts of supplemental O2 but remained hypoxic; she
was started on CPAP with improvement in O2 sats and respiratory
rate. Her hypertension was treated with nitro gtt. She was
started on heparin gtt for empiric treatment of ACS and PE. She
was given 8 units regular insulin; fingerstick was not
rechecked. Bedside echo did not reveal ventricular dysfunction
or tamponade. Pt was given 20 mg IV furosemide. Vitals prior
to transfer were HR 120, RR 18, BP 165/62 O2 100% on CPAP.
On arrival to the MICU, she reports significant relief in
regards to her breathing. She denies cough, fever, sick
contacts. She has never experienced similar symptoms. Her last
fingerstick check was with breakfast yesterday, when it was 101.
Of note, the patient was seen in the [**Hospital1 18**] ED yesterday
afternoon, after her outpatient provider referred her for
nausea, vomiting, and lateral ECG changes. She had two negative
troponins and no stress test, and was discharged home.
Past Medical History:
per d/c summary [**2119-11-18**], confirmed with patient
- DM1 - insulin dependent, poorly controlled HBA1c 12%, managed
by
[**Last Name (un) **] Dr. [**First Name (STitle) **]
- DM associated neuropathy
- HTN
- HLD - LDL 102 in [**2112**]
- Back pain s/p fall
- History of osteomyelitis left hallux s/p ulcer infection
debridement [**4-/2119**] and again 12/[**2118**].
- Trigger release right index and long fingers [**6-/2118**]
- s/p Left first toe and ray amputation [**2119-11-15**]- Dr.
[**Last Name (STitle) **]
Social History:
per d/c summary [**2119-11-18**]
Lives with husband, no children. Works as staff assistant at
[**University/College **] [**Location (un) **]. Smokes 2 cig/day, has been smoking for 20
years used to smoke 1ppd. No ETOH or IVDA.
Family History:
per d/c summary [**2119-11-18**]
Mother with DM2 and CVA, father died of MI at age 76, siblings
all healthy
Physical Exam:
Admission Physical Exam:
General: Alert, oriented, no acute distress, speaking in full
sentences
HEENT: Sclera anicteric, mild conjunctival injection, MMM,
oropharynx clear, EOMI
Neck: supple, JVP @8 cm H20, no LAD
CV: Tachycardic, regular, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Decreased breath sounds throughout. No wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ radial/DP/PT pulses bilaterally, no
clubbing, cyanosis or edema. S/p left toe amp, no erythema or
purulence
Neuro: 5/5 strength upper/lower extremities, grossly normal
sensation, 2+ reflexes bilaterally, gait deferred
Physical Exam on discharge:
VS: Tmax 99.3 Tc 99 BP 147/80(142/63-167/68) p 79 (79-84) 20 95
% RA
General: Alert, oriented, no acute distress, speaking in full
sentences
HEENT: Sclera anicteric, mild conjunctival injection, MMM,
oropharynx clear, EOMI
Neck: supple, no LAD
CV: Regular, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Decreased breath sounds throughout. No wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ radial/DP pulses bilaterally, no
clubbing, cyanosis or edema. S/p left toe amp with bandage in
place
Neuro: 5/5 strength upper/lower extremities, grossly normal
sensation
Pertinent Results:
Labs on admission:
[**2119-12-6**] 12:10AM ALBUMIN-3.6 CALCIUM-8.4 PHOSPHATE-4.3
MAGNESIUM-1.9
[**2119-12-6**] 12:10AM proBNP-2459*
[**2119-12-6**] 12:10AM cTropnT-0.02*
[**2119-12-6**] 12:10AM ALT(SGPT)-26 AST(SGOT)-21 CK(CPK)-49 ALK
PHOS-637* TOT BILI-0.4
[**2119-12-6**] 12:10AM GLUCOSE-619* UREA N-28* CREAT-1.8*
SODIUM-127* POTASSIUM-4.8 CHLORIDE-93* TOTAL CO2-19* ANION
GAP-20
[**2119-12-6**] 12:13AM LACTATE-2.5*
[**2119-12-6**] 04:54AM RET AUT-1.6
[**2119-12-6**] 04:54AM PT-13.5* PTT-76.5* INR(PT)-1.3*
[**2119-12-6**] 04:54AM PLT COUNT-234
[**2119-12-6**] 04:54AM WBC-5.4 RBC-2.68* HGB-7.4* HCT-22.7* MCV-85
MCH-27.6 MCHC-32.7 RDW-14.3
[**2119-12-6**] 04:54AM WBC-5.4 RBC-2.68* HGB-7.4* HCT-22.7* MCV-85
MCH-27.6 MCHC-32.7 RDW-14.3
[**2119-12-6**] 04:54AM CALCIUM-8.1* PHOSPHATE-4.1 MAGNESIUM-1.8
[**2119-12-6**] 04:54AM CK-MB-3 cTropnT-0.07*
[**2119-12-6**] 05:02AM LACTATE-2.4*
[**2119-12-6**] 11:27AM CK-MB-4 cTropnT-0.12*
[**2119-12-6**] 11:27AM CK(CPK)-59
[**2119-12-6**] 02:14PM GLUCOSE-175* UREA N-31* CREAT-1.9*
SODIUM-130* POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-21* ANION GAP-15
[**2119-12-6**] 07:49PM PT-12.0 PTT-43.8* INR(PT)-1.1
[**2119-12-6**] 07:53PM CK-MB-3 cTropnT-0.12*
[**2119-12-6**] 07:53PM CK(CPK)-46
ECHO [**2119-12-6**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). The right ventricular cavity is
mildly dilated with normal free wall contractility. The number
of aortic valve leaflets cannot be determined. The aortic valve
leaflets are mildly thickened (?#). There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is an anterior
space which most likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Technically suboptimal to exclude focal wall
motion abnormality. Mild mitral regurgitation. Mild right
ventricular dilation with normal function. Compared with the
prior study (images reviewed) of [**2119-11-16**], estimated pulmonary
artery pressure is mildly elevated (previously undetermined).
CT chest w/o contrast [**2119-12-6**]:
1. Lytic process T2 vertebral body and small associated
paravertebral soft
tissue mass could be infectious or malignant. Dedicated neuro
imaging
recommended for assessment of the spinal canal.
2. Moderate left and small right nonhemorrhagic layering pleural
effusions
may have increased slightly since [**19**]:00 a.m. No evidence of
extensive
pneumonia, but small areas of infection could be missed given
the large scale
left lower lobe atelectasis and smaller atelectasis at the right
base.
3. Numerous borderline bilateral axillary lymph nodes and
possibly in the
left hilus, and less extensive lymph node enlargement in the
mediastinum.
MRI w/o contrast [**2119-12-7**]:
Compression fracture of T2 with signal abnormalities involving
the adjacent T1/T2 and T2/T3 intervertebral disc spaces and T1
as well as T3 enplates. Small contiguous anterior paraspinous
soft tissue component.
Differential diagnosis includes osteomyelitis or, far less
likely, metastatic process.
There is no evidence of cord compression or epidural abscess in
this
non-enhanced exam.
RUQ ultrasound with dopplers:
1. Low volume, nondistended gallbladder containing sludge and
small,
[**Doctor Last Name 5691**]-like stones. Nonspecific gallbladder wall thickening and
pericholecystic fluid. In combination with lack of elevated
white blood cell count, ultrasound findings are not suspicious
for acute cholecystitis.
2. Moderate bilateral pleural effusions.
Labs on discharge:
[**2119-12-12**] 06:35AM BLOOD WBC-6.5 RBC-2.91* Hgb-8.0* Hct-23.7*
MCV-82 MCH-27.5 MCHC-33.7 RDW-14.3 Plt Ct-341
[**2119-12-12**] 06:35AM BLOOD Glucose-65* UreaN-22* Creat-1.0 Na-133
K-4.3 Cl-105 HCO3-21* AnGap-11
[**2119-12-12**] 06:35AM BLOOD AlkPhos-98
[**2119-12-12**] 06:35AM BLOOD Calcium-7.9* Phos-3.1 Mg-2.1
Brief Hospital Course:
This is a 54-year-old female with hx T1DM, tobacco abuse,
osteomyelitis of left foot on chronic antibiotics, recent ED
visit for nausea/vomiting and ECG changes, admitted with acute
onset pulmonary edema, hypertensive crisis, and mild diabetic
ketoacidosis.
Active Issues:
# Flash pulmonary edema: The patient was admitted to the MICU
with flash pulmonary edema in the setting of hypertensive
urgency. She did have a troponin rise that peaked at 0.12
without MB elevation. The patient was started on a heparin drip
for possibility of ACS versus pulmonary embolism. She was
unable to undergo CTA for PE secondary to acute kidney injury.
The patient underwent a transthoracic ECHO that showed a normal
ejection fraction, left ventricular hypertrophy, and could not
exclude a wall motion defect. She was started on BIPAP and
diuresed with initial good response. BIPAP was subsequently
removed in the ICU and diuresis was continued. She was
transferred to the cardiology wards. On the floor, the patient
continued to diurese well with normalization of her oxygen
saturation on room air. Heparin drip was stopped upon transfer
to the floor due to low likelhood of acute coronary syndrome and
pulmonary embolism (given rapid improvement in A-A gradient).
Ms. [**Known lastname 24166**] was continued on aspirin, statin, and beta
blocker. She was discharged on lasix 20 mg daily.
# Elevated troponin: On admission, troponin rose from 0.02 and
peaked at 0.12 without elevation in CK-MB. She was initially
started on a heparin drip for ACS, but the heparin drip was
discontinued as elevated troponin was likely related to demand
ischemia in setting of hypertensive urgency, flash pulmonary
edema, and tachycardia. ECG did show rate-related ST depressions
in V4-V6. The patient remained chest pain free throughout
admission. She was started on aspirin, a statin, and continued
on home metoprolol. Her home valsartan was held given acute
kidney injury. The patient should undergo cardiac cath as an
outpatient with improvement in her renal function. A repeat
echocardiogram should also be performed in follow-up.
# Hypertension: The patient was admitted with hypertensive
urgency to 216/80 complicated by flash pulmonary edema. She was
initially started on a nitro drip, that was weaned in the ICU.
She was continued on home amlodipine initially, increased to 10
mg daily before discharge. Home metoprolol was titrated up to
150mg [**Hospital1 **] for blood pressure control. Valsartan was held in the
setting of acute kidney injury until the day of discharge when
her creatinine decreased to 1.0. The cause of hypertensive
urgency is unclear, but may relate to poorly controlled type 1
diabetes.
# DM1/Hyperglycemia: Glucose >600 on admission, with mild anion
gap acidosis (gap 15). The patient was briefly placed on an
insulin drip, and then transitioned to her home insulin regimen
with closure of her anion gap. Precipitant for hyperglycemia
was unclear, though potential etiologies include insulin
nonadherence (patient unclear if took med and does not remember
sliding scale), infection (possible infectious diarrhea, chronic
osteomyeltis), or flash pulmonary edema. The patient was seen
by [**Last Name (un) **], who made changes to her home sliding scale. With
inpatient adherence to her insulin sliding scale, glycemic
control improved.
# Nausea/vomiting: The patient was admitted with 5 days of
nausea. On admission, she began to also experience non-bloody
diarrhea. The patient was seen by infectious disease for
possible antibiotic side effect for cause of her symptoms.
Stool studies were negative for infectious diarrhea. The
patient was given zofran as needed for nausea, which
significantly improved before discharge.
# Pleural effusions: Noted on CXR and CT scan. Likely secondary
to flash pulmonary edema. No evidence of pneumonia - patient
did not had any cough or CP, and did not have a leukocytosis.
As patient had concerning T2 lesion on CT scan, there was
concern for malignant effusions. Interventional pulmonary was
consulted for possible thoracentesis; however, further diuresis
was recommended as onset and appearance of effusions on imaging
makes them less likely malignancy. On day 4 of admission,
effusions began to improve with diuresis.
# [**Last Name (un) **]: The patient has had an elevated creatinine (as high as
2.2) since the end of [**Month (only) **] (baseline Cr 0.9-1.1). Recent
renal ultrasound was negative for hydronephrosis. Recent
SPEP/UPEP negative. [**Last Name (un) **] likely represents prerenal azotemia
from poor forward flow, as the patient's creatinine began to
improve with diuresis. Due to [**Last Name (un) **], the patient's valsartan was
held until discharge when her creatinine decreased to 1.0.
# MRSA Osteomyelitis: Per patient, wound healing well with
regular dressing changes by VNA. She is followed closely by
outpatient ID, on vancomycin. The patient's vancomycin was
discontinued by outpatient ID physician on the day of admission
for possible drug reaction (vanco as source of nausea). She
received one dose of daptomycin, and developed a drug rash.
Daptomycin was discontinued and the patient was resumed on
vancomycin. The patient was followed by inpatient infectious
disease throughout admission.
# T2 Lytic lesion: On CT scan, the patient was incidentally
noted to have a large, concerning lesion that takes up much of
T2 vertebral body. The patient underwent thoracic MRI that
revealed associated compression fracture with the T2 lesion and
soft tissue changes in T1-T3. The patient was seen by
infectious disease, who felt the lesion was in fact consistent
with vertebral osteomyelitis. They recommended follow up
imaging in [**1-28**] weeks to look at interval chane in the lesion.
If at that time there is no interval change, IR-guided biopsy
should be considered.
# Normocytic anemia: Hct trending down over recent admissions.
Iron studies c/w anemia of chronic inflammation. B12 and folate
WNL. Recent SPEP/UPEP negative. Labs not suggestive of
hemolysis. Hematocrit was trended throughout admission.
# Hyponatremia: The patient was admitted with hyponatremia to
130 (baseline normal). Hyponatremia likely hypervolemic,
secondary to fluid overload, as it improved to baseline with
diuresis.
# Hyperlipidemia: Patient not on medication as outpatient, but
has been started on pravavastatin this admission given cardiac
risk factors.
# Elevated AlkPhos: The patient was admitted with elevated alk
phos and GGT, likely secondary to hepatic source. She underwent
a right upper quadrant ultrasound that showed mild gallbladder
sludge, but was otherwise normal. No evidence of congestive
hepatopathy, as AST and ALT normal. AST had decreased to normal
before discharge.
# Anxiety regarding multiple new diagnoses: Patient very
anxious about recent dyspnea and multiple recent
hospitalizations. She was followed by social work throughout
admission.
Transitional Issues:
-Pt was full code for this admission
-Pt will be followed by [**Hospital 4898**] clinic for her osteomyelitis and
follow up lumbar spine CT scan
-Pt should be considered for an outpatient catherization based
on her troponin bump and new diagnosis of congestive heart
failure
Medications on Admission:
AMLODIPINE - 5 mg daily
CIPROFLOXACIN - 500 mg [**Hospital1 **]
INSULIN GLARGINE [LANTUS] - 15 units at bedtime
INSULIN LISPRO [HUMALOG] - SS scale
LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - 1
once a day as needed for back pain
METOPROLOL SUCCINATE [TOPROL XL] - 50 mg daily
MOXIFLOXACIN [AVELOX] - 400 mg daily
VANCOMYCIN - 1.25 grams Q24hrs
ASPIRIN 325 mg daily
Discharge Medications:
1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
2. insulin glargine 100 unit/mL Solution Sig: Nineteen (19)
units Subcutaneous at bedtime.
3. insulin lispro 100 unit/mL Solution Sig: please take as
directed on sliding scale Subcutaneous -.
4. lidocaine Topical
5. metoprolol tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*0*
6. vancomycin in D5W 1 gram/200 mL Piggyback Sig: Seven Hundred
Fifty (750) mg Intravenous Q 24H (Every 24 Hours).
Disp:*30 gram* Refills:*2*
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Outpatient Lab Work
1.Please check CBC, BMP and LFT's, ESR and CRP once a week and
fax results to infectious disease clinic at [**Telephone/Fax (1) 1419**], attn:
Dr. [**Last Name (STitle) **]
2. Please check a vancomycin trough level on [**2119-12-14**] and fax
results to infectious disease clinic at [**Telephone/Fax (1) 1419**], attn: Dr.
[**Last Name (STitle) **]
11. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Home Solutions
Discharge Diagnosis:
Primary:
- Acute Diastolic Heart Failure
- Osteomyelitis
- Hypertension
- Acute Kidney Injury
Secondary:
- Diabetes Mellitus type 1
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. [**Known lastname 24166**],
It was a pleasure taking of you during your hospitalization at
[**Hospital1 69**]. You were admitted with
shortness of breath. This is the result of heart failure. You
were treated with removing fluid from your lungs and controlling
your blood pressure. You will need to follow-up with a
cardiologist who can continue to monitor this.
We continued treating your foot infection with IV antibiotics.
We discovered that you had an area in your spine that most
likely is also an infection. In order to make sure that it
improves with your antibiotics (and isn't something besides an
infection, like malignancy) you will need to have a repeat MRI
in [**1-28**] weeks to evaluate for improvement of the lesion. If it
is not improved then a biopsy will likely need to be performed.
You are now ready for discharge home.
PLEASE NOTE THE FOLLOWING MEDICATION CHANGES:
- STARTED VALSARTAN 80 MG DAILY FOR HIGH BLOOD PRESSURE
- STARTED PRAVASTATIN 20 MG DAILY FOR HIGH CHOLESTEROL
- STARTED FUROSEMIDE (LASIX) 20 MG DAILY FOR INCREASED FLUID
- INCREASED AMLODIPINE TO 10 MG DAILY FOR HIGH BLOOD PRESSURE
- INCREASED METOPROLOL TO 150 MG TWICE A DAY FOR HIGH BLOOD
PRESSURE
- INCREASED INSULIN GLARGINE TO 19 UNITS AT BEDTIME FOR HIGH
BLOOD SUGAR
- INCREASED SLIDING SCLAE HUMALOG (PLEASE SEE ATTACHED SHEET)
- DECREASED VANCOMYCIN TO 750 MG DAILY FOR INFECTION
- STOPPED CIPROFLOXACIN 500 MG TWICE A DAY
- STOPPED MOXIFLOXACIN 400 MG DAILY
Followup Instructions:
Department: INFECTIOUS DISEASE
When: MONDAY [**2119-12-25**] at 10:30 AM
With: [**Name6 (MD) 14621**] [**Last Name (NamePattern4) 14622**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital3 249**]
When: [**Hospital3 **] [**2119-12-15**] at 1:50 PM
With: [**Doctor First Name 306**] C-[**Name Initial (MD) **] [**Name8 (MD) 308**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2119-12-28**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PODIATRY
When: MONDAY [**2120-1-1**] at 2:50 PM
With: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
ICD9 Codes: 5849, 2761, 4280, 4019, 3572, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1003
} | Medical Text: Admission Date: [**2120-10-7**] Discharge Date: [**2120-10-19**]
Date of Birth: [**2047-10-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Tetracyclines / Niacin
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2120-10-8**] Redo sternotomy, Aortic Valve replacement(21mm
[**Company 1543**] Mosaic Ultra porcine), Coronary artery bypass graft x
1(SVG-PDA)
History of Present Illness:
Known coronary artery disease in 72 year old diabetic. He has
had progressive dyspnea and arm pain with exertion for months.
Catheterization in [**Month (only) **] revealed critical aortic stenosis
([**Location (un) 109**] 0.7cm2) with patent LIMA to LAD, 30% lesion of radial
artery to ramus graft and an osteal 60% RCA stenosis. The vein
graft to the obtuse marginal was occluded. He is admitted now
for valve replacement and possible coronary graft. His Coumadin
was stopped recently and he was admitted for Heparin therapy
preoperatively.
Past Medical History:
insulin dependent diabetes mellitus
diabeteic neuropathy
hypothyroidism
lumbar disc disease
paroxysmal atrial fibrilation
obesity
s/p coronary artery bypass grafting
s/p tonsillectomy
hypertension
dyslipidemia
hearing loss
benign prostatic hypertrophy
degenerative joint disease
Social History:
He lives with his wife in [**Name (NI) 620**].
Rare alcohol use and denies any cigarette smoking.
He is a retired pharmacist.
Family History:
Coronary artery disease, Neg<55
Physical Exam:
Admission
VS: 70 16 174/70 69" 105kg
Gen: WDWN obese male in NAD
Skin: Unremarkable
HEENT: EOMI, PERRL NCAT
Neck: Supple, FROM -JVD
Chest: CTAB -w/r/r
Heart: RRR 4/6 systolic murmur radiating to carotids
Abd: Soft, NT/ND +BS
Ext: Warm, well-perfused -edema
Neuro: A&O x 3, MAE, non-focal
Discharge
VS T98.9 HR 75 BP 112/78 RR 20 O2sat 94%-RA Wt 101.2K
Gen NAD
Neuro A&Ox3, nonfocal exam
Pulm CTA-bilat
CV RRR, no murmur. Sternum stable, incision CDI
Abdm soft, NT/+BS
Ext warm, 1+ pedal edema bilat
Pertinent Results:
[**2120-10-19**] 07:30AM BLOOD WBC-10.4 RBC-3.13* Hgb-9.0* Hct-27.5*
MCV-88 MCH-28.9 MCHC-32.9 RDW-14.4 Plt Ct-399
[**2120-10-19**] 07:30AM BLOOD PT-25.4* INR(PT)-2.5*
[**2120-10-19**] 07:30AM BLOOD Glucose-140* UreaN-24* Creat-1.6* Na-135
K-4.1 Cl-97 HCO3-27 AnGap-15
[**2120-10-15**] 04:04AM BLOOD ALT-359* AST-205* AlkPhos-165* Amylase-25
TotBili-0.8
[**2120-10-19**] 07:30AM BLOOD WBC-10.4 RBC-3.13* Hgb-9.0* Hct-27.5*
MCV-88 MCH-28.9 MCHC-32.9 RDW-14.4 Plt Ct-399
[**2120-10-19**] 07:30AM BLOOD Plt Ct-399
[**2120-10-19**] 07:30AM BLOOD PT-25.4* INR(PT)-2.5*
[**2120-10-19**] 07:30AM BLOOD Glucose-140* UreaN-24* Creat-1.6* Na-135
K-4.1 Cl-97 HCO3-27 AnGap-15
[**Known lastname **],[**Known firstname 4075**] L. [**Medical Record Number 4076**] M 73 [**2047-10-15**]
Radiology Report CHEST (PA & LAT) Study Date of [**2120-10-18**] 10:19
AM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 4077**]
Reason: f/u atx, effusions
Final Report
CHEST PA AND LATERAL
REASON FOR EXAM: 73-year-old man status post redo sternotomy,
AVR, CABG,
pacemaker.
Since [**2120-10-15**], left-sided pacemaker ends in expected
position. Prior sternotomy for CABG is again seen. Small
bilateral pleural effusion with adjacent atelectasis decreased,
now minimal. There is no volume overload.
Incidentally, DISH of the thoracic spine is unchanged.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 4078**] [**Name (STitle) 4079**]
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: FRI [**2120-10-18**] 3:47 P
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 4075**] [**Hospital1 18**] [**Numeric Identifier 4080**]TTE (Focused
views) Done [**2120-10-12**] at 1:52:50 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2047-10-15**]
Age (years): 72 M Hgt (in):
BP (mm Hg): 80/50 Wgt (lb):
HR (bpm): 50 BSA (m2):
Indication: Coronary artery disease. H/O cardiac surgery
(CABG/AVR), postoperative hypotension.
ICD-9 Codes: 780.2, V43.3
Test Information
Date/Time: [**2120-10-12**] at 13:52 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD
Test Type: TTE (Focused views) Son[**Name (NI) 930**]:
Doppler: Color Doppler only Test Location: West SICU/CTIC/VICU
Contrast: None Tech Quality: Suboptimal
Tape #: 2008W050-: Machine: Vivid [**6-25**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Diastolic Dimension: 4.7 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 30% to 40% >= 55%
Findings
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV.
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
Moderate global LV hypokinesis. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size. Mild global RV free
wall hypokinesis.
AORTIC VALVE: Bioprosthetic aortic valve prosthesis (AVR). AVR
leaflets move normally. No AR.
MITRAL VALVE: Normal mitral valve leaflets. Mild thickening of
mitral valve chordae.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Emergency study performed by the cardiology fellow on call.
Conclusions
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. There is moderate global
left ventricular hypokinesis initially with bradycardia (LVEF =
30%) that improves with pacing to 80/min (LVEF 40%).. Right
ventricular chamber size is normal. with mild global free wall
hypokinesis. A well-seated bioprosthetic aortic valve prosthesis
is seen with good leaflet motion. No aortic regurgitation is
seen (focused color Doppler). The mitral valve leaflets are
structurally normal. No definite mitral regurgitation is seen.
There is a trivial/physiologic pericardial effusion.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2120-10-12**] 14:16
Brief Hospital Course:
Mr. [**Known firstname **] was admitted one day prior to his surgery to be
started on Heparin (he d/c'd Coumadin 4 days prior to admission)
and undergo complete pre-operative work-up. On [**10-8**] he was
brought to the operating room where he underwent a
redo-sternotomy, coronary artery bypass graft x 1, and aortic
valve replacement. Please see operative report for surgical
details. In summary he had a redo sternotomy with AVR(#21
[**Company 1543**] Mosaic porcine) and CABGx1(SVG-Pda). His bypass time
was 94 minutes with a crossclamp of 65 minutes. he tolerated the
operation well and following surgery he was transferred to the
CVICU for invasive monitoring in stable condition. In the
immediate post-op period he remained hemodynamically stable, his
anesthesia was reversed he was weaned from sedation, awoke
neurologically intact and extubated. Endocrine/[**Last Name (un) **] were
consulted post-op to assist with patients poor diabetes control
(recent A1C 8%). On post-op day one he was started on beta
blockers and diuretics. On POD2 he was transferred from the ICU
to the stepdown floor for continued care. Once on the floor he
had several episodes of atrial fibrillation which were treated
with Beta blockers. Following beta blockade Mr [**Known lastname 23**] had
symptomatic bradycardia and was transferred back to the ICU for
closer monitoring, EP service was consulted and a permenant
pacemaker was placed on [**10-14**].
On POD7/1 he was again transferred to the stepdown floor. Over
the next several days the patients activity level was advanced
and he was anticoagulated for his atrial fibrillation. On POD
[**10-23**] he was discharged home with visiting nurses. His INR is to
be drawn by the VNA on [**10-21**] and coumadin dosing is to be
followed by Dr [**Last Name (STitle) 2204**].
Medications on Admission:
Thyroxine 25mcg/D, Warfarin(dc 4 days), Amitryptilline 25mg/D,
Lisinopril 30mg [**Hospital1 **], Neurontin 300mg/D, Simvistatin80mg/D, ASA
81mg/D, Flomax 0.4mg/D, ToprolXL 100mg TID, Flonase, Glucosamine
1000mg [**Hospital1 **], Plavix 75mg/D (dc 5 days)
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
6. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
7. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
Disp:*1 bottle* Refills:*2*
10. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day) for 10 days.
Disp:*60 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for
10 days.
Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
13. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
14. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime:
Take as directed by Dr. [**Last Name (STitle) 2204**] for INR goal of [**1-20**].5.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Aortic stenosis s/p Aortic Valve Replacement
Coronary Artery Disease s/p coronary artery bypass graft x 1
PMH: s/p Coronary Artery Bypass Graft x 3 ([**2113**]), Hypertension,
paroxysmal atrial fibrillation, hearing loss, degenerative joint
disease, lumbar disc disease, insulin dependent diabetes
mellitus, benign prostatic hypertrophy
Discharge Condition:
good
Discharge Instructions:
shower daily, no baths or swimming
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
no creams, lotions or powders to incisions
report any fever more than 100.5, redness of, or drainage from
incisions
report any weight gain greater than 2 pounds a day or 5 pounds a
week
Take all medications as prescribed
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 120**] in 2 weeks
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2204**] in [**12-20**] weeks
Please call for appointments
Completed by:[**2120-10-21**]
ICD9 Codes: 3572, 5990, 2762, 4241, 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1004
} | Medical Text: Admission Date: [**2180-7-26**] Discharge Date: [**2180-7-31**]
Date of Birth: [**2101-9-13**] Sex: F
Service: SURGERY
Allergies:
Alendronate Sodium
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p Pedestrian struck by auto
Major Surgical or Invasive Procedure:
None
History of Present Illness:
78 yo female pedestrian who was struck by car at low speed in
mall parking lot. + brief LOC. She was taken to an area hospital
where she was found to have a cervical spine injury and facial
fractures; she was then transferred to [**Hospital1 18**] for further
management.
Past Medical History:
CAD s/p CABG [**2161**]
HTN
Social History:
Recently widowed
Family History:
Noncontributory
Pertinent Results:
[**2180-7-26**] 09:23PM GLUCOSE-132* LACTATE-1.7 NA+-141 K+-3.9
CL--111 TCO2-22
[**2180-7-26**] 09:15PM UREA N-23* CREAT-0.5
[**2180-7-26**] 09:15PM AMYLASE-88
[**2180-7-26**] 09:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2180-7-26**] 09:15PM WBC-12.3* RBC-3.75* HGB-12.7 HCT-36.9 MCV-99*
MCH-34.0* MCHC-34.5 RDW-13.6
[**2180-7-26**] 09:15PM PT-12.1 PTT-21.7* INR(PT)-1.0
[**2180-7-26**] 09:15PM PLT COUNT-336
CT SINUS/MANDIBLE/MAXILLOFACIA
Reason: frax
[**Hospital 93**] MEDICAL CONDITION:
78 year old woman with ped vs MVA
REASON FOR THIS EXAMINATION:
frax
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 78-year-old pedestrian struck by auto.
COMPARISON: Non-contrast head CT performed concurrently.
TECHNIQUE: Contiguous axial images were obtained through the
facial bones without intravenous contrast. Multiplanar
reconstructions were performed.
FINDINGS: There are minimally displaced bilateral nasal bone
fractures. There is also a nondisplaced fracture through the
lateral wall of the right maxillary sinus. A high-density fluid
level in the right maxillary sinus presumably represents
hemorrhage. An incompletely imaged fracture through the anterior
of C1 is characterized fully on the accompanying cervical spine
CT. The globes appear intact and no retrobulbar hematoma or
edema is present. There is moderate soft tissue swelling and
hyperdense foci in the soft tissues over the forehead, which may
represent retained foreign bodies. Evaluation of the mandible
was limited due to streak artifact from dental hardware. The
TMJs appear well seated.
IMPRESSION:
1. Minimally displaced fractures of the nasal bones and lateral
wall of the right maxillary sinus.
2. C1 vertebral bfracture. See accompanying CT cervical spine
for further details.
3. Frontal soft tissue swelling with imbedded hyperdense foci,
which may represent retained foreign bodies. Please correlate
clinically.
ELBOW (AP, LAT & OBLIQUE) RIGH; SHOULDER (AP, NEUTRAL & AXILLA
Reason: frax
[**Hospital 93**] MEDICAL CONDITION:
78 year old woman with ped vs MVA
REASON FOR THIS EXAMINATION:
frax
RIGHT UPPER EXTREMITY RADIOGRAPHIC SERIES.
COMPARISON: None.
CLINICAL HISTORY: 78-year-old pedestrian struck by car, rule out
fracture.
FINDINGS: Nine views of the right upper extremity are obtained.
RIGHT SHOULDER: A fracture is noted through the right humeral
neck which is nondisplaced but appears impacted. Findings are
best appreciated on axillary view. The AC joint is unremarkable.
RIGHT ELBOW: The right elbow appears unremarkable. There is no
evidence of dislocation or fracture in the osseous structures.
There is no evidence of elbow joint effusion or soft tissue
swelling.
RIGHT WRIST: The right wrist appears intact. A well-corticated
ossific density is seen adjacent to the ulnar styloid, which may
represent sequelae of prior trauma. The carpal alignment appears
intact. Mild degenerative changes are noted at the basal joint
of the right hand. Osteopenia is noted.
IMPRESSION:
1. Right humeral neck fracture, impacted.
2. No acute injury present in the right elbow or right wrist.
CT C-SPINE W/O CONTRAST
Reason: cspine
[**Hospital 93**] MEDICAL CONDITION:
78 year old woman with ped vs MVA
REASON FOR THIS EXAMINATION:
cspine
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 78-year-old struck by automobile.
COMPARISON: Non-contrast head CT performed concurrently.
TECHNIQUE: MDCT axial images through the cervical spine without
intravenous contrast. Multiplanar reconstructions were
performed.
FINDINGS: The skull base through the T3 vertebral body are well
visualized on the lateral view. Assessment of fine detail is
limited due to severe osteopenia. There are nondisplaced
fractures through the anterior and posterior arches of C1.
Fracture lines extend to the left lateral mass and appear to
extend to the left transverse foramen. No other fractures are
identified. No prevertebral or paraspinal soft tissue
abnormality is seen. There is extensive multilevel degenerative
change with exaggeration of the cervical lordosis, loss of disc
space height, facet hypertrophy and marginal osteophytosis. The
atlanto-occipital and atlantoaxial relationships are maintained.
There is mild right foraminal stenosis at C3-4 secondary to
facet hypertrophy and uncovertebral spurring. There is no
significant osseous encroachment upon the spinal canal. The lung
apices demonstrate calcified granulomas consistent with prior
granulomatous infection. An air-fluid level is present in the
right maxillary sinus. Visualized mastoid air cells are well
aerated.
IMPRESSION:
1. Non-displaced C1 fracture with apparent fracture lines
through the left transverse foramen. Further characterization
with MRA would be useful for evaluation of the traversing
vertebral artery.
2. Multilevel degenerative change with features as described
above.
ATTENDING REVIEW: I don't see definite fractures in the
transverse process or posterior arch. However, the anterior arch
cleft is new since previous neck CT of [**2179-5-26**] and is consistent
with acute fracture.
CT HEAD W/O CONTRAST
Reason: ICH
[**Hospital 93**] MEDICAL CONDITION:
78 year old woman with ped vs MVA
REASON FOR THIS EXAMINATION:
ICH
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 78-year-old pedestrian versus MVA.
COMPARISONS: None.
TECHNIQUE: Contiguous axial images were obtained through the
brain. No intravenous contrast was administered.
FINDINGS: There is no evidence of hemorrhage, mass effect,
masses, shift of normally midline structures or hydrocephalus. A
crescent upper density anterior to the left frontal lobe
presumably represents volume averaging from the adjacent osseous
inner table. The ventricles and sulci are normal in caliber and
configuration. [**Doctor Last Name **]-white matter differentiation is preserved.
Bone algorithm windows demonstrate a non-displaced fracture
through the lateral right maxillary sinus wall. There are
minimally displaced nasal bone fractures, incompletely imaged. A
fluid level, likely hemorrhage, is seen in the right maxillary
sinus. Several ethmoid air cells are opacified. A fracture
through the anterior C1 arch is more fully assessed on the
accompanying cervical spine study.
IMPRESSION:
1. No intracranial hemorrhage or mass effect.
2. Non-displaced fracture of the lateral right maxillary sinus
and minimally displaced nasal bone fractures. Further
characterization with CT of the facial bones is recommended.
3. Incompletely imaged C1 fracture, please refer to the CT
cervical spine, (clip [**Clip Number (Radiology) 106130**]) for additional details.
Brief Hospital Course:
She was admitted to the Trauma Service. Her injuries were
nonoperative. Her cervical spine injury was evaluated by
Orthopedic Spine; clinically she had no posterior neck
tenderness. She underwent an MRI of her cervical spine which
revealed that the fracture was a new vs old injury. It was
recommended that she remain in a hard collar by Dr. [**Last Name (STitle) 1352**],
Orthopedic Spine Surgery, for at least 8 weeks. She will return
in [**1-23**] weeks for repeat imaging. She was started on bone
prophylaxis with Calcium and Vitamin D.
OMFS was consulted because of her facial fractures; these were
nonoperative as well. It is being recommended that she maintain
a full liquid/soft diet for the next 2 weeks and will follow up
Dr. [**First Name (STitle) **] at that time. Any chewing motion should be avoided
until follow up.
Orthopedics was consulted for the right distal humerus fracture;
this did not require surgical intervention. She is to wear a
sling for comfort and remain non weight bearing until follow up
in 2 weeks with Dr. [**Last Name (STitle) **].
Physical and Occupational therapy were consulted and have
recommended short rehab stay.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for HR <60; SBP<110.
5. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO at bedtime.
8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
15. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
16. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
s/p Pedestrian struck by auto
C1 [**Location (un) 5621**] type fracture
Left mandible fracture
Right maxillary sinus fracture (non-displaced)
Bilateral nasal bone fractures (minimally displaced)
Right proximal humerus fracture
Discharge Condition:
Good
Discharge Instructions:
It is being recommended by Spine Surgery that you continue to
wear the cervical collar for the next 2 weeks until follow up.
DO NOT bear any weight on your right arm because of your
fracture.
Wear the sling for comfort.
Avoid foods that you have to chew. You must maintain a full
liquid/soft diet.
Followup Instructions:
Follow up with Dr. [**First Name (STitle) **] in [**Hospital 40530**] Clinic on Friday [**8-4**], call
[**Telephone/Fax (1) 274**] for an appointment time.
Follow up with Dr. [**Last Name (STitle) **], Orthopedics, in 2 weeks. Call
[**Telephone/Fax (1) 1228**] for an appointment.
Follow up with Dr. [**Last Name (STitle) 1352**], Orthopedic Spine Surgery in 2 weeks,
call [**Telephone/Fax (1) 1228**] for an appointment.
Completed by:[**2180-7-31**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1005
} | Medical Text: Admission Date: [**2164-8-8**] Discharge Date: [**2164-8-12**]
Date of Birth: [**2111-8-31**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 51887**] is a 52-year-old male
who has had worsening anginal symptoms with exertion and has
undergone recent cardiac catheterization that showed a
significant proximal left anterior descending lesion prior to
diagonal takeoff and a subsequent total occlusion of the left
anterior descending artery. He has also had significant
disease in his right coronary artery and an occluded
circumflex system. He had been turned down for surgery at an
outside hospital and is now presenting for coronary artery
bypass surgery. Of note, his medical history consists of
coronary artery disease, hyperlipidemia, and he is deaf in
his left ear.
PAST MEDICAL HISTORY: Significant for coronary artery
disease, hyperlipidemia, and he is deaf in his left ear.
MEDICATIONS AT HOME: Imdur 30 mg daily, Toprol XL 25 mg
daily, Lipitor 20 mg daily, aspirin 81 mg daily, sublingual
nitroglycerin as needed for chest pain.
PHYSICAL EXAMINATION ON ADMISSION: The patient was afebrile
with all vital signs within normal limits. He was
normocephalic and atraumatic. The pupils were equally round
and reactive to light. The oropharynx was clear. The neck was
supple with no lymphadenopathy. The lungs were clear to
auscultation bilaterally. Heart was in regular rate and
rhythm with no murmurs, rubs or gallops appreciated. The
abdomen was nontender, nondistended, with normal active bowel
sounds. The extremities revealed no clubbing, cyanosis or
edema. Neuro was focally intact throughout; cranial nerves II
through XII, and the patient was [**5-3**] in terms of strength and
sensation throughout. Psych revealed the patient was noted to
have normal mood and affect, and thought content was
organized.
HOSPITAL COURSE: Thus, at this time the patient was admitted
for coronary artery bypass grafting. The patient was brought
to the operating room, and 2 grafts were performed with the
left internal mammary artery to the first diagonal branch of
the LAD and a reverse saphenous vein graft to the right
coronary artery. There were no untoward events in the
operating room or in the immediate perioperative period. The
patient was brought to the cardiac intensive care unit after
the procedure. The patient progressed well, and his chest
tubes were removed on postoperative day 1, and his cardiac
pacing wires were removed on postoperative day 3. His Foley
catheter was discharged, and the patient began to work with
physical therapy while on the floor after being sent out of
the intensive care unit. The patient progressed well. His
pain was well controlled at this time. He had no signs of
arrhythmias. He was restarted on his home medications as well
and was noted to be fit for discharge on postoperative day #4
([**2164-8-12**]), and this was done accordingly.
DISCHARGE STATUS: The patient was to be discharged to home
with visiting nurse assistance service.
DISCHARGE INSTRUCTIONS: The patient to keep wounds clean and
dry. The patient allowed to shower with no bathing or
swimming. The patient to take all medications as directed.
The patient to call for any fever, redness or drainage from
the wounds, any chest pain, shortness of breath, nausea,
vomiting or if there are any other questions or concerns.
DISCHARGE FOLLOWUP: The patient to follow up with Dr.
[**Last Name (STitle) **] in 1 month and to call to set up an appointment. The
patient to follow up with Dr. [**Last Name (STitle) 63441**] and to call to schedule
an appointment. The patient to follow up with a cardiologist
within 7 to 10 days.
MEDICATIONS ON DISCHARGE: Potassium chloride 20 mEq p.o.
daily for 10 days, Colace 100 mg p.o. b.i.d., aspirin 81 mg
p.o. daily, atorvastatin 20 mg p.o. daily, hydromorphone 1 to
2 tablets p.o. q.3-4h. as needed for pain, furosemide 20 mg
p.o. daily for 10 days, metoprolol 50 mg p.o. b.i.d.
DISCHARGE DISPOSITION: The patient to be discharged to home
with visiting nurse assistance and to follow up with Dr.
[**Last Name (STitle) **] in 1 month.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D: [**2164-8-12**] 12:41:22
T: [**2164-8-12**] 13:12:48
Job#: [**Job Number 63442**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1006
} | Medical Text: Admission Date: [**2185-7-21**] Discharge Date: [**2185-8-4**]
Date of Birth: [**2116-6-26**] Sex: M
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 103266**] is a 69-year-old male
with a history of CAD, hypertension and diverticulosis as
well as diverticulitis who was brought to the Emergency Room
by ambulance for diarrhea, nausea and vomiting. He was found
history of chest pain, shortness of breath or abdominal pain.
He does admit to mild headache. Other past medical history
is abbreviated due to the fact that the patient presented
acutely ill. On Emergency Room arrival his temperature was
99.3, blood pressure 82/42, heart rate 133, breathing 96% on
room air and overall he was sluggish. He was given several
liters of normal saline and begun on peripheral Dopamine. He
incident in the Emergency Room. The patient was complaining
of headache and of neck pain. He, however, denied chest
pain, abdominal pain, pelvic pain as well as any nausea. In
the Emergency Room he had a total of 8 liters of normal
saline and Dopamine drip was started at 5 mg. He was treated
with Levaquin and Gentamycin. He spiked to 104.2 and initial
ABG was done and was 7.29/39/132 on a non rebreather. About
90 minutes later on 4 liters, the patient's ABG was
7.32/28/66.
PAST MEDICAL HISTORY: Significant for CAD, status post PTCA
in [**2169**] and again in [**2170**]. Last catheterization in [**2171**]
revealed two vessel disease. Ejection fraction was normal
per patient's PCP with [**Name Initial (PRE) **] history of hypertension, spinal
fusion in the past, no history of diabetes, history of a
chronic muscle wasting disease, extensive work-up negative,
history of depression, history of diverticulosis and history
of diverticulitis, most recent recurrence [**2185-1-27**].
Surgery was recommended but the patient refused the
procedure.
MEDICATIONS: Per the patient's PCP include Diltiazem 240 mg
q d, Atenolol 25 mg q d, Effexor 150 mg [**Hospital1 **], Trazodone 300 mg
q h.s., Risperdal 2 mg q d, Zocor and Aspirin.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He lives alone in [**Location (un) 86**]. He is a retired
taxi driver. He is originally from [**State 2748**]. His mother
is currently living in [**State 2748**]. PCP is [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 32630**].
PHYSICAL EXAMINATION: He was moaning but alert, interactive
and oriented. Temperature 103.4, heart rate 131, blood
pressure 79/49. HEENT: Extraocular movements intact.
Sclera anicteric. Pupils equal, round and reactive to light.
Mucus membranes dry. Neck supple. Cardiovascular, regular
rhythm, tachycardic with distant heart sounds. Pulmonary
exam, anterolaterally clear. Abdomen obese, soft, nontender,
non distended, normoactive bowel sounds, no surgical scars.
Rectal exam, heme positive per Emergency Room staff.
Extremities without edema. EKG tachycardic, likely sinus
tachycardia at 133, normal axis, right bundle branch block.
Old report also shows right bundle branch block. Chest x-ray
with bibasilar infiltrate vs atelectasis.
LABORATORY DATA: Initial laboratory data, white count 3.3,
hematocrit 44.7, platelet count 258,000, differential 41%
polys, 22% bands, 10% monos, 1% basophils, 2 metas.
Urinalysis was greater than 300 protein, trace ketones,
otherwise negative. Chemistries, sodium 143, potassium 5.6,
hemolyzed repeat 3.5, chloride 105, CO2 18, BUN 31,
creatinine 2.6, glucose 150, anion gap 21. First CK 331,
troponin negative. Serum tox and urine tox negative.
HOSPITAL COURSE: The patient initially presented therefore a
69-year-old gentleman with past medical history of CAD and
diverticulitis with septic shock without a clear source on
the background of past medical history previously mentioned.
The patient was admitted to the medical ICU. His respiratory
status worsened and he was intubated on [**2185-7-21**] and abdominal
CT was obtained that revealed an SBO, right middle lobe,
right lower lobe and left lower lobe consolidation. In
Intensive Care Unit he required four pressors to maintain his
blood pressure including Neo, Levo, Dopa and Vasopressin. He
was also given stress dose steroids for a question of
Addison's. He required approximately 16 liters of fluid
resuscitation. He had an exploratory laparotomy on [**2185-7-22**]
after serial CT showed evidence of an SBO. No bowel was
excised during the procedure, however, and the patient was
decompressed with an OG tube in the OR. Perioperatively the
patient had a troponin leak with a CK bump thought to be
related to demand ischemia in the setting of overwhelming sepsis
and causing him to have an MI.
Postoperatively he was afebrile for a few days and then he
spiked a temperature again. His mental status was slow to
return to baseline postoperatively. His lines were changed
and coag negative staph grew from his right IJ line on
[**2185-7-26**]. He was then started on Vancomycin. He had, at that
point, completed a 10 day course of Levo and Flagyl and had
completed a course of Vancomycin as well. Within 24 hours of
starting the Vancomycin, his temperature stopped. However,
they returned a couple of days later and A line was pulled on
[**2185-7-31**] and sent for culture as a potential source of his
persistent fevers. The patient's mental status continued to
improve starting on [**2185-7-29**] and when his mental status had
started to clear he was complaining of back pain which is a
chronic problem for him. An MRI of the spine was done and
was normal. Repeat abdominal CT was negative. He was
started to wean off the ventilator on [**2185-7-29**] and was
extubated on [**2185-7-31**]. On [**2185-8-1**] he was transferred to the
medicine floor and he was communicating with much improved
mental status and in retrospect, at the time of transfer to
the floor, it was felt that his initial septic shock was due
to severe likely aspiration pneumonia in the right middle,
right lower and left lower lobes and his subsequent fevers
postoperatively were likely due to line sepsis.
His medications on transfer to the medical floor included
Aspirin 325 mg q d, Protonix 40 mg q d, Lopressor 25 mg [**Hospital1 **],
Ramipril 2.5 mg q d as well as prn Tylenol, Nystatin cream,
Ambien 5 mg q h.s.
Hospital Course on the floor is as follows:
1. Pulmonary: He was extubated as mentioned on [**2185-7-29**] and
he was able to be weaned to room air by [**2185-8-3**] with oxygen
saturations in the high 90's. An abdominal CT showed
moderate right and small left pleural effusions with collapse
of the left lower lobe. The patient had completed a 10 day
course of Levo and Flagyl for presumed aspiration pneumonia
on admission. His pleural effusions were found to be too
small to tap per ultrasound and interventional radiology.
His respiratory status was stable throughout the remainder of
his hospitalization.
2. Infectious Disease: The patient was continued on
Vancomycin intravenously for a 7 day course which started on
[**2185-8-1**]. This was treating an A line tip which grew out gram
positive bacteria. There were mixed morphologies that were
not speciated, however, since the patient demonstrated
persistent fevers (despite antibiotics) with this line in place
which resolved promptly after its removal, there was reasonable
suspicion to suggest a true line infection. It was therefore felt
prudent to
continue the patient on a 7 day course of Vancomycin.
Echocardiogram done on [**2185-7-29**] was negative for any evidence
of endocarditis. In summary then, the only cultures of his
that were positive included a catheter tip on [**7-26**] that was
coag negative staph treated with a course of Vancomycin.
Sputum gram stain [**7-31**] grew out gram positive cocci in pairs
and [**7-31**] A line tip grew out gram positive bacteria, not
speciated. All other urine cultures and blood cultures are
negative at the time of this dictation.
3. Neuro/Psychiatric: The patient's mental status continued
to improve and he was awake, alert and conversational, able
to provide a history and an explanation for the reason he
came to the hospital initially. The patient had been on
Haldol for agitation but that was discontinued when he was
transferred to the floor. He was not agitated for the
remainder of his hospital stay on the medical floor. He had
a head CT that was negative for any acute process. An MR of
his spine was negative for any epidural abscess. Based on
his own Effexor, Trazodone and Risperdal for depression, none
of those psychiatric medications were started while the
patient was in the hospital.
4. Cardiovascular: Patient with a history of CAD, status
post PTCA times three on Lopressor and Aspirin at baseline.
He was hemodynamically stable for his stay on the medical
floor. As mentioned, his echocardiogram was negative except
for mild LVH. Ejection fraction of 55%. His troponin leak
represented likely demand ischemia leading to an MI in the
setting of severe sepsis and a known reversible ischemic lesion
from outpatient ETT performed prior to his admission. His CKs
were elevated but then were
trending down. He will need to have an ETT done in
approximately 4-6 weeks following his discharge from the
hospital. This will be arranged via his primary care
physician and will be done to follow-up this MI that he had
based on elevated troponin in the perioperative setting.
5. Fluids, Electrolytes & Nutrition: The patient was
tolerating po well and his electrolytes remained within
normal limits.
6. GI: Patient with a history of diverticulosis and
diverticulitis, has been on Protonix while in the hospital.
Exploratory laparotomy was negative. He developed diarrhea
approximately on [**7-31**]. Stool cultures were sent for C. diff,
those results are not back at the time of this dictation. At
this time there is a question of whether the diarrhea is due
to Vancomycin or C. diff. Those culture results are as
mentioned, still pending. The patient had a swallowing study
evaluation due to concern over future aspiration risk. That
study was interpreted as normal and the patient was
determined to be able to tolerate a regular diet including
clears.
7. Prophylaxis: The patient was maintained on subcutaneous
Heparin 5,000 units [**Hospital1 **].
8. Pain: The patient continued to complain of back pain and
neck pain which is a chronic problem for him. He was treated
with Tylenol and Percocet for the pain. In terms of
disposition, PT and OT consults were done and the patient was
screened for rehabilitation. At the time of this dictation
it is not known what rehabilitation facility he will go to.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Discharged to a rehabilitation facility.
DISCHARGE DIAGNOSIS:
1. Septic shock.
2. Aspiration pneumonia.
3. Bacteremia.
4. Coronary artery disease, status post PTCA times three.
5. Hypertension.
6. Diverticulosis.
7. Status post spinal fusion L5,S1.
8. Chronic muscle wasting disease of unknown etiology.
9. Depression.
10. Status post compound fracture of his left wrist and skull
fracture as a child due to an accident.
DISCHARGE MEDICATIONS: Aspirin 325 mg po q day, Protonix 40
mg po q day, Lopressor 25 mg po bid, Ramipril 2.5 mg po q d,
Tylenol 650 mg q 4-6 hours prn, Nystatin cream, Miconazole
powder, Ambien 5 mg po q h.s. and Vancomycin 1 gm q 12 hours
times 7 day course. The course started on [**2185-8-1**].
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Last Name (NamePattern1) 29450**]
MEDQUIST36
D: [**2185-8-3**] 17:47
T: [**2185-8-3**] 20:17
JOB#: [**Job Number **]
ICD9 Codes: 0389, 5185, 5070, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1007
} | Medical Text: Admission Date: [**2192-5-25**] Discharge Date: [**2192-5-29**]
Service: MEDICINE
Allergies:
Zosyn
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mrs. [**Known lastname 44865**] is a [**Age over 90 **] year-old female with advanced dementia who
presented with respiratory distress, BIBA on bipap, tachypneic
and tachycardic, likely secondary to aspiration event; after
goals of care discussion, patient is now CMO.
By report, patient was being fed by her caretaker, received some
advil and developed respiratory distress with a question of
aspiration. Patient's baseline function nonverbal and they use a
device to mobilize her from bed to chair. Spends day watching
TV, not interactive with people. In the ED it was discussed that
there would be no intubation, no compressions, no
defibrillation, no central line, no pressures. Medications by
vein and BiPap OK. Would not want cath.
Upon EMS arrival, tachypneic to 30-40, received nitropaste and
lasix en route with improvement. SBP 80-90 on arrival. Improved
off of bipap with SBP 140. Was taken off nitro paste in ED. Did
well on CPAP and then on NC, then shovel mask.
Labs significant for lactate 2.7, K 5.3, creatinine 0.9, trop
0.07, BNP 8751. WBC 21.7, Hct 42.4, Plate 493, N 88, band 1. UA
negative
She was given Ceftriaxone 1,250mg, Flagyl 500mg. CXR showed low
lung volumes, no focal consolidation or pleural effusion,
minimal left basilar atelectasis. EKG with ?STE I, avL. Blood
cultures were sent.
On the floor, does not appear to be in pain. She occassionally
tracks with her eyes but is nonverbal. She is not in respiratory
distress.
Past Medical History:
- Advanced dementia, multi-infarct
- Diverticulosis
- Hearing loss
- Retinal detachment
- B12 deficiency
- Chronic abdominal pain
- Irritable bowel syndrome
- Spinal Stenosis
Social History:
She was an English professor for many years. Lives with husband
who is her primary care giver. Had health aides that come to the
house 7 days a week. She has 2 sons. She has profound vascular
dementia, is dependent with all ADLs and is non verbal at
baseline.
Family History:
Non-contributory.
Physical Exam:
ADMISSION EXAM
General Appearance: No acute distress
Eyes / Conjunctiva: R>L pupil, both reactive (baseline)
Cardiovascular: (S1: Normal), (S2: Normal)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear :)
Abdominal: Soft, Non-tender
Extremities: Right lower extremity edema: 2+, Left lower
extremity edema: 2+
Skin: Stage V pressure ulcers bilateral calves
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed
DISCHARGE EXAM
GEN: no apparent distress
RESP: 14-20, anterior clear to auscultation
CV: RRR, nl S1, S2, no MRG
ABD: soft
EXT: stage V pressure ulcers bilateral posterior calves, R
appears with purulent discharge & foul-smelling odor, bilateral
large toes with ulcers
Pertinent Results:
# LABORATORY DATA
Admission Labs
[**2192-5-25**] 06:00PM BLOOD WBC-21.7* RBC-4.66 Hgb-13.8 Hct-42.4
MCV-91 MCH-29.6 MCHC-32.5 RDW-14.1 Plt Ct-493*
[**2192-5-25**] 06:00PM BLOOD Neuts-88* Bands-1 Lymphs-6* Monos-5 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2192-5-25**] 06:00PM BLOOD PT-11.6 PTT-21.8* INR(PT)-1.0
[**2192-5-25**] 06:00PM BLOOD Glucose-218* UreaN-38* Creat-0.9 Na-135
K-5.3* Cl-97 HCO3-24 AnGap-19
[**2192-5-25**] 06:00PM BLOOD cTropnT-0.07* proBNP-8751*
[**2192-5-25**] 06:15PM BLOOD Lactate-2.7*
Discharge Labs: N/A.
# IMAGING
[**5-25**] CHEST (Portable AP)
SEMI-UPRIGHT AP VIEW OF THE CHEST: The lung volumes are low. The
heart size is mildly enlarged with left ventricular
predominance. The aorta is mildly tortuous and diffusely
calcified. The pulmonary vascularity is normal. There may be
minimal left basilar atelectasis, but no focal consolidation is
seen. No pleural effusion or pneumothorax is present.
Degenerative changes are noted within the imaged thoracolumbar
spine, as well as involving both glenohumeral and
acromioclavicular joints.
IMPRESSION: Minimal left basilar atelectasis.
# MICROBIOLOGY
[**5-25**] Blood cultures: Pending at discharge.
Brief Hospital Course:
[**Age over 90 **] year-old female with advanced dementia who presented with
respiratory distress, likely secondary to aspiration event.
# Goals of care: After multiple conversations the patient's
husband/HCP and son decided that care to prolong life was not
the priority and they would like to focus on comfort.
Antibiotics, lab draws & imaging studies were discontinued and
the patient was made comfort measures only. Palliative care was
consulted and helped the family arrange home hospice.
# Stage V pressure ulcers: Patient has stage V pressure ulcers
on her bilateral posterior calves inferiorly, as well as
bilateral ulcers on her 1st toes. Wound care was consulted and
made recommendations for appropriate wound care. At this point,
surgical debridement of the ulcers is not in line with the
patient's goal of care, which is comfort.
# Leukocytosis: With bands, most likely secondary to occult
infection versus stress response. See 'goals of care' above.
# Elevated troponin: Had been elevated in the past. No
significant EKG changes. See 'goals of care' above.
# Code status: Changed to comfort measures only (CMO) during
this admission.
Medications on Admission:
Aspirin 81 mg daily
Vitamin D 400 U daily
Advil 600 mg daily
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day). Disp:*qs bottle* Refills:*2*
2. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation. Disp:*20
Suppository(s)* Refills:*1*
3. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
[**2-5**] mL PO q1h (every one (1) hour) as needed for pain or
respiratory distress. Disp:*30 mL* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
circle of caring
Discharge Diagnosis:
Primary diagnosis:
# Aspiration pneumonitis
# End-stage dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
# You were admitted to the hospital because you were having
difficulty breathing. You likely aspirated food or a pill (food
went down the wrong way, into your lungs rather than to your
stomach). You were initially taken to the intensive care unit,
but after discussion about goals of care, you were transferred
to the medical floor with comfort care as our primary goal.
# We made the following changes to your medications:
- STARTED morphine solution for pain
- STARTED docusate sodium liquid to soften stool
- STARTED bisacodyl suppositories as needed for constipation
- STOPPED aspirin
- STOPPED Advil (ibuprofen)
- STOPPED vitamin D
# For comfort, you should take morphine 30 minutes prior to your
dressing changes.
# You should take docusate sodium liquid twice a day to soften
your stools. Use the bisacodyl suppository as needed for
constipation.
# Follow up with hospice care as needed.
Followup Instructions:
Follow up with Circle of [**Hospital **] hospice as needed (tel:
[**Telephone/Fax (1) 77096**]).
Completed by:[**2192-5-29**]
ICD9 Codes: 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1008
} | Medical Text: Admission Date: [**2180-2-12**] Discharge Date: [**2180-2-28**]
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
[**Age over 90 **] year old female admitted with abdominal pain and no BM x 8
days.
Major Surgical or Invasive Procedure:
Status Post exploratory laparotomy with lysis of adhesions.
History of Present Illness:
Ms. [**Known lastname 14936**] is a [**Age over 90 **]-year-old woman
who presents from an outside institution ([**Hospital3 2558**]) with a
several-day history of increasing constipation, nausea without
vomiting. She has noted that her abdomen has been increasingly
distended over the last several days. Her most recent bowel
movement was days ago. She has received a number of enemas in
an
effort to relieve this. She has had no flatus in the last day
or
so. Per her recollection, no change in stool caliber or
hematochezia. She has had diminished oral intake and at this
point is n.p.o. She denies any abdominal pain or cramping.
Past Medical History:
Depression
Shortness of breath associated with pectus carinatum and age
appropriate obstructive ventilatory deficit - seen in pulmonary
clinic
Colon Ca and small bowel Ca/resected in past
History of falls
Hypothyroidism
Glaucoma
Cataracts
? some short term memory loss
Social History:
Smoking: 60 pack year
no alcohol use. Lives at home iwth a 24 hr aide
Family History:
patient denies any med issues in family
Physical Exam:
VITAL SIGNS: Temperature is 97.3, pulse is 82. Blood pressure
124/68, respirations 21, saturation on 2 liters is 97.
GENERAL: She is alert, oriented, and in no acute distress.
HEENT: Sclerae are anicteric. Oropharynx is clear. There is a
plaque on the soft palate of a whitish hue.
NECK: Supple. Trachea midline. No lymphadenopathy. No
bruits.
LUNGS: Clear with few wheezes bilaterally.
HEART: Regular.
ABDOMEN: Markedly distended. There are no obvious hernias, no
organomegaly. She does have active high pitched bowel sounds.
She has some discomfort to palpation. No peritoneal signs.
EXTREMITIES: Without edema. Feet are warm. No ulcers.
Pertinent Results:
Admission Labs
---------------
[**2180-2-11**] 08:15PM WBC-15.5* RBC-4.61 Hgb-14.6 Hct-41.4 MCV-90
MCH-31.8 MCHC-35.4* RDW-13.4 Plt Ct-417 Neuts-85.6* Lymphs-8.2*
Monos-5.6 Eos-0.2 Baso-0.4 Plt Ct-417 Glucose-125* UreaN-16
Creat-0.7 Na-122* K-4.9 Cl-86* HCO3-30 AnGap-11
.
[**2180-2-22**] 05:55AM BLOOD WBC-26.2*# RBC-3.55* Hgb-10.7* Hct-32.4*
MCV-91 MCH-30.2 MCHC-33.1 RDW-14.3 Plt Ct-387
.
[**2180-2-23**] 09:15AM BLOOD Neuts-90.0* Lymphs-5.6* Monos-3.5 Eos-0.8
Baso-0.1
.
[**2180-2-24**] 05:25AM BLOOD WBC-14.2* RBC-3.19* Hgb-9.6* Hct-30.1*
MCV-94 MCH-30.1 MCHC-32.0 RDW-14.3 Plt Ct-412 Glucose-112*
UreaN-28* Creat-0.4 Na-139 K-4.1 Cl-107 HCO3-28 AnGap-8
[**2180-2-23**] 09:15AM BLOOD CK-MB-NotDone cTropnT-0.03*
.
Radiology
---------
[**2180-2-11**] 9:22 PM ~ ABDOMEN (SUPINE & ERECT)
INDICATION: [**Age over 90 **]-year-old female with possible small-bowel
obstruction on outside film.
IMPRESSION: Multiple, relatively proportionately gas-distended
loops of large and small bowel extending to the rectum, without
free intraperitoneal air. Appearance is suggestive of adynamic
ileus, though early or incomplete SBO cannot be completely
excluded; correlate clinically, with imaging follow- up as
indicated.
.
[**2180-2-12**] 9:46 PM ~CHEST PORT. LINE PLACEMENT
HISTORY: Right IJ line. Assess placement, evaluate for
pneumothorax.
IMPRESSION: Tube and line placement as described.
.
[**2180-2-12**] 4:50 AM ~ CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
INDICATION: [**Age over 90 **]-year-old female with history of colon CA status
post resection, presenting with abdominal distention and nausea.
IMPRESSION:
1. Multiple dilated loops of fluid-filled small bowel with
fecalized material in the distal ileum extending to the
ileocolonic anastomosis in the mid abdomen. Findings are
consistent with partial small- bowel obstruction. No evidence
for free intraperitoneal fluid or air. 2. Cystic mass in the
right adnexa and fluid filled endometrial cavity are both
concerning findings given the patient's age. Further
characterization with pelvic ultrasound is recommended on a
non-emergent basis if additional followup is warranted. 3. Small
bilateral pleural effusions and bibasilar atelectasis. 4.
Dilatation of the aortic root to 4.5 cm. Coronary artery
calcifications and enlargement of the pulmonary artery
suggestive of pulmonary arterial hypertension. 5. Left adrenal
adenoma. 6. Severe degenerative changes in the thoracolumbar
spine with numerous wedge compression deformities of unknown
chronicity.
.
[**2180-2-17**] 6:29 PM ~FOOT 2 VIEWS RIGHT
[**Hospital 93**] MEDICAL CONDITION:R foot pain and bruising
FINDINGS: No previous images. Frontal and lateral view show no
definite fracture. There is apparent dislocation of the third
PIP and subluxed fourth PIP. Question of a well-corticated bone
fragment at the distal fourth proximal phalanx. This could be a
sequela of previous injury, though an acute fracture cannot be
unequivocally excluded.
.
[**2180-2-17**] 2:57 PM ~ CHEST (PORTABLE AP)
[**Hospital 93**] MEDICAL CONDITION: Rales and crackles
FINDINGS: In comparison with the study of [**2-13**], there has been
the development of substantial pleural effusions bilaterally.
The pulmonary vessels are less sharply seen, consistent with
increasing pulmonary venous pressure. The endotracheal tube has
been removed and the right IJ catheter remains.
.
[**2180-2-18**] 2:21 PM ~FOOT AP,LAT & OBL RIGHT
INDICATION: Pain in the third and fourth right toes.
IMPRESSION: Overall unchanged appearance when compared to
[**2180-2-17**]. Dislocation of the third and fourth proximal
interphalangeal joint. Subluxation/dislocation of the second and
fifth metatarsophalangeal joint. A fracture at the base of the
fourth middle phalanx cannot reliably be excluded.
.
[**2180-2-20**] 11:28 AM ~CHEST (PORTABLE AP)
Reason: increased white count, please eval for acute pulmonary
proce
FINDINGS: Again noted are large bilateral pleural effusions and
right IJ line with tip in the SVC. The upper lungs are clear.
The lower lungs cannot be assessed due to the overlying
effusions.
.
[**2180-2-21**] 7:47 PM ~PORTABLE ABDOMEN
INDICATION: Recent small bowel obstruction status post LOA,
presenting with nausea and vomiting.
IMPRESSION: Limited examination. Recommend upright and supine
views to further assess bowel as indicated. No definite evidence
of obstruction. Dense material of the colon is probably from CT
evaluation nine days prior.
.
[**2180-2-22**] 9:00 PM ~CHEST PORT. LINE PLACEMENT
PROCEDURE: Chest portable for line placement on [**2180-2-22**].
IMPRESSION:
1. Right PICC line in a fairly satisfactory location at the
SVC/atrial junction. 2. New bilateral mild interstitial
pulmonary edema.
.
[**2180-2-22**] 11:52 AM ~CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST
INDICATION: Status post exploratory laparotomy, [**2-12**], now
with elevated white blood cell count. Evaluate for abscess.
IMPRESSION:
1. Dilated loops of small bowel and moderate amount of stool in
the colon. Findings are most suggestive of ileus. 2. Focal area
of peripheral circumferential gas within the colon, just
adjacent to the ileocolic anastomosis, most likely represents
gas trapped around luminal contents, as no other signs to
suggest bowel ischemia are present. 3. Increased bilateral
pleural effusions and atelectasis. 4. Small amount of fluid in
the pelvis without evidence of abscess. 5. Left adrenal gland
prominence could relate to adenoma as previously suggested,
although a focal nodule is not definitely visualized on today's
examination.
.
[**2180-2-24**] 10:00 AM ~CHEST (PORTABLE AP)
Reason: pulm edema, ? increasing effusions INDICATION: Followup.
IMPRESSION: No relevant changes as compared to [**2-22**].
.
.
Cardiology
----------
TTE (Complete) Done [**2180-2-18**] at 11:48:15 AM
FINAL IMPRESSION: Mild symmetric left ventricular hypertrophy
with preserved global and regional biventricular systolic
function. Moderate aortic stenosis. Mild-moderate aortic
regurgitation. Moderate mitral regurgitation. Moderate pulmonary
hypertension. Dilated thoracic aorta.
.
Pathology
---------
SPECIMEN SUBMITTED: right ovary.
Procedure date Tissue received Report Date Diagnosed
by
[**2180-2-12**] [**2180-2-14**] [**2180-2-17**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/cma??????
Previous biopsies: [**-6/3243**] EGD (2).
DIAGNOSIS: Right ovary, exploratory laparotomy:
1. Fallopian tube with paratubal cyst and reactive mesothelial
cells.
2. Ovary with simple cyst.
Dr. [**Last Name (STitle) **] [**Last Name (NamePattern5) 16189**] reviewed slide B.
Clinical: Small bowel obstruction.
Gross: The specimen is received fresh labeled with "[**Known lastname 14936**],
[**Known firstname 2127**]" the medical record number and "right ovary." It consists
of a fallopian tube and ovary. The fallopian tube measures 5.5
cm in length and 0.3 cm in diameter and the ovary measures 2.5 x
2.0 x 1.5 cm. At the junction of the fallopian tube and the
ovary is what appears to be a paratubal cyst which measures 3.5
x 3.0 x 2.0 cm. The surface of the specimen is inked in black
and the specimen is serially sectioned to reveal a biloculated
cyst with a smooth lining and contains approximately 15 cc of
clear fluid. The ovary is also serially sectioned to reveal a
simple cyst with approximately 5 cc of yellow fluid. The cyst
wall has a smooth lining and measures 0.1 cm in thickness. No
solid component is identified. Representative sections are
submitted as follows: A = fallopian tube, B-C = paratubal cysts.
D-E = ovary with cyst.
.
Brief Hospital Course:
This is a [**Age over 90 **] year old female admitted on [**2180-2-12**] with small
bowel obstruction. Underwent exploratory laparotomy.
Postoperative Issues:
1. Cardiac - Has been tachycardic intermittently. Ekg confirms
sinus rhythm to sinus tach. Troponin checked with normal to
slight elevations. [**Date Range **] [**2-18**]: IMPRESSION: Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. Moderate aortic stenosis.
Mild-moderate aortic regurgitation. Moderate mitral
regurgitation. Moderate pulmonary hypertension. Dilated thoracic
aorta. Acute on chronic heart failure.
2. Respiratory - Pulmonary consult called for management of CHF,
COPD and pectus carinatum. Chest x-rays have showed bilateral
pleural effusions with some CHF. Diuresised with lasix multiple
times. Albuterol nebulizers given for expiratory wheezes.
Currently respiratory status stable. Daily advair and spiriva.
3. Infectious Disease - WBC up to 26 on [**2180-2-22**] Pancultured with
negative cultures for blood, urine, sputum. Stool sent for c.
diff. negative times four. Central line discontinued, negative
growth of culture tip. Started on vancomycin and flagyl. White
count trending down to 11.6 on [**2180-2-28**]. Flagyl discontinued.
Will continue oral vancomycin for 14 more days per Infectious
Disease.
4. Abdomen/GI - Patient has been getting a fleets enema daily
with colace. Her abdomen is now soft, positive bowel sounds,
slightly distended. Incision line dry and intact without
erythema. Has been tolerating a soft diet with fluid intake
approx. 1 liter a day. As oral intake good will discontinue TPN
today.
5. GU - Foley discontinued on [**2180-2-26**]. Incontinent at times.
Baseline bun 15-20, creatinine .3 -.8.
6. Mobility - Out of bed with assistance. She has been
ambulating with physical therapy with walker with much
assistance.
7. Discharge plans - She will be discharged to rehab. at
[**Hospital1 **] today. She is to follow up with Dr. [**Last Name (STitle) **] in 2
weeks.
Medications on Admission:
Advair
Spiriva
ASA
Levoxyl 75'
Diltiazem XL 180'
Remeron 7.5 mg daily and 15 mg QHS
Lisinopril 7.5'
Trosopt eye drops TID rt eye
Centrum silver
Discharge Medications:
1. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3
times a day).
2. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
1-2 puffs Inhalation Q6H (every 6 hours) as needed.
3. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO QAM (once a day
(in the morning)).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
9. Lisinopril 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
10. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): continue until [**2180-3-8**].
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location 12243**] Senior Care - [**Hospital1 189**]
Discharge Diagnosis:
High grade small bowel obstruction
Post-operative Ileus
Post-operative Leukocytosis
Discharge Condition:
Stable
Discharge Instructions:
Please call Dr. [**Last Name (STitle) **] or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* If you are nauseous and vomiting; cannot keep in fluids or
your medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat or feeling dizzy or faint when standing.
* Your pain is not improving within 8-12 hours or becoming
progressively worse, or inadequately controlled with the
prescribed pain medication.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Abdominal pain and/or tenderness
* Abdominal fullness
* Abdominal distention
* Increase in cramping and/or bloating sensation
* Failure to pass gas or stool (constipation)
* Changes in bowel habits ?????? such as constipation or diarrhea
* Any serious change in your symptoms, or any new symptoms that
concerns you.
Followup Instructions:
Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in clinic on
[**3-17**] at 1:15.
Completed by:[**2180-2-28**]
ICD9 Codes: 5119, 5990, 5180, 2449, 4280, 496, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1009
} | Medical Text: Admission Date: [**2170-10-4**] Discharge Date: [**2170-10-10**]
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an 84 y/o female recently dx with AML on supportive
treatment only, on coumadin for atrial fibrillation and h/o TIA,
who presented to the ED with c/o maroon-colored stools x 6 days
and fatigue with SOB x several days. Pt noted blood also mixed
in with stool, but denies any increase in frequency of stool. No
abd pain, n/v/hematemesis or other changes in bowel habits.
.
In the ED, labs were significant for a Hct of 15.8, WBC of 45.8,
and INR of 7.7. Maroon stool, guiac positive in rectum but NG
lavage negative. Pt was hemodynamically stable throughout. She
was given 1 U PRBC, 2 U FFP, and 5 mg SC vit K. GI was consulted
in the ED and feels this may be a LGIB, but also could be a
UGIB. Conversation with PCP and family lead to decision of
tagged RBC scan to attempt localization of site in an effort to
avoid invasive procedures, including EGD/colonoscopy given
comorbid conditions. Tagged RBC scan demonstrated brisk bleeding
from the cecum.
.
Currently, pt fatigued, but otherwise denies other sx including
LH/dizziness, h/a, vision changes, URI sx,
SOB/palpitations/chest pain, abd pain, n/v,
weakness/numbness/loss of sensation, dysuria. No further BM's
since yesterday.
Past Medical History:
1. Atrial fibrillation with a history of TIA 10 years ago on
chronic anticoagulation with Coumadin.
2. Status post left hip replacement.
3. Polymyalgia rheumatica, previously treated with steroids,
with persistent proximal leg weakness.
5. Osteoporosis.
6. Status post total abdominal hysterectomy with bilateral
salpingo-oophorectomy.
7. Mild-to-moderate Alzheimer dementia.
Social History:
The patient lives with her husband in [**Name (NI) 2312**], MA. She has
never smoked and drinks one glass of wine per day. She is quite
physically active and walks approximately one quarter of a mile
daily and lifts weights twice a week. Family involved in care,
pt is DNR/DNI.
Family History:
NC
Physical Exam:
VS: T 98.8, BP 132/53, HR 90's, RR 29, SaO2 98%/RA
General: Pleasant elderly female in NAD, AO x 2 (place, year)
HEENT: NC/AT, PERRL, EOMI. No scleral icterus. +conjuntival
pallor. MM slightly dry, OP clear
Neck: supple, no JVD
Chest: CTA-B, no w/r/r
CV: RRR, s1 s2 normal, no m/g/r
Abd: soft, NT/ND, NABS. Guiac positive in ED.
Ext: pt has chronic LE pain, refuses exam of LE
Neuro: AO x 2, non-focal
Pertinent Results:
[**2170-10-4**] 03:30PM GLUCOSE-114* UREA N-29* CREAT-0.8 SODIUM-141
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-26 ANION GAP-12
[**2170-10-4**] 03:30PM CK(CPK)-26
[**2170-10-4**] 03:30PM cTropnT-<0.01
[**2170-10-4**] 03:30PM WBC-45.8*# RBC-1.60*# HGB-5.4*# HCT-15.8*#
MCV-99* MCH-34.0* MCHC-34.5 RDW-20.5*
[**2170-10-4**] 03:30PM PT-61.9* PTT-34.4 INR(PT)-7.7*
.
Brief Hospital Course:
84 y/o female with AML, Alzheimer's dementia, Afib and h/o TIA's
on coumadin, p/w acute drop in Hct and maroon-colored stools.
.
# GIB - tagged RBC scan demonstrates brisk bleeding from cecum,
likely in setting of coagulopathy. Pt was hemodynamically stable
throughout the course of her stay. Spoke with IR, who
recommended medical management with PRBCs and FFP for now as pt
stable and procedure invasive given pt's co-morbid conditions.
Family and pt agreed with conservative management. Hct was 30
and stable upon discharge.
.
# AML - currently on supportive treatment for AML. Pt may be in
acute blast crisis given leukocytosis of 45 K, with prior counts
at 13 K. She is managed for goal of comfort at this time by
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. She will be discharged on 7
days of PO levofloxacin for neutropenia.
.
# A fib - rate-controlled on digoxin.
.
# Dementia - Mild to moderate Alzheimer's, at baseline.
Continued Aricept and Namenda.
.
#Dispo - patient is being discharged to nursing home unit at her
[**Hospital3 **] complex with goals of care directed at comfort
only.
Medications on Admission:
1. Aricept 5 mg [**Hospital1 **]
2. Coumadin 4 mg M/W/F, 5 mg S/[**Doctor First Name **]/Tues
3. Detrol 1 mg [**Hospital1 **]
4. Digoxin 250 mcg qd
5. Fosamax 70 mg qweek
6. Namenda 10 mg [**Hospital1 **]
7. MVI qd
8. Ca/Vit D qd
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Memantine 5 mg Tablet Sig: Two (2) Tablet PO bid ().
Disp:*30 Tablet(s)* Refills:*1*
3. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
4. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO QDAY () for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 8463**] [**Last Name (NamePattern1) **] House/Hospice
Discharge Diagnosis:
Primary
Lower GI bleed
.
Secondary
AML
Discharge Condition:
Stable
Discharge Instructions:
Please contact your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], if you have any pain or
concerns upon discharge.
Followup Instructions:
Please contact your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], if you have any pain or
concerns.
At this time, you do not have any scheduled follow up.
ICD9 Codes: 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1010
} | Medical Text: Admission Date: [**2174-8-30**] Discharge Date: [**2174-9-5**]
Date of Birth: [**2128-5-20**] Sex: F
Service: MEDICINE
Allergies:
Ceclor
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Persistent Fevers, Diffuse Arthralgias, Rash
Major Surgical or Invasive Procedure:
Central Line Placement
Femoral Dialysis Cath
A-Line
Intubation and Ventilator support
Sternal Bone Marrow Aspirate
CVVH
History of Present Illness:
46 yo F with PMH with PMh of diabetes, left internal carotid
artery aneurysm, status post coiling, Bell's palsy, sciatica,
s/p hysterectomy in [**2157**] for menorrhagia who presented to OSH
with fevers, chills, diffuse joint pains, muscle pain. The
patient reports that she was in [**Location (un) 32407**] from [**Date range (1) 32408**] when
on the morning of Sunday [**8-14**], when she was at her friend's
house, she had acute onset of a red confluent raised, itchy rash
that involved all apsects of her legs from the waist down, and
both of her arms from the shoulders down. She had never had a
rash like this before. That evening the patient had onset of
significant fevers and chills and over the next days developed
significant diffuse joint pain affecting all joints from her
shoulders, elbows, wrists fingers knees, ankles and toes with
associated diffuse muscle pain. She initially was seen as an
outpatient and reportedly started on a 1 week prednisone taper
(unclear if other meds initiated at that time also) The patient
had persistent symtoms and was admitted to Caritas Good [**Hospital 32409**]
medical center in [**Hospital1 1474**] with persistent fevers to 103, rash,
diffuse arthralgias. She underwent evaluation there including
numerous ID studies there, LP, MRI, TTE and multiple
rheumatologic studies which were all nondiagnostic to date. Due
to continued high fevers up to 104 at night, the patient was
started on vanc , levo and high dose steroids which rheum
reportedly diagnoisng adult onset JRA versus viral arthritis.
Past Medical History:
Diabetes
Left internal carotid artery aneurysm, status post coiling
Bell's palsy
Sciatica
S/p hysterectomy in [**2157**] for menorrhagia
Social History:
Patient lives in [**Hospital1 1474**]. Denies IVDA, tattoos, any significant
outdoor exposure in tick endemic areas. Patient reports travel
to [**Location (un) 5354**] in past. When she was in [**State 108**] she reports being
in the city the entire time. She was not in the everglades.
She has not been in the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9880**] region nor upstate NY
(sounded like she was in [**Location (un) 7349**], can clarify). Patient has been to
[**Male First Name (un) 1056**] of note, but denies being in the jungle. She
repeatedly denies being bitten by mosqitoes or any insect.
Family History:
Denies family history of arthritis or rheumatologic ailments.
Denies history of IBD.
Physical Exam:
Vitals: T 99.1 BP 98/54 HR 82 RR 18 O2sat 100%RA FS 276
HEENT: PERRL, anicteric, supple neck, no meningeal signs.
HEART: RRR with respiratory variation, nml s1s2, no m,r,g.
LUNGS: CTAB
ABD: +BS, soft, NT, ND
EXT: no pedal edema
DERM: Patient has dark erythematous macular rash on left
shoulder, appearance not consistent with hyperacute
presentation. Patient also has erythematous rash around the
base of her neck (patient reports more chronic for her).
LAD: No cervical axillary LAD detected. Inguinal LAD deferred.
NEURO: AAOx3, no evidence of encepthalopathy or meningeal signs,
patient had decreased bilateral hand grasp apparently secondary
to pain and weakness. [**3-5**] bilateral biceps strength. Full
extensive neuro exam to be performed tomorrow.
MSK: Patient without noted overt effusions or erythema of her
joints. Her wrists and fingers [**Last Name (un) **] most affected and tender
with some ROM exercises.
Pertinent Results:
[**2174-9-5**] 06:28AM BLOOD WBC-16.8* RBC-3.82* Hgb-10.6*# Hct-28.6*
MCV-75* MCH-27.7 MCHC-37.1* RDW-16.3* Plt Ct-32*
[**2174-9-5**] 06:28AM BLOOD Neuts-66 Bands-1 Lymphs-28 Monos-3 Eos-2
Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-3*
[**2174-9-5**] 06:28AM BLOOD Hypochr-NORMAL Anisocy-1+
Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL
[**2174-9-5**] 06:28AM BLOOD PT-26.2* PTT-140.8* INR(PT)-2.6*
[**2174-9-5**] 06:28AM BLOOD Fibrino-300
[**2174-9-5**] 06:28AM BLOOD Heparin-PND
[**2174-9-2**] 03:22PM BLOOD ACA IgG-PND ACA IgM-PND
[**2174-9-2**] 03:22PM BLOOD Lupus-PND AT III-PND ProtCFn-PND
ProtSFn-PND
[**2174-9-1**] 03:26PM BLOOD ACA IgG-5.2 ACA IgM-27.2*
[**2174-9-5**] 07:10AM BLOOD Glucose-96 UreaN-90* Creat-5.8*# Na-128*
K-4.3 Cl-88* HCO3-15* AnGap-29*
[**2174-9-5**] 07:10AM BLOOD ALT-2237* AST-[**Numeric Identifier 32410**]* LD(LDH)-[**Numeric Identifier 32411**]*
AlkPhos-685* TotBili-4.0*
[**2174-9-4**] 05:45AM BLOOD ALT-505* AST-1752* LD(LDH)-5375*
CK(CPK)-1625* AlkPhos-343* TotBili-4.1* DirBili-2.7* IndBili-1.4
[**2174-9-5**] 07:10AM BLOOD Albumin-1.5* Calcium-6.9* Phos-9.4*
Mg-2.0 UricAcd-12.0*
[**2174-9-3**] 05:01AM BLOOD Hapto-395*
[**2174-9-1**] 03:01PM BLOOD TSH-1.2
[**2174-9-2**] 05:55AM BLOOD Cortsol-73.0*
[**2174-9-2**] 02:15AM BLOOD Cortsol-44.2*
[**2174-9-2**] 12:42AM BLOOD Cortsol-39.0*
[**2174-9-1**] 03:01PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM
HBc-NEGATIVE
[**2174-8-30**] 07:55PM BLOOD HCG-<5
[**2174-9-1**] 03:01PM BLOOD CRP-GREATER TH
[**2174-9-4**] 05:45AM BLOOD IgM-41
[**2174-9-1**] 06:56PM BLOOD PEP-AWAITING F IgG-595* IgA-124 IgM-59
IFE-PND
[**2174-9-4**] 05:45AM BLOOD C3-PND C4-PND
[**2174-9-1**] 03:01PM BLOOD C3-63* C4-2*
[**2174-9-1**] 02:55PM BLOOD HIV Ab-NEGATIVE
[**2174-9-1**] 03:01PM BLOOD HCV Ab-NEGATIVE
[**2174-9-5**] 06:37AM BLOOD Type-ART pO2-94 pCO2-28* pH-7.33*
calTCO2-15* Base XS--9
[**2174-9-5**] 06:37AM BLOOD Lactate-6.8*
[**2174-9-5**] 08:01AM BLOOD freeCa-0.92*
[**2174-9-4**] 02:14PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-PND
[**2174-9-4**] 02:14PM BLOOD B-GLUCAN-PND
[**2174-9-3**] 09:56PM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA,
IGM, IGG)-PND
[**2174-9-3**] 06:45AM BLOOD ADAMTS13 ACTIVITY AND INHIBITOR-PND
[**2174-9-2**] 11:07AM BLOOD PROTHROMBIN MUTATION ANALYSIS-PND
[**2174-9-2**] 05:55AM BLOOD Q-FEVER (COXIELLA BURNETTI) ANTIBODY-PND
[**2174-9-2**] 05:55AM BLOOD LEPTOSPIRA ANTIBODY-PND
[**2174-9-2**] 05:55AM BLOOD BRUCELLA ANTIBODY, IGG, IGM-PND
[**2174-9-2**] 05:55AM BLOOD STRONGYLOIDES ANTIBODY,IGG-PND
[**2174-9-1**] 06:56PM BLOOD HEPARIN DEPENDENT ANTIBODIES-PND
[**2174-9-1**] 03:01PM BLOOD PARVOVIRUS B19 ANTIBODIES (IGG &
IGM)-Test
[**2174-9-1**] 03:01PM BLOOD HERPES 6 DNA PCR, QUANTITATIVE-PND
Brief Hospital Course:
46 year-old female with fever, rash, arthralgias of unknown
origin with hospital course complicatedy by sepsis, respiratory
failure, and DIC.
1. DIC/sepsis/multisystem organ failure: Patient developed
fulminant DIC in setting of septic shock secondary to coag
negative Staph. Was also found to be weakly ACL IgM positive,
suggesting possible anti-phospholipid syndrome component.
Still's disease and HLH were also considered during admission,
and patient received skin biopsy and bone marrow biopsy during
admission. Patient during her hospital course received
meropenem and vancomycin empirically during admission, and was
maintained on levophed, vasopressin, and neosenephrine. She
also received multiple transfusions of cryoprecipitate, rAPC,
and heparin gtt during admission. Patient developed acute renal
failure and was on CVVH during admission. She was also found to
have a coagulopathy, thrombocytoepnia, and low fibrinogen
transfused with cryoglobulinemia and PRBCs.
2. Code status: As patient continued to deteriorate, multiple
family discussions resulted in decision to make patient CMO and
patient was extubated with pressors held. She died shortly
thereafter.
Medications on Admission:
MEDICATIONS (at home):
-Naproxen 500 mg PO Q12H
-Nicotine Patch 14 mg TD DAILY
-GlyBURIDE 2.5 mg PO DAILY
-Docusate Sodium 100 mg PO BID
-Acetaminophen 650 mg PO Q6H:PRN temp
-Milk of Magnesia 30 mL PO Q6H:PRN constipation
-Oxazepam 10 mg PO HS:PRN insomnia
.
MEDICATIONS (on transfer):
Vancomycin 1000 mg IV Q 12H
Sarna Lotion 1 Appl TP TID:PRN
Naproxen 500 mg PO Q12H
Doxycycline Hyclate 100 mg PO Q12H
Insulin SC (per Insulin Flowsheet)
Oxazepam 10 mg PO HS:PRN insomnia
Milk of Magnesia 30 mL PO Q6H:PRN constipation
Acetaminophen 650 mg PO Q6H:PRN temp
Nicotine Patch 14 mg TD DAILY
GlyBURIDE 2.5 mg PO DAILY
Docusate Sodium 100 mg PO BID
Discharge Medications:
Patient died
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient died
Discharge Condition:
Patient died
Discharge Instructions:
Patient died
Followup Instructions:
Patient died
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2174-9-5**]
ICD9 Codes: 5849, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1011
} | Medical Text: Admission Date: [**2126-9-23**] Discharge Date: [**2126-9-24**]
Date of Birth: [**2072-11-14**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 53-year-old man with a
history of metastatic melanoma to the brain and lungs who
came into the hospital for a bronchoscopy given new onset of
respiratory distress. He was found to have a 60% stenosis of
his trachea and a complete occlusion of his right main stem
bronchus from two separate mass lesions. He did poorly after
bronchoscopy although he was initially extubated and required
reintubation for hypoxia. He then became hypotensive
requiring pressors. He was admitted to the unit and
monitored but had no improvement whatsoever over the course
of the day. Rather, his blood pressure continued to require
more and more support. His family arrived at his bedside and
after his pressors ran out they were not renewed. The
patient passed away shortly thereafter on the evening of
admission.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Name8 (MD) 1552**]
MEDQUIST36
D: [**2126-11-1**] 10:43
T: [**2126-11-4**] 21:40
JOB#: [**Job Number 31635**]
ICD9 Codes: 5185, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1012
} | Medical Text: Admission Date: [**2105-7-27**] Discharge Date: [**2105-7-28**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Central Venous line (Right IJ)
Arterial line (Left)
History of Present Illness:
Mr. [**Known lastname **] is a [**Age over 90 **] year old male with a history of atrial
fibrillation, systolic heart failure, chronic kidney disease who
presents from NH with altered mental status. Per report, pt was
noted by staff at NH yesterday to be difficult to arouse and
having labored breathing. His vitals at the time included BP
112/57, and O2 sats and temperature were not obtainable due
likely to hypothermia. He was sent to the [**Hospital1 18**] ED for further
revaluation. Of note, per his daughter, he was recently
hospitalized ([**2015-7-16**]) from [**Hospital3 **] Hospital with congestive
heart failure. During this hospitalization he was noted to have
deteriorating mental status and delirium, which is why he had
been discharged to NH.
In the ED, VS T 92.1 axillary, BP 100/50, HR 50, RR 21 88% 6L
initially then placed 99% NRB. He received vancomycin,
ceftriaxone, and flagyl for aspiration pneumonia. Also received
vitamin K IV 10 mg for coagulopathy with INR to 7.2. With CT
head negative for acute intracranial process. Also received 1 L
IVF total in ED.
On arrival to MICU, he was noteedd to be bradycardic to HRs to
30s and hypotensive to SBP 80s with MAPS 50s. He was given 1 mg
atropine with HR to 50s. He was given 500 cc fluid bolus x 2
and SBP came up to 90s.
Past Medical History:
Systolic Heart Failure with EF 30%
Hypertension
Atrial Fibrillation
Hypothyrodism
Chronic kidney disease, stage III
Dysphagia
Dementia?
Social History:
Currently lives in a nursing home. Has a daughter and son.
[**Name (NI) 3003**] to being in the nursing home, he lived with his daugther.
Family History:
NC
Physical Exam:
VS: HR 46 96/49 RR 18 100% NRB
GEN: On NRB, difficult to arouse, non-verbal, opens eyes to
painful stimuli, unable to follow commands
HEENT: AT, NC, EOMI, no conjuctival injection, anicteric, MM
dry, right pupil reactive 3 to 2 mm, left pupil unreactive
CV: Irreg irreg, nl s1 s2
PULM: Diffuse crackles anteriorly
ABD: soft, mild distension, + BS, no HSM
EXT: cool, b/l lateral malleolus venous stasis ulcers
NEURO: Unable to assess due to mental status
Pertinent Results:
[**2105-7-26**] 10:40PM BLOOD WBC-4.8 RBC-3.30* Hgb-10.5* Hct-32.1*
MCV-98 MCH-32.0 MCHC-32.8 RDW-17.6* Plt Ct-124*
[**2105-7-27**] 05:10PM BLOOD WBC-5.9 RBC-3.06* Hgb-10.0* Hct-30.5*
MCV-100* MCH-32.7* MCHC-32.8 RDW-17.2* Plt Ct-100*
[**2105-7-26**] 10:40PM BLOOD Neuts-85.0* Bands-0 Lymphs-9.2* Monos-4.7
Eos-0.6 Baso-0.5
[**2105-7-26**] 10:40PM BLOOD PT-60.4* PTT-67.9* INR(PT)-7.2*
[**2105-7-27**] 04:49AM BLOOD Fibrino-405* D-Dimer-686*
[**2105-7-26**] 10:40PM BLOOD Glucose-61* UreaN-50* Creat-2.0* Na-137
K-4.8 Cl-100 HCO3-27 AnGap-15
[**2105-7-26**] 10:40PM BLOOD ALT-23 AST-40 CK(CPK)-175* AlkPhos-164*
TotBili-0.8
[**2105-7-26**] 10:40PM BLOOD CK-MB-17* MB Indx-9.7* cTropnT-0.12*
proBNP-5749*
[**2105-7-27**] 03:32AM BLOOD Albumin-2.8* Calcium-7.5* Phos-4.1 Mg-1.9
[**2105-7-27**] 03:32AM BLOOD TSH-20*
[**2105-7-27**] 04:55PM BLOOD T4-5.9 calcTBG-0.82 TUptake-1.22
T4Index-7.2
[**2105-7-26**] 11:01PM BLOOD Lactate-1.4
Relevant Imaging:
CT Head
FINDINGS: There is no intra- or extra-axial hemorrhage, mass
effect, or shift of normally midline structures. Extensive
bilateral periventricular as well as subcortical white matter
hypoattenuation related to chronic
microangiopathic ischemic changes is evident.
The ventricles and sulci are moderately prominent, appropriate
for age-
associated involutionary changes. Bilateral basal ganglia
calcification and extensive calcification along the tentorium
and falx cerebri are evident. The osseous and soft tissue
structures are unremarkable. A nonspecific focus of hyperdense
focus is noted in the left pre-zygomatic soft tissue. Clinical
correlation is advised.
IMPRESSION: No acute intracranial process. A small hyperdense
focus in the
left pre-zygomatic soft tissue could represent calcification and
clinical correlation is advised.
ECHO
The left atrium is moderately dilated. The right atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with severe hypokinesis of the
basal half of the inferior and inferolateral walls. The
remaining segments contract normally (LVEF = 40 %). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is dilated at the sinus level. The descending
thoracic aorta is mildly dilated. The aortic valve leaflets are
severely thickened/deformed. Significant aortic stenosis is
present (not quantified). No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction c/w CAD. Aortic stenosis. Dilated
ascending aorta.
If clinically indicated, a follow-up study to assess aortic
stenosis is suggested when the patient can be transported to the
Echo laboratory.
Brief Hospital Course:
[**Age over 90 **] year old male with a history of systolic congestive heart
failure, atrial fibrillation, who presented with hypoxia,
hypotension, and hypothermia.
Upon admission to the MICU, agressive therapy was initiated
keeping a broad differential diagnosis. Patient however
continued to deteriorate and abruptly became profoundly
bradycardic, unresponsive to atropine or increasing doses of
pressors, culminating in asystole; patient was pronounced dead
at 1:05am on [**2105-7-28**]. Below are the details leading to these
events, arranged by problem:
1)Hypotension / Hypothermia: On initial presentation on the
floor SBP 80s, given 500cc fluid bolus x 2 with SBP to 90s.
Meets SIRS criteria with hypothermia and tachpnea and
hypotension concerning for sepsis, with pneumonia as the most
likely source. Also on differential was hypovolemic hypotension
for occult blood loss, cardiogenic shock, adrenal insuffiency
and myxedema coma. Cooling blanket placed on patient upon
arrival.
Patient was given fluid boluses and central access was obtained.
Echocardiogram was obtained and revealed mildly depressed
ejection fraction (40%) with inferolateral wall hypokinesis and
moderate tricuspid regurgitation. Central venous pressure was
measured and found to be elvated to 24mmHg, which even in the
setting of TR was felt to rule out hypovolemia. Patient was
initiated on Dopamine in hopes of supporting both blood pressure
and heart rate. Arterial line was placed for accurate assessment
of arterial pressure. Hematocrit remained stable and pressure
responded to pressor support.
Patient started on stress dose steroids for possible adrenal
insufficiency.
2)Hypoxia: With bilateral infiltrates and likely superimposed
fluid overlaod. Given recent hospitalization and extent of O2
requirement, high suspicion for Hospital Acquired Pneumonia
(HAP) with vancomycin and zosyn. This was later changed to
Vancomycin and Cefepime. Patients blood gas was concerning for
hypercarbia, and after re-discussing goals of care with family
and confirming patient did not want to be intubated, non
invasive ventillation was initiated. Patient tolerated NIPPV
well and hypoxia / hypercarbia / respiratory acidosis improved
until his sudden decompensation.
3)Bradycardia: With baseline bradycardia per history, unclear
etiology. On arrival to MICU, bradycardic to HR in 30s, gave 1
mg atropine with HR to 50s. All nodal agents were stopped and
heart rate improved with Dopamine administration.
4)Meningitis: Given patients poor baseline mental status and
findings of significant nuchal rigidity, concern for meningitis
was raised. Given patients decompensated status, lumbar puncture
was not pursued and empiric coverage with Ampicillin for
listeria, Vancomycin/Cefepime for Staph/Strep were initiated.
5)Hypothyroidism: TSH of 20, difficult to interpret in this
setting as sick euthyroid may have impacted laboratory results.
Given decompensated state, endocrine consult was placed and
thyroid hormone was supplemented intravenously at higher doses
than per outpatient regimen. Free T3, T4 and Thyroid binding
protein were ordered but were not available before patient
decompensated. Per endocrine team recommendations, T3 was not
given due to concerns for arrythmia and cardiac side effects,
and given very poor level of evidence for its efficacy.
6)Coagulopathy: INR 7.2 on admission in setting of
anticoagulation. Given vitamin K and FFP. DIC labs negative.
7)Chronic kidney disease: With known baseline CKD stage III,
likely exacerbated in the setting of hypotension.
Medications on Admission:
Acetaminophen 325 mg PRN
[**Doctor Last Name **] Milk of Magnesia PRN
Dulcolax 10 mg Rectal Suppository PRN
Fleet Enema PRN
Albuterol INH PRN
Coumadin 2.5 mg DAILY
Flomax 0.4 mg DAILY
Ferrous Sulfate 325 mg DAILY
Levothyroxine 125 mcg DAILY
Lasix 20 mg DAILY
Lisinopril 2.5 mg DAILY
Magnesium Oxide 400 mg DAILY
Calcium 500 with Vitamin D DAILY
Proscar 5 mg DAILY
Ranitidine 150 mg DAILY
Zyprexa 2.5 mg [**Hospital1 **]
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired
Followup Instructions:
Patient expired
ICD9 Codes: 0389, 5070, 4280, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1013
} | Medical Text: Admission Date: [**2146-1-4**] Discharge Date:
Date of Birth: [**2076-12-7**] Sex: M
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is a 68-year-old
male with substernal chest pain, status post cardiac
catheterization two years prior. He has positive stress teat
and cardiac catheterization at an outside hospital revealed a
50% to 55% stenosis of his left main and 80% of the LAD. The
patient was transferred to the [**Hospital1 188**] for further management.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Coronary artery disease.
3. Status post salivary gland removal in [**2121**].
MEDICATIONS:
1. Atenolol 25 once a day.
2. Aspirin 325 once a day.
3. Lipitor 10 once a day.
ALLERGIES: The patient is allergic to SULFA DRUGS.
SOCIAL HISTORY: No cigarette smoking, no ethanol abuse.
After review of films, it was determined that the right RCA
also had 60% occlusion and his ER 60% by echocardiogram. He
had preserved EF.
HOSPITAL COURSE: He was taken to the operating room on
[**2146-1-5**] with the diagnosis of coronary artery disease. He
had a CABG times four done by Dr. [**Last Name (STitle) 70**].
Postoperatively, the patient was transferred to the
Cardiothoracic Intensive Care Unit, where he was extubated
and transferred to the floor on postoperative day #1. The
patient required some Neodrips for pressor support. He was
not transferred to the floor until the evening of [**2146-1-7**],
after being weaned.
Postoperatively, the patient was doing well. Foley catheter
was discontinued. Wires were discontinued. Chest tube was
discontinued. However, the patient pulled the wires,
suffered some atrial fibrillation. The patient was given
Lopressor and Amiodarone. A light rash was noted and the
patient's physical examination remained benign. This was
discussed and some Benadryl was started.
On [**2146-1-9**] it was noted that the patient's rash seemed
stable. He remained in atrial fibrillation. Amiodarone was
given, Magnesium, otherwise, he was at no time
hemodynamically unstable. The Gram stain of his sputum
showed 3 to 4 gram negative rods, which eventually grew out
Serratia. The patient was noted on postoperative day #5,
[**2146-1-10**] to have a white count of 29.7, remained in atrial
fibrillation with a blood pressure, which was relatively low
at 86/50 nonsymptomatic. He was transferred to the Intensive
Care Unit for pressor support, if required while being given
Lopressor.
The Department of Dermatology was called and they stated that
we should discontinue any unnecessary medications and start
topical creams and ointments as well as Zyrtec every night
and topical steroids such as Lidex, which was done.
On [**2146-1-11**] the patient remained on Ancef, Amiodarone,
Lopressor and Heparin for anticoagulation. The patient was
doing relatively well. The rest of his Intensive Care Unit
stay was uneventful. He maintained his pressure without the
requirement for Neomycin. He was started on Augmentin on
[**2146-1-12**]. He was transferred to the back to the floor
without incident.
The Department of Infectious Disease was called that same day
because the patient's white count had now gone to 32.
Infectious Disease recommended blood cultures and urine
cultures. They recommended us discontinuing Augmentin, which
was done and they felt that the reaction was allergic to a
medication he had received, which was consistent with the
eosinophilia seen on the peripheral differential. This was
done and a C.difficile culture was also sent because it was
felt that the C. difficile could also cause white counts to
be high. The C. difficile specimen returned negative.
The patient's wound, throughout all these events, remained
stable with no discharge. The patient was ambulating very
well to level 5 in the hospital mainly because of his rash.
It was noted that he had fluid on his foot and arms, which
were noninfected looking and left alone for the time being on
[**2146-1-14**].
Final discharge summary to follow. Another addendum will be
inserted regarding the final disposition and the discharge
medications.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-358
Dictated By:[**Name8 (MD) 16758**]
MEDQUIST36
D: [**2146-1-14**] 13:18
T: [**2146-1-14**] 13:29
JOB#: [**Job Number 38473**]
ICD9 Codes: 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1014
} | Medical Text: Admission Date: [**2123-8-31**] Discharge Date: [**2123-9-6**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1171**]
Chief Complaint:
Chest pain and shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a 97-yo Russian-speaking man w/ h/o CAD s/p BMS
[**11/2122**] and angioplasty [**5-/2123**], CHF (EF 40%), HTN, h/o GI
bleeding and colon Ca, who presented to the ED for evaluation of
chest pain. CP consistently 4-5x/day both with exertion and at
rest, always responding to SL NTG. Pt saw his cardiologist on
the day PTA, at which point the decision was made to pursue
optimization of medical management rather than interventions.
However, on the morning of admission, the pt developed more
severe chest pain with radiation to the left shoulder, assoc w/
SOB and diaphoresis, non-responsive to SL NTG, so he came to the
ED for evaluation. In the ED - VS Temp 97.8F, HR 100, BP 85/53,
R 18, O2-sat 100. Hct 20 (baseline 28), with Guaiac + brown
stool. The pt reported dark stools x3 months, and has never been
scoped [**2-13**] cardiac risk factors. The pt was started on PRBCs for
transfusion, but he developed chest pain and diaphoresis, so the
transfusions were stopped for concern for a transfusion
reaction. Per the blood bank there was no evidence of a
transfusion reaction. The pt was seen by Cardiology, who wanted
to continue ASA / Plavix but not start heparin gtt. Upon
transfer to the floor, the pt triggered for HR 130s and RR >30.
He had 2/10 chest pain with ECG showing worsening ST depressions
precordially, which resolved with Nitro gtt and Lopressor. He
then received an additional 2units PRBCs + Lasix.
.
At 1230 am pt noted by nursing to have BP 50's/30's on automatic
cuff, mentating well, asymptomatic. Of note he had been given
lasix 20mg IV x1 at 8pm when he was noted to be tachypnic to
30's, O2 sat 93-94% on 3-4L, diffuse crackles and expiratory
wheezing with chest xray per the radiology resident showing
worsened pulmonary edema compared with admission. He responded
well to lasix with resolution of respiratory distress and put
out 600+ ml of urine with blood pressures 110-120. At 8pm he
was given amlodipine 2.5mg. At 11pm he was given metoprolol
37.5mg and terazosin 1mg. At 12:30 he was noted to be
hypotensive as above on bp check. Recheck with manual cuff with
blood pressure of 70's/40's, HR 70-73, RR 18, 97% on 2L NC. He
was given 500ml NS with improvement of SBP to 76. At that time
he had completed his second unit PRBC and his third unit was
started. Of note he had a large melanotic stool in the early
evening. After observing for 30-40 minutes blood pressure
remained in the low 70's systolic so he was given an additional
250ml NS. He remained asymptomatic throughout. EKG showed
improvement in precordial ST segment depressions compared with
admission.
Past Medical History:
--Coronary Artery Disease - s/p BMS to OM2, D1, LCX ([**2122-11-16**])
for unstable angina with TWI in V2-V4
- NSTEMI s/p cardiac cath and balloon angioplasty on [**2123-5-24**]
--CHF, systolic EF 40% and [**Date Range 7216**] dysfunction with sever LVH
--Valvular disease - moderate aortic stenosis, mild to moderate
aortic and mitral regurgitation, ?bicuspid congenital valves
--HTN
--COPD
--Gout
--DJD - bilateral knee pain
--h/o chronic pyelonephritis
--s/p bladder stone removal
--Colon cancer
Social History:
Social history is significant for occasional cigarrettes
socially 20 years ago. He drinks about 1 glass of wine or
alcoholic drink /week. He is from [**Country 532**] and worked as a
general surgeon in [**Location (un) 4551**]. He retired at age 63 due to his hand
tremor. He has been widowed for 8 years and lives alone in
[**Location (un) **]. He has children in the area who are helpful. The pt
lives alone in [**Location (un) **] with an aid who comes to clean the apt
and bathe him. His son lives nearby. He is a retired general
surgeon.
.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
.
Physical Exam:
VS - Temp F, BP 85/53, HR 72, R 25, O2-sat 99% 2L
GENERAL - elderly man in NAD, comfortable, interactive
HEENT - PERRL, EOMI, sclerae anicteric, MMM
NECK - supple
LUNGS - CTA bilat, no r/rh/wh
HEART - RRR, nl S1-S2, no MRG
ABDOMEN - +BS, soft/NT/ND, no HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
Pertinent Results:
[**2123-8-31**] 09:30AM BLOOD WBC-5.7 RBC-2.77*# Hgb-5.9*# Hct-20.0*#
MCV-72*# MCH-21.4*# MCHC-29.6* RDW-18.6* Plt Ct-236
[**2123-8-31**] 04:05PM BLOOD WBC-8.0 RBC-3.13* Hgb-6.6* Hct-23.8*
MCV-76* MCH-21.0* MCHC-27.6* RDW-17.6* Plt Ct-250
[**2123-9-1**] 03:16AM BLOOD WBC-8.1 RBC-3.71* Hgb-8.9*# Hct-29.3*
MCV-79* MCH-23.9*# MCHC-30.2* RDW-17.1* Plt Ct-194
[**2123-8-31**] 09:30AM BLOOD Neuts-73.8* Lymphs-19.4 Monos-3.7 Eos-2.8
Baso-0.4
[**2123-9-1**] 03:16AM BLOOD PT-14.3* PTT-28.6 INR(PT)-1.2*
[**2123-9-1**] 03:16AM BLOOD Glucose-108* UreaN-42* Creat-1.3* Na-145
K-4.2 Cl-110* HCO3-26 AnGap-13
[**2123-9-1**] 03:16AM BLOOD ALT-12 AST-21 LD(LDH)-165 CK(CPK)-84
AlkPhos-87 TotBili-0.8
[**2123-8-31**] 09:30AM BLOOD cTropnT-0.03*
[**2123-8-31**] 04:05PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2123-8-31**] 11:24PM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2123-9-1**] 03:16AM BLOOD CK-MB-NotDone cTropnT-0.13*
Labs on Discharge:
[**2123-9-6**] 05:30AM BLOOD WBC-6.7 RBC-4.33* Hgb-10.9* Hct-34.5*
MCV-80* MCH-25.0* MCHC-31.4 RDW-18.8* Plt Ct-207
[**2123-9-6**] 05:30AM BLOOD Glucose-141* UreaN-43* Creat-1.1 Na-143
K-4.6 Cl-107 HCO3-29 AnGap-12
[**2123-9-6**] 05:30AM BLOOD CK(CPK)-35*
[**2123-9-6**] 05:30AM BLOOD CK-MB-NotDone cTropnT-0.19*
[**2123-8-31**] Chest Xray:Mild pulmonary edema has worsened, small
right pleural effusion and mild-to-moderate cardiomegaly stable.
No pneumothorax. No free subdiaphragmatic gas.
[**2123-9-3**] ECHO:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 0-10mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is top
normal/borderline dilated. No masses or thrombi are seen in the
left ventricle. Overall left ventricular systolic function is
mildly depressed (LVEF= 40-45 %) with infero-lateral
hypokinesis. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. Right ventricular chamber size is
normal. with mild global free wall hypokinesis. The aortic root
is mildly dilated at the sinus level. The aortic valve leaflets
are severely thickened/deformed. There is moderate aortic valve
stenosis (area 1.0-1.2cm2). Mild (1+) aortic regurgitation is
seen. The aortic regurgitation jet is eccentric. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Brief Hospital Course:
Mr. [**Known lastname 95893**] is a [**Age over 90 **] yo M with PMH of severe CAD s/p multiple
prior PCI, moderate aortic stenosis, daily angina, anemia due to
chronic GI blood loss admitted with NSTEMI and hematocrit of 21.
.
1) NSTEMI/severe CAD- He has significant CAD hx s/p numerous
percutaneous interventions and stenting previously. He
presented with chest pain, worsening ECG findings with marked
precordial ST segment depressions and uptrending cardiac
enzymes. He was initially started on a nitroglycerin gtt and
was transferred to the floor with persistant chest pain. He was
given metoprolol 5mg IV x1 which resolved his hypertension,
tachycardia and chest pain. His hematocrit was noted to be 21
which was the likely causing factor of his worsening symptoms.
Given the severity of his symptoms and his multiple prior PCI he
was continued on his aspirin and plavix despite his GI blood
loss. Heparin was not started given the significant risk of
worsening his blood loss. Otherwise he was continued on maximal
medical management of his NSTEMI/CAD including ASA, plavis,
atorvastatin, metoprolol xl, isosorbide mononitrate. He is not
at this time considered to be candidate for additional PCI and
stenting. He will follow up with his outpatient cardiologist,
Dr. [**Last Name (STitle) 171**].
2)Anemia/GI bleeding - Pt has h/o colon Ca and melanotic stools
x1 on the day of admission. He has not had colonoscopy or
endoscopy due to his tenuous cardiac status but he has had
melena in the past making an upper GI source the likely cause of
his continued blood loss. He was transfused 4 units in the
first 24 hours of admission and a fifth unit on the day prior to
discharge. He did not have any additional melena and his
hematocrit remained generally stable, at 34 on the day of
discharge. He was initially treated with IV PPI [**Hospital1 **] and was
changed to po prior to discharge. He was followed by the GI
service who felt that the risks of Colonoscopy/EGD were much
higher than the benefits that he would receive from the
procedures. He was continued on aspirin and plavix despite the
bleeding given his cardiac status. He will follow up with
gastroenterology as an outpatient.
3) Hypotension - On admission patient was normotensive to
hypotensive despite gastrointestinal bleeding. During the
initial night his blood pressure dropped to a systolic in 70's
likely due to multiple etiologies including cardiac ischemia,
gastrointestinal bleeding and antihypertensive medications. In
addition he received lasix prior to the episode for dyspnea and
worsening pulmonary edema seen on CXR following transfusion. He
was transferred to the MICU for closer monitoring and care of
his hypotension. On arrival to the MICU the pt's SBP was in the
mid 80s and improving. He was given gently IV fluids and his
blood transfusion were continued to total of 4 units. He
remained asymptomatic throughout his hypotension with
improvement of EKG changes compared with admission EKG. His
antihypertensive medications were restarted slowly and he was
back on his full regimen prior to discharge with no recurrance
of hypotension or melena.
4) Acute on Chronic Systolic heart failure- mild to moderate
regional left ventricular systolic dysfunction with inferior
akinesis and inferior septal/inferior lateral [**Last Name (LF) 95894**], [**First Name3 (LF) **]
40%. Known modearte-to-severe aortic valve stenosis (area
0.9cm2) and left ventricular hypertrophy. He had repeat
echocardiogram which did not show any significant changes. He
did have intermittent periods of dyspnea which were thought most
likely to be due to intermittent flash pulmonary edema that
seemed to be provoked by pain or anxiety and responded to low
dose morphine 0.25mg x1 or NTG. In addition, when hypertensive
these episodes responded quickly to metoprolol 5mg IV x1. He
was not diuresed given poor oral intake during his admission and
hypotension on admission following lasix administration for
dyspnea.
5) AF with RVR - he remained in sinus rhythm during the majority
of his hospital stay but did have period of afib with RVR with
HR 110s while he was in the ICU. At that time his metoprolol
was at a lower dose of 12.5mg [**Hospital1 **]. His Metoprolol dose was
increased to back to 37.5mg [**Hospital1 **] and he did not have any
recurrance of Afib.
6) Bladder Spasm, penile pain - patient had episodes of severe
bladder spasm and pain for which he was evaluated by urology.
There was not evidence of urinary retention however foley
placement was difficulty due to his BPH. In addition, he had
[**7-22**] penile pain following foley placement which improved with
removing foley and morphine 0.25mg IV. In speaking with urology
there was not evidence of obstruction or retention. There was
no growth on urine culture however he was treated with bactrim
for 3 day course given that he had pyuria and bladder spasm.
7) Gout - cont home allopurinol. held colchicine
8) Hyperlipidemia - cont home statin
9) FEN - regular diet
10) FULL CODE, confirmed with pt and son
11) Communication - Son [**Name (NI) 12584**] primary contact: (H)
[**Telephone/Fax (1) 95895**], (W) [**Telephone/Fax (1) 95896**].
Daughter [**Name (NI) **]: [**Telephone/Fax (1) 95897**]
Medications on Admission:
allopurinol 300mg PO daily
ASA 325mg daily
amlodipine 2.5mg daily
atorvastatin 80mg daily
plavix 75mg daily
colace 100mg [**Hospital1 **]
colchicine .6mg [**Hospital1 **] prn
imdur 60mg daily
metoprolol succinate 37.5 mg [**Hospital1 **]
NTG 0.3 SL
pantoprazole 40mg [**Hospital1 **]
Polysaccharide Iron suppliment 150mg daily
terazosin 1mg qhs
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb
Inhalation Q6H (every 6 hours).
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day): last day of treatment is [**2123-9-7**].
9. Polysaccharide Iron Complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
13. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) Neb Inhalation every four (4) hours as needed for SOB.
14. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tab
Sublingual as directed as needed for chest pain: please take for
your chest pain, you may take every five minutes for up to three
pills. Please be cautious with this as it can cause low blood
pressure.
15. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for Acute Gout.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1643**] Center
Discharge Diagnosis:
Severe Anemia likely due to gastrointestinal bleeding
Coronary Artery disease
Unstable Angina
NSTEMI
Chronic Systolic and [**Hospital6 7216**] heart failure, EF 40%, severe LVH
Moderate-severe AS (area 0.8-1.0cm2 in [**2123-3-17**])
COPD
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital because you were having severe
chest pain. You were found to have a low blood count of 21
which was likely the cause of your worsened chest pain. You
were transfused a total of 5 units PRBC during your hospital
stay. You were seen by the gastroenterologists who think that
you are losing blood in your GI tract. You did not have a
colonoscopy or endoscopy because of the severity of your heart
disease. At this time the gastroenterologists felt that it
would be risky to do either of these procedures. You will
likely continue to require occasional blood transfusions to
treat the blood loss becausing having a low blood count will
cause you to have more chest pain. You were discharged to rehab
to help work on your strength.
Medications:
1)You were changed to Flomax to treat your prostatic
hypertrophy. This is a better medication given your other
medical conditions. Please stop taking your terazosin.
2) Your dose of allopurinol was reduced to be more appropriate
for your age and kidney function.
3)
None of your other medications were changed.
Please follow up as below.
Please call your doctor or return to the hospital if you
experience any concerning symptoms including chest pain that is
wore or different than your usual angina, light headedness,
fainting, low blood pressure, difficulty breathing, evidence of
blood loss or any other worrisome symptoms.
Followup Instructions:
1) Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2123-9-15**] 2:20
2) Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 4200**], M.D. Date/Time:[**2123-9-16**] 11:20
3) Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 13545**]
Date/Time:[**2123-9-23**] 11:00
Completed by:[**2123-9-7**]
ICD9 Codes: 5789, 4280, 4019, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1015
} | Medical Text: Admission Date: [**2179-10-26**] Discharge Date: [**2179-11-6**]
Date of Birth: [**2119-5-18**] Sex: M
Service: OMED
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old
male with history of metastatic [**Year (4 digits) 499**] cancer to the liver
with low back pain times four to five weeks with an acute
worsening of pain last night while sleeping. The patient
says he "rolled onto his side or something" and awoke in
severe pain. No history of recent fall. No bladder or bowel
incontinence. The patient states his pain is constant and
localizes to the bone and muscle; however, it is worse in the
bone. He localizes his pain to the L1 level. No fevers,
chills, weight loss, or diarrhea. The patient states his
appetite is good. He reports a mild cough with sore throat
and hoarseness for the past couple of days, but otherwise
review of systems is negative.
PAST MEDICAL HISTORY: Metastatic [**Year (4 digits) 499**] cancer to the liver-
possible candidate for trisegmentectomy with wedge resection
(referred to Dr. [**Last Name (STitle) **] secondary to rapidly progressing
liver metastasis despite recent chemotherapy.
Status post sigmoid colectomy with low anterior resection on
[**2178-9-23**] with one moderately differentiated and one poorly
differentiated lesion with 11 out of 12 lymph nodes positive,
status post adjuvant chemotherapy from [**11-9**] to [**6-10**]
consisting of 5-FU plus leucovorin. CEA on [**2179-9-27**] elevated
to 29, at which time a CT revealed new large liver
metastasis.
MEDICATIONS:
1. Tylenol p.r.n.
2. Vitamin B6 q.d.
ALLERGIES: ALEVE CAUSES URTICARIA.
FAMILY HISTORY: Sister with [**Name2 (NI) 499**] cancer. Father deceased
at 52 secondary to a CVA. Mother deceased at 92 secondary to
natural causes.
SOCIAL HISTORY: No tobacco or alcohol. The patient is
married with three sons. [**Name (NI) **] is a retired pipe fitter. He
denies IV drug use, blood transfusions, or hepatitis.
PHYSICAL EXAMINATION: Temperature 97.4 degrees, blood
pressure 138/88, heart rate 79, respiratory rate of 20, and
O2 saturation 97 percent on room air. General: The patient
is clearly in distress secondary to pain, unable to move in
the bed without complaints of pain. HEENT: Pupils are
equally round and reactive to light and accommodation.
Extraocular movements are intact. Sclerae is anicteric.
Neck: No lymphadenopathy. Cardiovascular: Regular rate and
rhythm. No murmurs, rubs, or gallops. Pulmonary: Clear to
auscultation bilaterally. Abdomen: Normoactive bowel
sounds, soft, nontender, nondistended; no masses or
hepatosplenomegaly. Extremities: No clubbing, cyanosis, or
edema. Neuro: Cranial nerves II through XII grossly intact,
moving legs bilaterally. No complaints of weakness. Intact
to vibration bilaterally. Back: Point tenderness over L1.
Rectal: Good rectal tone. Guaiac negative.
LABORATORY AND DIAGNOSTIC DATA: Admission white count 9.5
increased to 16.4 during this admission, hematocrit 44.2
decreased to 34.9 during this admission, platelets 265 with a
decrease to 85 over his hospital stay. Initial chem-7 within
normal limits. Increasing creatinine to 1.3 following
episode of hypotension. LFTs increased into the 1000s
following episode of hypotension. Troponin 0.16 following
episode of hypotension. Lactate of 8.0 during the course of
this admission. Hepatitis B surface antigen positive,
hepatitis B core antibody positive, hepatitis A virus
antibody positive, hepatitis C virus antibody negative.
MRI of the spine:
Metastatic involvement of T12 without pathologic compression
or deformity.
Moderate cervical spondylosis most notably at C5-C6 level;
also minor spondylosis at C4-C5 and C3-C4. Loss of signal
within the body of L1 with mild loss of height anteriorly and
perhaps slightly posteriorly. An epidural mass extending
posterior to L1 without compression of the cauda equina.
Mild disc narrowing at L3-L4 and L4-L5 without evidence of
canal stenosis or focal disc protrusion.
Gallbladder ultrasound from [**2179-10-30**]: No gallstones, no
common bile duct dilation, portal vein patent.
CT of the head from [**2179-10-30**]: No acute intracranial
hemorrhage, mass effect, or enhancing lesion. Small lacunar
infarct within right basal ganglia, likely remote.
Blood cultures from [**2179-10-30**] and [**2179-11-3**] are negative for
growth. Sputum culture from [**2179-10-31**] consistent with MSSA.
Urine culture from [**2179-10-30**] negative. Stool culture from
[**2179-10-30**] and [**2179-11-5**] negative for Clostridium difficile and
other cultures. GGT 130.
HOSPITAL COURSE: This is a 60-year-old male with history of
metastatic [**Month/Day/Year 499**] cancer to the liver presenting with acute
worsening of chronic low back pain with evidence of
metastatic spinal disease on admission MRI involving T12 and
L1.
Metastatic [**Month/Day/Year 499**] cancer: The patient is status post 5-FU and
leucovorin completed in [**6-10**], however, with rapid
development of liver metastases on CT diagnosed prior to
admission. He was prior in consideration for hepatic
resection due to his single site of metastasis. However, he
now presents with new bony metastasis. During the course of
his admission, Surgery was consulted and the patient was
staffed with Dr. [**Last Name (STitle) **], whom he was referred to in the past
for liver lesion resection. The decision was made that
resection is not appropriate at this time given the two sites
of metastatic disease. Thus, Radiation Oncology was
consulted with a plan to initiate palliative radiation for
pain control. The patient will likely also undergo further
chemotherapy as an outpatient. Due to ongoing pain,
difficult to control by p.o. medications, the patient's
palliative radiation was started in-house.
Pathologic vertebral body compression fracture: The patient
was started on MS Contin, which was titrated up to permit
adequate mobility. Neurosurgery was consulted regarding the
benefit of a potential brace. It was their opinion that a
brace will offer the patient little to no benefit. Due to
ongoing pain despite p.o. medication, the patient was
initiated on palliative radiation. However, this seemed to
acutely worsen his back pain and his MS Contin was gradually
titrated up. However, this was complicated by hypercarbic
respiratory failure due to likely narcotic overdose plus or
minus history of aspiration due to decreased mental status
and supine positioning necessary due to the patient's ongoing
back pain. In addition to narcotic analgesia, the patient
received a dose of IV pamidronate on [**2179-10-27**] and was managed
on Vioxx. He was ultimately discharged on rofecoxib,
OxyContin, and hydromorphone p.r.n.
Epidural mass at L1: On admission MRI, patient was noted to
have an epidural mass at the level of L1 vertebral body
without compression in the cauda equina. He received IV
steroids; however, these were discontinued the following day
due to the confirmation of no cord compression, and the
approval of Radiation Oncology for the absence of need for
steroids with the initiation of palliative radiotherapy.
Hypercarbic respiratory failure: The patient was noted to be
unresponsive and hypoxic with saturations in the 80s on
[**2180-10-30**]. ABG at that time was 7.18/58/79. Initial thought
for narcotic overdose as the underlying etiology, thus the
patient received one dose of Narcan with some improvement in
his oxygenation and respiration. However, he continued to be
poorly responsive and agitated with a drop in his blood
pressure following intubation, thus suspicious for sepsis
secondary to possible aspiration pneumonia in the setting of
narcotic analgesia and the patient's supine position, all
necessary for control of his back pain. The patient was
initially managed with vancomycin, cefepime, and Flagyl; and
continued on cefepime to complete a total of 10 days of
antibiotics following a sputum culture revealing MSSA. The
patient's narcotic analgesia was titrated down prior to
discharge. His O2 saturations had returned to 97 percent on
room air.
Sepsis: Following hypercarbic respiratory failure and
unresponsiveness, the patient was intubated, at which time
his systolic pressures dropped into the 70s. He responded
well to peripheral dopamine and IV fluids. A central line
was placed and he was continued on pressors for two days to
maintain his blood pressure while on broad-spectrum
antibiotics. His sputum culture grew out MSSA. His
antibiotics were narrowed to cefepime alone. His blood
pressures recovered and his lactate decreased from its
initial level of 8. However, the patient suffered shock
liver with elevation of his LFTs into the 1000s; acute renal
failure with bump of the creatinine to 1.3, which has
subsequently improved; in addition to cardiac-demand ischemia
and mild DIC. All these values have improved since his
initial insult. His blood cultures remain negative, stool
cultures negative including Clostridium difficile times two.
Thus likely, the patient's sepsis is secondary to aspiration
pneumonia.
Prophylaxis: Subcutaneous heparin, PPI, aspiration
precautions.
FEN: Patient maintained on the house diet.
Full code.
DISCHARGE DIAGNOSES: Metastatic [**Date Range 499**] cancer to liver and
vertebral body.
Pathologic compression fracture.
Aspiration pneumonia.
Sepsis.
Disseminated intravascular coagulation.
Shock liver.
Acute renal failure secondary to acute tubular
necrosis/hypotension.
DISCHARGE CONDITION: Good. Pain controlled. Saturating
well on room air.
DISCHARGE STATUS: The patient is to be discharged to home
with services.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o. q.d.
2. Colace 100 mg p.o. b.i.d.
3. Senna 8.6 mg 2 tablets p.o. b.i.d. p.r.n. constipation.
4. Rofecoxib 12.5 mg p.o. q.d.
5. Oxycodone SR 20 mg p.o. q.12 h.
6. Calcium carbonate 500 mg p.o. t.i.d.
7. Hydromorphone 1 to 2 mg p.o. q.3 h. p.r.n. pain.
8. Levofloxacin 500 mg p.o. q.d. x3 days.
FOLLOW UP: The patient is to follow up with Dr. [**Last Name (STitle) 150**]
for continued care.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 150**], [**MD Number(1) 32196**]
Dictated By:[**Last Name (NamePattern1) 19957**]
MEDQUIST36
D: [**2180-6-19**] 19:13:25
T: [**2180-6-20**] 02:25:43
Job#: [**Job Number 44447**]
ICD9 Codes: 5070, 0389, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1016
} | Medical Text: Admission Date: [**2144-8-11**] Discharge Date: [**2144-8-26**]
Service: MICU
HISTORY OF PRESENT ILLNESS: This is an 85 [**Hospital **] nursing
home resident with a history of cerebrovascular accident,
coronary artery disease, status post coronary artery bypass
graft who presents with shortness of breath and respiratory
distress. The patient has been a nursing home resident for
two years, is wheel chair bound times eight months prior to
admission according to his son, had a fever and shortness of
breath earlier the week prior to admission. The patient was
started on Levofloxacin on [**8-7**] at the nursing home
and Flagyl was also added. The morning prior to admission
the patient was noted to have increased respiratory distress,
diaphoretic, complaining of shortness of breath. This was
the morning of [**2144-8-11**]. The patient's O2 sats in
the Emergency Room were found to be in the low 70s on 4
liters nasal cannula. The patient was felt to be in severe
respiratory distress and was intubated emergently in the
Emergency Room. According to the physician, [**Name10 (NameIs) **] patient was
alert prior to intubation.
Subsequently after intubation the patient's blood pressure
decreased and the patient was started on Dopamine and his
heart rate increased into the 150s. The pressures were
changed to Neosinephrine with significant decrease in blood
pressure without any excessive tachycardia associated with
it. The patient was given Vanco, Ceftriaxone, Flagyl in the
Emergency Room. An nasogastric lavage was performed in the
Emergency Room, which was significant for coffee ground,
which were OB positive. The patient was also grossly OB
positive from below.
The patient was transferred to the MICU sedated, intubated
with a left groin catheter.
PAST MEDICAL HISTORY: 1. History of cerebrovascular
accident in [**2141-8-1**] with associated left sided
weakness. 2. Dementia. 3. Coronary artery disease status
post four vessel coronary artery bypass graft in [**2136**]. 4.
Diabetes mellitus type 2. 5. Peptic ulcer disease. 6.
Atypical psychosis. 7. Prostate cancer. 8.
Hypercholesterolemia. 9. Mild congestive heart failure with
an EF between 40 and 50% and an echocardiogram in 9/98
showing left ventricular hypertrophy and moderate aortic
stenosis, moderate mitral regurgitation with global decrease
in contractility. 9. Aortic insufficiency status post AVR.
MEDICATIONS ON ADMISSION: 1. Cardura 4 mg q.o.d. 2.
Glipizide 5 mg q day. 3. Lipitor 10 mg q.d. 4. Norvasc 5
mg q.d. 5. Prevacid 15 mg q day. 6. Dulcolax 5 mg b.i.d.
7. Depakote 500 mg b.i.d. 8. Lopressor 25 mg b.i.d. 9.
Ultram 50 mg b.i.d. 10. Risperdal 0.25 mg q.h.s. 11. Senna
two tablets q day. 12. Vitamin E. 13. Allopurinol 100 mg
q.d. 14. Coumadin 0.5 mg q.d. 15. Levofloxacin. 16.
Flagyl.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient has been living at [**Hospital3 7511**] for two years. The patient denies any tobacco or
alcohol use.
PHYSICAL EXAMINATION: The patient's vital signs on arrival
temperature 97.0. Pulse 104. Blood pressure 112/52.
Respiratory rate 17. Generally, this is an elderly, thin
male, intubated, sedated. HEENT examination normocephalic,
atraumatic. Pupils are equal, round and reactive to light
from 2 mm down to 1 with light. ET tube is in place and
attached. Nasogastric tube is also in place. Neck is
without lymphadenopathy. JVP was difficult to assess, but
was not appreciated. The patient had course breath sounds
bilaterally throughout. Heart was regular rate and rhythm
with normal S1 and S2. No murmurs, rubs or gallops were
appreciated. Abdomen was soft, nontender, nondistended with
normal abdominal bowel sounds. Extremities without edema.
The patient had no clubbing, cyanosis or edema. Neurological
examination was difficult to perform given that the patient
was sedated.
LABORATORY ON ADMISSION: A white blood cell count of 9.1,
hematocrit 30.9, platelets 509, sodium 159, potassium 3.7,
chloride 123, bicarb 16, BUN 5, creatinine 1.7, glucose 297,
CPK was 132, ABG obtained in the Emergency Room was 7.23 with
a CO2 of 47 and a PAO2 of 367. The patient had a chest
x-ray, which showed a right lower lung infiltrate and a
questionable mild congestive heart failure and
electrocardiogram was obtained, which showed the patient to
be in atrial fibrillation at a rate of 123 without any acute
changes.
HOSPITAL COURSE: 1. The patient was admitted to the MICU
with the presumptive diagnosis of an aspiration pneumonia
secondary to worsening dementia and nursing home bound.
According to the family prior to this admission the patient
has had a gradual decline in mental status and was not
responding appropriately prior to this recent insult. The
patient was initially placed on vent settings of assist
control with a tidal volume of 700, respirations of 10 and a
FI2 of 60%. Arterial blood gases were sent, which stayed
within that range with a resolving respiratory acidosis. The
patient's antibiotics of Vancomycin, Levofloxacin and
Ceftriaxone were continued for broad spectrum coverage. A
sputum culture was sent, which was consistent with
oropharyngeal flora. The patient remained afebrile with a
right lower lobe infiltrate on chest x-ray. Therefore
Vancomycin was continued for gram positive coverage, Flagyl
was continue for anaerobic coverage, and Ceftriaxone was
changed to Levofloxacin for further gram negative and
atypical coverage. A legionella and urinary antigen was
checked, which was negative.
Throughout the course of the hospital stay the patient became
afebrile and his white count decreased and was within normal
limits at the time of discharge. The patient, however, did
not seem to be appropriately improving his right lower lobe
pneumonia with serial chest x-rays obtained. A bronchoscopy
was performed by the pulmonary fellow, which did not find any
focus of infection or any masses. Only mucous was noted.
The patient's vent settings were weaned slowly and eventually
the patient tolerated pressure support of 5 with a PEEP of 5
on FIO2 of .4. The patient was stable on this level for one
week prior to extubation. The patient was optimize with
suctioning of secretions prior to extubation and was
successfully extubated on [**2144-8-25**].
2. The patient was felt to be in possible mild congestive
heart failure at the time of admission. The patient was
diuresed aggressively with Lasix and oxygenation improved as
well as resolution of his congestive heart failure. The
patient was found to be in atrial fibrillation at the time of
admission. The patient was placed on Lopressor and titrated
up to Lopressor 50 mg po t.i.d. with good control of his
supraventricular tachycardia. The patient was ruled out for
a myocardial infarction with a negative troponin and multiple
negative CK. Cardiac issues have been stable throughout the
hospital stay.
3. The patient had some decreased urine output during his
hospital stay, which was felt to be secondary to prerenal
azotemia in the setting of possible sepsis verses decreased
cardiac output secondary to heart failure. At the time of
discharge the patient's renal functions had improved and is
stable.
4. ID. The patient initially was stable and cultures were
all negative. Blood cultures, urine cultures and sputum
cultures were nonspecific and did not show any source of
infection. As a result antibiotics were initially stopped.
However, after stopping the antibiotics the patient dropped
his blood pressure with a systolic in the 70s and the patient
became febrile with a temperature of 103.7. The patient was
restarted on Vancomycin, Levofloxacin and Flagyl for presumed
sepsis. The patient underwent a fourteen day course and at
the completion of the course the patient is currently
afebrile with no increase in white count. The patient's
blood pressure has also been stable and it was felt that the
patient had a transient sepsis, which was corrected with a
fourteen day course of broad spectrum antibiotics.
Throughout the hospital stay the patient has not grown out
any positive cultures except for the patient did have some
positive cultures secondary to central lines as well as A
lines. However, all blood cultures were negative and those
were felt to be contaminants.
6. Code status, the patient's code status was readdressed
with the family given his presentation. The family was
informed that the patient would be unlikely to improve from a
neurological standpoint. The patient had been decreasing
mentally prior to this admission and it was felt that this
admission added additional anoxic insult, which the patient
would not likely recover from. A neurological consult was
obtained during this hospital admission and they agreed with
our prognosis and the family is informed of these studies.
Throughout the hospital stay the patient was pretty much
unresponsive even as his pulmonary status improved. It was
felt that the patient would be unlikely to ever return to his
baseline status and if extubated would not respond to his
family. The patient's family was informed of all of this and
after discussing with the rest of their family they felt that
they still wanted everything done for the patient. Therefore
the patient will remain full code. The patient was also
given a PEG tube for enteral feedings. In the future if the
patient were to aspirate again and be reintubated, the
patient's family would like a tracheostomy to be performed.
At this time a tracheostomy was not performed as the patient
was successfully extubated.
DISCHARGE CONDITION: Unresponsive, but stable from
cardiovascular and pulmonary standpoint. The patient is
likely at optimal baseline, although he is not responsive.
DISCHARGE STATUS: The patient will be discharged to [**Hospital3 7511**] or other rehab facility for management.
DIAGNOSES:
1. Dementia.
2. Aspiration pneumonia.
3. Congestive heart failure.
4. Sepsis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 7512**]
Dictated By:[**Name8 (MD) 2402**]
MEDQUIST36
D: [**2144-8-26**] 14:21
T: [**2144-8-26**] 14:29
JOB#: [**Job Number 7513**]
ICD9 Codes: 5070, 4280, 5789, 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1017
} | Medical Text: Admission Date: [**2133-1-5**] Discharge Date: [**2133-1-7**]
Date of Birth: [**2062-5-29**] Sex: M
Service: NEUROSURGERY
Allergies:
Biaxin
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Increased ventricular size
Major Surgical or Invasive Procedure:
Removal of VP shunt
Placement of VP shunt
History of Present Illness:
70 y/o former physician at [**Name9 (PRE) 756**] presents to ED after being
found walking outside without a shirt, he was thought to be
dehydrated after being left alone over the weekend. No food was
noted to be eaten in his home, his wife was in [**Name (NI) **]. He has
short term memory loss after a right frontal AVM hemorrhage and
had shunt placed. It is a programmable shunt from [**Hospital1 **], last adjusted to 120 in [**2131-9-13**]. Per patients son and
daughter he is high functioning but has short term memory loss.
He can be trusted to live alone. He has week neurocognitive
training.
Past Medical History:
Right frontal AVM hemorrhage in [**2126**] requiring VP shunt
(programmable from [**Hospital6 **]), cavernous angiomas
Social History:
Retired physician, [**Name10 (NameIs) **] with wife, know short term memory loss
gets continuous cognitive therapy
Family History:
Congential AVMs
Physical Exam:
O: T:97 BP:160/96 HR:96 R 11 O2Sats 96%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:4.5 bil min reactive EOMs no bilateral upward
gaze; Shunt in place unable to feel reservoir
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person only
Recall: 0/3 objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4.5 min reactive
. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements restricted in upgaze (not new
according to family)
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-16**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2+
Left 2+
Toes downgoing bilaterally
Upon discharge:
a and o x 3, cn 2-12 intact, incision cdi, motor full,
ambulating independently
Pertinent Results:
[**2133-1-6**] 01:00AM BLOOD WBC-8.3 RBC-4.98 Hgb-15.2 Hct-45.0 MCV-90
MCH-30.5 MCHC-33.8 RDW-13.4 Plt Ct-179
[**2133-1-5**] 03:25PM BLOOD Neuts-73.1* Lymphs-20.2 Monos-4.6 Eos-1.5
Baso-0.6
[**2133-1-6**] 01:00AM BLOOD Plt Ct-179
[**2133-1-6**] 01:00AM BLOOD Glucose-114* UreaN-20 Creat-1.1 Na-142
K-4.2 Cl-107 HCO3-26 AnGap-13
[**2133-1-5**] 03:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
Mr [**Known lastname 1940**] was assessed in the ED, his programmable shunt was
felt not to be working. A CT of his abdomen was completed it did
not show any psuedocyst. He was brought to the OR and his shunt
pressure measured 180 as compared to his previous setting which
should have been 120. His shunt was removed and replaced with a
[**Company 1543**] shunt. Post operatively he recovered in the SICU and
was found to be orientated X3 within 24 hours of his surgery.
His CT showed decrease ventricular site. He transferred to the
floor. Diet and activity were advanced. he was much brighter
on exam and with functioning. He was seen by PT and cleared for
discharge to home. He will return for suture removal.
Medications on Admission:
Wellbutrin, Lexapro and Simivastatin
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take while on narcotic.
Disp:*60 Capsule(s)* Refills:*0*
2. bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hydrocephalus
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**6-21**] days(from your date of
surgery) for removal of your sutures and a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**] to be seen in 6 weeks.
??????You will need a CT scan of the brain without contrast
* Please follow up with your urologist for urination issues.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2133-1-7**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1018
} | Medical Text: Admission Date: [**2123-9-14**] Discharge Date: [**2123-9-14**]
Date of Birth: Sex: F
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient has a history of
coronary artery disease who presented complaining of nausea,
vomiting, and abdominal pain.
Prior to admission, the patient noted right lower quadrant
pain. She then developed nausea and had several episodes of
vomiting which began on the afternoon of admission. She then
went to the bathroom and noted bright red urine. Her family
then brought her to the Emergency Department.
She arrived at the Emergency Department at approximately 3
a.m. At this point, she complained of bilateral lower
abdominal pain which radiated into her back. She vomited
bilious fluid in the Emergency Department times one. At the
time, she denied any chest pain. She denied any shortness of
breath, fevers, or chills.
She was sent for an abdominal computed tomography which
showed a 5-cm X 4-cm abscess within the portal system of the
liver as well as trabeculation and wall thickening in the
bladder consistent with cystitis.
While in the process of being evaluated, the patient
developed progressive shortness of breath and an oxygen
desaturation down to the 80%. She was emergently intubated
for hypoxemic respiratory failure and acute respiratory distress.
Subsequent to intubation, the patient developed hemoptysis with
profuse blood coming from the endotracheal tube, requiring
extensive suctioning. She was sent for an emergent chest
computed tomography which revealed marked pulmonary parenchymal
consolidation consistent with a pulmonary hemorrhage.
Multiple attempts to obtain blood for laboratory analysis
were attempted; however, all samples drawn were severely
hemolyzed and unable to be processed by the laboratory.
Laboratories were again attempted but continued to be
markedly hemolyzed. An arterial blood gas was obtained which
showed her hematocrit to be 15 with a pH initially of 7.19
which had dropped to 6.87. Further laboratories were unable
to be obtained at this time given her hemolysis.
Given her clinical symptoms and laboratory findings, there
was concern that the patient was in massive disseminated
intravascular coagulation. An emergent Hematology
consultation was obtained. In addition, an emergent Surgery
Service consultation was obtained to evaluate for hepatic
abscess for possible surgical intervention.
Transfer to the Medical Intensive Care Unit was arranged for
further treatment.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Diabetes.
3. Coronary artery disease (with exertional angina).
4. Hypothyroidism; status post partial thyroidectomy in [**2114**]
for a thyroid nodule.
5. Cardiac catheterization in [**2120**] with 80% stenosis of the
first diagonal.
MEDICATIONS ON ADMISSION: Home medications included Norvasc,
atenolol, Imdur, aspirin, Levoxyl, and Celebrex.
ALLERGIES: NIACIN.
SOCIAL HISTORY: The patient was a retired pharmacist who
immigrated to the United States in [**2113-10-6**] with her
son and granddaughter. [**Name (NI) **] tobacco or alcohol use.
FAMILY HISTORY: No family history of coronary artery
disease.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
on admission with vital signs which revealed the patient was
afebrile, her blood pressure was 123/67, her heart rate was
86, her respiratory rate was 15 times per minute per
ventilator with a tidal volume of 650 mL, positive
end-expiratory pressure of 5, and oxygen saturation of 92% on
an FIO2 of 100%. In general, the patient was an obese female
who was intubated and sedated. She was unresponsive. Head,
eyes, ears, nose, and throat examination revealed pupils were
sluggish. There was an endotracheal tube in place with
extensive blood exsanguinating from the endotracheal tube.
Pulmonary examination revealed coarse breath sounds
bilaterally. Cardiovascular examination revealed no murmurs,
rubs, or gallops. The abdomen was soft and distended. There
were positive bowel sounds. Extremity examination revealed
the extremities were cool. There were intermittent faint
radial pulses. The dorsalis pedis pulses were not
dopplerable.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission revealed the patient's white blood cell count was
56.6, her hematocrit was 15, and her platelets were 277.
Differential revealed 65% neutrophils, 15% basophils, 16%
lymphocytes, 1% monocytes, 2% metamyelocytes, 1% myelocyte,
and 2% nucleated red blood cells. The patient's lactate was
8.3. Urinalysis with large blood, 0 to 2 red blood cells,
positive nitrites, and moderate leukocytes.
PERTINENT RADIOLOGY/IMAGING: Electrocardiogram revealed a
sinus rhythm at 87 beats per minute. There were ST
depressions in leads I, II, and V2 through V6; consistent
with a strained pattern. There were T waves in lead III.
There were T wave inversions in leads II and aVF.
A chest x-ray revealed bilateral patchy infiltrates and lower
lobe consolidations.
A computed tomography of the abdomen and pelvis revealed
bilateral lower lobe consolidation, 5-cm X 4-cm air-filled
abscess in the liver, and mild pneumobilia.
A computed tomography of the chest without contrast revealed
bilateral lower lobe consolidation.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. LIVER ABSCESS ISSUES: The patient was admitted with
right upper quadrant pain with a subsequent abdominal
computed tomography showing a liver abscess with air in the
abscess and biliary tree. Blood cultures, urine cultures,
and sputum cultures were sent. The patient subsequently
developed a clinical picture concerning for sepsis with
disseminated intravascular coagulation. She was aggressively
treated with Levaquin, Flagyl, and vancomycin. She was
aggressively hydrated.
The Surgery Service was emergently consulted to see if she
might benefit from drainage of the abscess. The surgical consult
team felt the patient was not a surgical consult secondary to
hemodynamic instability and severe coagulopathy. It was thought
that she might benefit from percutaneous drainage of her liver
abscess should she stabilize clinically to the point where
she would tolerate and Interventional Radiology procedure.
The patient continued to decompensate despite aggressive
treatment of her sepsis including aggressive fluid
resuscitation and pressors.
2. DISSEMINATED INTRAVASCULAR COAGULATION ISSUES: The
patient was admitted with complaints of hematuria. She soon
developed a septic picture with concern for disseminated
intravascular coagulation. Her blood was massively hemolyzed
to the point where laboratory analysis was unable to be
obtained.
The patient also developed massive hemoptysis, and a computed
tomography of the chest was concerning for massive pulmonary
hemorrhage. The patient was aggressively transfused with
packed red blood cells, fresh frozen plasma, and
cryoprecipitate to counter her disseminated intravascular
coagulation. Specimens continued to be sent in an attempt to
obtain coagulations or fibrinogen. An emergent Hematology
Service consultation was obtained. They concurred with
aggressive transfusions.
Despite aggressive care, the patient's hematocrit further
dropped from 15 to 10.5; presumably due to her massive
hemoptysis, hematuria, and hemolysis. In addition, her
abdomen became progressively distended raising concern for
hemorrhage into the abdomen.
3. PULMONARY ISSUES: The patient developed acute
respiratory distress in the Emergency Department with
hypoxia, necessitating intubation. She subsequently
developed massive hemoptysis. A computed tomography of the
chest showed pulmonary consolidations consistent with a
pulmonary hemorrhage.
Due to her hypoxemic respiratory failure and severe pulmonary
hemorrhage presumed secondary to disseminated intravascular
coagulation, the patient was maintained on mechanical
ventilation. Despite adjustments of the ventilatory settings, and
positive end-expiratory pressure, and increase of the FIO2 to
100%, the patient continued to have transient hypoxia. She
continued to have massive hemoptysis despite aggressive
suctioning.
4. URINARY TRACT INFECTION ISSUES: The patient presented
with hematuria. A computerized axial tomography of the
pelvis showed trabeculae and bladder wall thickening;
consistent with cystitis. Her urinalysis did show
leukocytes. There was concern for possible urosepsis which
could have been contributing to her other problems. She was
maintained on Levaquin, Flagyl, and vancomycin for broad
spectrum antibiotic coverage.
5. PULSELESS ELECTRICAL ACTIVITY ISSUES: Following
admission to the Medical Intensive Care Unit, the patient was
aggressively treated with aggressive transfusions and fluid
resuscitation. She continued to decompensate clinically.
She then went into a rhythm of pulseless electrical activity.
A code was called, and the patient was treated per pulseless
electrical activity protocol. She briefly had return of a
wide irregular rhythm and pulse, but was unable to
sustain a blood pressure. She subsequently went into
pulseless electrical activity again. She then went into
aystole. The patient was aggressively coded for
greater than 45 minutes with no clinical response.
Given the medical futility of further cardiopulmonary
resuscitation, the code was ended at this point. The
patient's family members were aware and in agreement with
cessation of cardiopulmonary resuscitation at this point.
The patient's family agreed to a postmortem examination.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 5587**]
Dictated By:[**Last Name (NamePattern1) 5212**]
MEDQUIST36
D: [**2124-1-14**] 19:23
T: [**2124-1-14**] 08:30
JOB#: [**Job Number 7989**]
ICD9 Codes: 0389, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1019
} | Medical Text: Admission Date: [**2131-3-22**] Discharge Date: [**2131-4-20**]
Date of Birth: [**2064-6-17**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Abnormal labs; weakness, altered mental status
Major Surgical or Invasive Procedure:
Intubation
Central venous line placement
Arterial line placement
Trach/Peg
History of Present Illness:
Mr. [**Known lastname 916**] is a 66 year old man with CKD (baseline Cr 1.7-2), CAD,
chronic back pain and recent hospitalization after a fall with
altered mental status and acute on chronic renal failure who
presents from home with weakness. Patient was discharged from
rehab two weeks ago. Was initially doing well at home, but
started having difficulty getting up and being active for a
week. Per report, increased confusion, waxing and [**Doctor Last Name 688**] in
nature, over the last couple of days. VNA came to his home
yesterday and drew labs which were notable for a elevated
creatinine of 3.59 and hyperkalemia. He was brought to the ED
for further evaluation and management.
.
In the ED, initial vs were: T 97.3 HR78 BP113/55 RR16 O2 sat95%
RA. Initial ED labs were otherwise notable for K of 7.4,
creatinine of 6.4 and BUN of 106. EKG with peaked T waves.
Patient received kayexelate, calcium gluconate, bicarb, 10 units
of insulin and 1 amp D50 with minimal improvement of K to 4.9
(after an interval increase to 8.8). Renal was consulted and
recommended renal u/s, more D50 with bicarb, and placement of an
HD line for emergent dialysis. Three hours into his ED visit an
EKG was done, which was remarkable for ST elevations in the
inferior leads, II, III, aVF. Initial cardiac markers were
notable for troponin 3.70, CK 3965 and MB 82. Repeat troponin 3
hours later was 4.03. He was given aspirin 81, but given guaic
positive stool heparin and plavix was held. Cardiology was
notified and deferred catheterization secondary to time elapsed
and his multiple other co-morbidities. Other notable labs from
the ED included an initial WBC was 15 with 93% neutrophils. UA
was notably dirty with >50 WBCs and a lactate of 2.2. Patient
had a pH of 7.23 with an anion gap of 18. Patient's blood
pressures dropped to 80s/50s, he received 3 liters of fluid in
boluses and he was started on dopamine and neo. Pressures
improved to 110s. Patient's sat's started to drop and he was
showing signs of increased WOB. He was subsequently intubated
with rocuronium and etomidate. LIJ HD catheter was placed. He
was given a dose of Vancomycin and CTX for presumed urosepsis.
.
VS prior to transfer were afebrile, HR129 BP113/74 O2 sat 100%
on vent. In the MICU, patient was intubated. Patient underwent
beside echo with akinesis of inferior wall, EF of about 40%.
.
Review of systems: Unable to obtain given to patient's altered
mental status.
Past Medical History:
Coronary Artery Disease
Macular Degeneration
Chronic back/leg pain secondary to DJD
Tremor
Peripheral Neuropathy
Abdominal bruit
Chronic Renal Failure believed secondary to vascular disease
([**12-7**], Cr: 2.6 and BUN 49, K: 5.9)
GERD
Anemia ([**12-7**]: Hct: 33.5)
Bilateral CEA
Depression
Hyperlipidemia
Colonic polyps???
COPD???, in record, however patient denies
Left and Right Total hip replacements
PVD: mild-moderate aorto-[**Hospital1 **]-ilac disease as noted in [**2119**]
Social History:
Denies current tobacco use (h/o 20+ pack year, quit 15-20 years
ago) Admits to approximately 2+ beers most nights of the week.
Denies h/o illicit drug use. Lives with wife.
Family History:
Non-contributory
Physical Exam:
ON ADMISSION:
Vitals: T 97.5 BP: 124/107 P: 118 R: 22 O2: 100% (on AC FIO2
100%, PEEP 10, TV .500)
General: Alert, intubated; follows simple commands
HEENT: endotracheal tube in place; MMM, R eye with ptosis; PERRL
Neck: supple, no JVD, LIJ HD catheter in place
Lungs: Clear to auscultation in R field anteriorly; coarse BS in
left anterior lung field;, no wheezes, rales
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: Foley in place
Ext: cool to touch, diminished DP and PT pulses, intact radial
pulses; non-blanching violaceous ischemic appearing macules on
toes b/l; heel ulceration with deep necrosis R>L; no exudates or
purulence visible; 1+ pedal edema
Back: unstageable sacral decubitus ulcer with necrotic
appearance
.
ON DISCHARGE:
General Appearance: awake, alert, following commands, NAD
HEENT: EOMI, sclera anicteric, mucus membranes moist
Neck: trach collar in place, site clean and dry
Cardiovascular: regular but slightly tachycardic, no r/m/g
appreciated
Respiratory / Chest: coarse BS bilaterally with decreased BS at
bases, no wheezes or rales
Abdomen: soft, NT/ND, bowel sounds present
Extremities: right foot cooler than the left, warmer on exam
today compared to yesterday
Neurologic: alert, CNs grossly intact, sensation intact, still
somewhat delirious, oriented to person, year, season
Pertinent Results:
ADMISSION LABS:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
15.0* 3.40* 10.6* 32.2* 95 31.3 33.0 13.9 352
Glucose UreaN Creat Na K Cl HCO3 AnGap
131*1 106* 6.4* [**Numeric Identifier 28961**] 7.4*11 99 13*12 30*
.
PERTINENT LABS:
[**2131-3-23**] 07:42 CK-MB MB Indx cTropnT
157* 3.0 5.37*1
[**2131-3-23**] 20:44 79* 2.3 4.95*1
calTIBC VitB12 Folate Ferritn TRF
233* 724 7.8 342 179*
[**2131-4-18**] 15:45
FiO2 O2 Flow pO2 pCO2 pH calTCO2 Base XS AADO2 REQ O2 Intubat
Vent 12/ 409* 44 7.46* 32* 7 ASSIST/CON1 INTUBATED
.
DISCHARGE LABS:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
8.2 2.46* 8.0* 23.1* 94 32.6* 34.8 17.7* 62*
Glucose UreaN Creat Na K Cl HCO3 AnGap
143*1 56* 1.7* 145 4.0 105 28 16
ALT AST AlkPhos TotBili
44*2 229*3 65 0.2
................................................................
MICRO:
[**2131-3-22**], [**2131-3-23**], [**2131-3-27**] Urine Cx: Enterococcus
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S
.
[**2131-3-29**] Blood Cx: Enterococcus
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
................................................................
STUDIES:
[**2131-3-22**] EKG: Sinus rhythm. Inferior ST elevation myocardial
infarction. Compared to the previous tracing of [**2131-1-31**]
myocardial infarction pattern is new.
.
[**2131-3-22**] CXR: Mild cardiomegaly, but no acute intrathoracic
process.
.
[**2131-3-23**] TTE (Bedside): Left ventricular wall thicknesses are
normal. The left ventricular cavity size is top
normal/borderline dilated. LV systolic function appears
depressed (ejection fraction 30%) secondary to severe
hypokinesis/akinesis of the inferior and posterior walls. The
right ventricular cavity is dilated with depressed free wall
contractility. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. There
is no pericardial effusion.
Impression: inferior posterior infarction; right ventricular
infarction
.
[**2131-3-23**] EKG: Sinus tachycardia. Inferior ST segment elevations
with rare reciprocal precordial depressions are suggestive of
inferoposterior myocardial infarction. Compared to the previous
tracing ST-T wave changes are more extensive.
.
[**2131-3-23**] Renal U/S: Atrophy of the right kidney is unchanged. The
left kidney is normal. No hydronephrosis or mass noted.
.
[**2131-3-24**] TTE: The left atrium is mildly dilated. Left ventricular
wall thicknesses and cavity size are normal. There is moderate
regional left ventricular systolic dysfunction with
inferior/inferolateral akinesis and hypokinesis of the inferior
septum. Doppler parameters are indeterminate for left
ventricular diastolic function. The right ventricular cavity is
mildly dilated with moderate global free wall hypokinesis. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. The
mitral valve leaflets are mildly thickened. The tricuspid valve
leaflets are mildly thickened. There is mild pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Inferior/inferolateral akinesis and septal
hypokinesis consistent with inferior infarction/ischemia.
Dilated and hypokinetic right ventricle likely due to
ischemia/infarction.
.
[**2131-3-28**] CXR: Compared to most recent prior, there is increased
pulmonary
vascular prominence, consistent with vascular congestion.
Cardiomegaly is
stable compared to prior. Persistent retrocardiac density likely
represents a combination of atelectasis and left pleural
effusion. There is increased opacity at the right base,
consistent with atelectasis. An endotracheal tube is seen with
the tip approximately 6.5 cm above the
carina. A left internal jugular line is seen with tip projecting
over the mid SVC. An intestinal tube is seen traversing the
diaphragm with tip coiled in the stomach.
IMPRESSION: Increased right basilar atelectasis with stable
pulmonary edema.
.
[**2131-3-28**] CT ABD/PELVIS: 1. Atrophic right kidney with extensive
vascular calcifications. No renal calculi identified. 2.
Bilateral small pleural effusions and atelectasis. 3.
Gallbladder wall edema likely due to third spacing and possible
hepatitis; this is unlikely to be cholecystitis, but correlation
with physical exam is recommended.
.
[**2131-3-29**] RUQ U/S: 1. No son[**Name (NI) 493**] signs of cholecystitis. No
gallstones and no sludge identified. 2. Atrophic right kidney
again noted. 3. Mild splenomegally.
.
[**2131-3-30**] RUE U/S: 1. Occlusive clot in the right cephalic vein.
Of note, the cephalic vein is a superficial vein. 2. Otherwise,
no deep vein thrombosis in the right upper extremity.
.
[**2131-4-2**] CXR: ET tube is in standard placement. Left internal
jugular line ends at the origin of the left brachiocephalic
vein. Nasogastric tube passes below the diaphragm and out of
view. Mild pulmonary edema has not changed appreciably since
[**4-1**]. Heart size is normal. Small left pleural effusion
is likely. Lateral aspect left lower chest is excluded from the
examination. There is no evidence of pneumothorax along the
imaged pleural surfaces.
.
[**2131-4-4**] CXR: Left IJ catheter tip is in the proximal SVC. There
is no pneumothorax. Cardiac size is top normal. ET tube is in
standard position. NG tube tip is in the stomach. If any, there
is a small right pleural effusion. Bibasilar opacities are
improved, consistent with improving atelectasis. Persistent
opacities in the right perihilar region, and right lower lobe
that have improved from [**4-3**], stable from [**4-4**] earlier in
the morning, are a combination of atelectasis and pleural
effusion. Superimposed infection cannot be totally excluded.
.
[**2131-4-7**] CXR: AP chest compared to [**4-4**] through 4: Over the
past 24 hours, pulmonary edema has worsened, moderate
cardiomegaly and mediastinal vascular engorgement have increased
and small bilateral pleural effusion, left greater than right,
has increased as well. Findings are more consistent with
cardiogenic edema than non-cardiogenic. Left internal jugular
line ends in the SVC.
.
[**2131-4-9**] CT Chest:
1. Moderate bilateral pleural effusions, right greater than
left, without
evidence of loculation. Bilateral adjacent dependent
atelectasis, with
slightly heterogeneous in shape on the right. Possible right
lower lobe
pneumonia. No cavitary lesion.
2. Severe centrilobular emphysema.
3. Two sub-5-mm perifissural nodules. Given the underlying
emphysema and
increased risk for lung cancer, recommend followup in 6 to 12
months for
stability.
5. Moderate-to-severe 3-vessel coronary artery disease. Moderate
systemic
atherosclerotic disease.
6. ETT tip 7cm above carina, and nasogastric tube ends in the
proximal
stomach with most proximal sideport in the distal esophagus.
Consider
advancing both for better positioning.
.
[**2131-4-13**] CXR: As compared to the previous radiograph, there is no
relevant
change. Widespread parenchymal opacities are constant. Enlarged
pulmonary
vessels suggest that these opacities are predominantly caused by
edema. In addition, particularly at the right lung bases, a
second opacity is seen that shows subtle air bronchograms and
could reflect pneumonia. Moderate retrocardiac atelectasis. The
presence of small pleural effusions cannot be excluded.
.
3/12/1 KUB: Portable AP radiograph of the abdomen was reviewed
with no relevant prior studies available for comparison. The
limited view obtained in portable technique of supine AP abdomen
demonstrates known percutaneous gastrostomy. There is diffuse
pattern of bowel gas that might be consistent with ileus,
although the pattern is nonspecific and no dilatation of the
bowel is present. There is left lower lobe atelectasis and small
amount of pleural effusion seen.
.
[**2131-4-17**] CT Head: No evidence of an acute intracranial process.
.
[**2131-4-17**] CT torso:
1. Moderate-sized bilateral pleural effusions, with associated
opactities of both lower lobes. Superimposed infection cannot be
excluded, but the
appearance could be explained by atelectasis. Effusions are
similar, but
parenchymal opacity has improved somewhat at the right lung
base.
2. No evidence of bowel obstruction or ileus.
3. Tracheostomy tube, left upper extremity PICC, and a
percutaneous
gstrostomy tube are in optimal position.
4. Extensive atherosclerotic calcification of the aorta and the
coronary
arteries.
.
[**2131-4-19**] CXR: As compared to the previous radiograph, there is no
relevant change. The tracheostomy tube is in unchanged position.
Unchanged mild bilateral pleural effusions. Unchanged evidence
of mild pulmonary edema. Retrocardiac atelectasis. Normal size
of the cardiac silhouette. No newly occurred focal parenchymal
opacities.
Brief Hospital Course:
66 year old man with CKD (baseline Cr 1.7-2.3), CAD, chronic
back pain and recent hospitalization for altered mental status
and acute on chronic renal failure, who presents from home with
weakness and altered mental status in the setting of STEMI and
shock.
.
# Goals of care: Patient has a progressive deterioration over
the course of his hospital stay, with many complications. On
[**4-18**] patient developed recurrent episodes of VT (see below), and
family decided to make patient DNR/I with goals of care being
lack of escalation, but with plan to continue current
therapeutic measures.
.
# Shock/Urosepsis: Patient was admitted to the MICU on dopamine
and neo for blood pressure support. An arterial line was placed
for hemodynamic monitoring. He was transitioned to levophed and
vasopressin and was gradually weaned off of pressors as his
blood pressures improved. Patient's shock was attributed to
sepsis rather than a cardiogenic presentation given his high
mixed venous oxygen saturation and hyperdynamic cardiac
function. The source of his sepsis was attributed to a UTI given
his dirty UA and eventual multiple enteroccocal urine cultures.
He was treated empirically with vancomycin and cefepime, and
cipro was added when fevers persisted. Blood cultures were
initially negative, but eventually grew enterococcus (VRE).
Antibiotics were switched to daptomycin and patient's lines were
removed and replaced. Patient was transitioned to linezolid and
meropenem, and subsequent cultures were negative.
.
# Respiratory failure: Patient was intubated [**3-7**] increased work
of breathing and was put on assist control ventilation. Initial
CXR was without focal consolidation, but with signs of pulmonary
congestion after resuscitation with 3 L IVF. Attempted to wean
patient off vent but ran into difficulty as diuresis was limited
by patient's compromised cardiac function and pre-load
dependence after his inferior MI. In addition, patient developed
a MRSA pneumonia for which he was treated with 8 days of
vancomycin. Patient was extubated on [**4-6**], but reintubated on [**4-9**]
for increased work of breathing. On [**4-12**] trach and peg were
placed at bedside. Patient intermittently required lasix and he
has responded to lasix 80 mg IV. We would advise using lasix
intermittently to maintain euvolemia.
.
# STEMI: Patient suffered an STE inferior MI with depressed RV
function (dilated and hypokinetic on serial echos). Cardiology
was consulted in the ED and patient was medically managed with
heparin, plavix, asa, statin. Cardiac catheterization was not
pursued as it was felt there was little therapeutic benefit to
intervention. The heparin drip was stopped after 48 hours.
Attention was paid to his blood pressure given his preload
dependence and small boluses of IVF were given as needed.
Eventually his blood pressures stabilized and it was possible to
gently diurese with lasix drip to attempt to wean patient off
vent. Patient was tachycardic and was started on metoprolol
which was gradually uptitrated.
.
# Acute on chronic renal insufficiency: Patient with baseline
creatinine of 2.3, presenting here with initial creatinine of
6.4 and hyperkalemia to 7.4. Acute renal failure was attributed
primarily to obstruction as urine output picked up quickly and
creatinine trended down rapidly after Foley was placed. However,
renal U/S did not show signs of hydronephrosis. ATN was felt
less likely given the speed of recovery and the relatively acute
onset of hypotension in the ED which was quickly addressed with
pressors. Regardless of etiology, patient's renal function
rapidly improved and his creatinine trended down as low as 1.0.
His new baseline appears to be 1.2 to 1.8.
.
# Ventricular tachycardia: on [**4-18**] patient developed in the
setting of desaturating from presumed mucous plugging. Patient
had 6 episodes, 2 that self terminated, and 4 that required
synchronized shock because of loss of pulse. Patient was bolused
with IV amiodarone and then transitioned to oral amiodarone. His
betablocker was stopped. PLan to continue amiodarone 400 mg TID
for 1 week, then switch to 400 mg [**Hospital1 **] for 2 weeks, and then
transition to amiodarone 400 mg daily therafter.
.
# Thrombocytopenia: Patient developed thromobcytopenia to the
70s, and heparin was discontinued. HIT antibody was pending at
the time of discharge, and as such we have held heparin
products. Platelet count nadir was in the 50s, and improved to
62 on the day of discharge. We would ask that his facility
please call [**Telephone/Fax (1) 28962**] in order to check on the status of his
antibody on [**2131-4-23**]. We will also try to reach out to the
facility in order to facilitate this process. For now, please
hold heparin products.
.
# Guaiac positive stool/anemia: Patient with guaiac positive
stool in ED. Has known severe (Grade 3) erosive esophagitis and
gastritis on EGD in [**Month (only) 404**]. Hct similar to prior
hospitalization, baseline may be in mid 30s. He was continued on
his home [**Hospital1 **] PPI and did drop his hct slightly while on the
heparin drip. He was transfused 2 units on [**3-24**] and [**4-6**], and one
unit on [**4-9**], and [**4-15**].
.
# Wounds: Patient with deep necrotic heel ulcers and advanced
sacral decubitus ulcer. Per wife these are relatively new and
likely developed during stay in rehab. Wound care was consulted
and provided recommendations for dressing changes. Patient was
seen by vascular surgery when there was concern that the heel
ulcers may have been infected and contributing to his fevers,
however it was felt the ulcers were not infected and no further
intervention was pursued. General surgery was consulted
regarding the sacral decub and perforemed bedside debridement on
[**4-3**]. Wound care consult on [**4-16**] made the following recs
# Discontinue dakins to bilateral feet cleanse all wounds with
wound cleanser then pat dry
# aloe vesta to B/L LE's and feet
# For left foot ulcers: Xeroform dressing daily - cover with dry
gauze/ABD and secure with Kerlix change daily
# For right foot: duoderm gel to ulcers ( none on Achilles
ulcer) then cover with moist NS gauze cover with dry ABD then
wrap with Kerlix change daily
# For sacrum : No Sting barrier to periwound tissue then
antifungal powder
Continue with Santyl - rub into [**Doctor Last Name 352**] /yellow tissue cover wound
with moist NS gauze
cover with ABD or softsorb dressing secure with pink hy tape to
protect from stooling
change daily
.
# Depression: On clonazepam and olanzapine at home, which were
held given acute illness and restarted prior to discharge.
Medications on Admission:
Clonazepam 2mg qAM
Olanzapine 20 qAM
Metoprolol tartrate 50mg [**Hospital1 **]
Diltiazem 300mg SR qd
ASA 81mg qd
Gabapentin 100mg tid
Protonix 40mg [**Hospital1 **]
Colace [**Hospital1 **]
Ferrous sulfate
Carafate slurry qid
Senna
Tylenol prn
Dilaudid 2 mg PO PRN dressing changes
Discharge Medications:
1. atorvastatin 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
2. polyethylene glycol 3350 17 gram/dose Powder [**Hospital1 **]: One (1)
pack PO DAILY (Daily) as needed for Constipation.
3. acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
4. sodium hypochlorite 0.5 % Solution [**Hospital1 **]: One (1) Appl
Miscellaneous ASDIR (AS DIRECTED).
5. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: One Hundred (100) mg
PO BID (2 times a day) as needed for constipation.
6. insulin lispro 100 unit/mL Solution [**Hospital1 **]: One (1) unit
Subcutaneous ASDIR (AS DIRECTED): Per sliding scale.
7. ascorbic acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
8. collagenase clostridium hist. 250 unit/g Ointment [**Hospital1 **]: One
(1) Appl Topical DAILY (Daily).
9. aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
10. clopidogrel 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
11. chlorhexidine gluconate 0.12 % Mouthwash [**Hospital1 **]: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
12. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
13. quetiapine 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO HS (at bedtime)
as needed for anixety or insomnia.
14. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]:
Six (6) Puff Inhalation Q6H (every 6 hours) as needed for
wheezing.
15. amiodarone 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3 times
a day): For 1 more week, then 400 mg [**Hospital1 **] for 2 weeks, then 400
mg daily.
16. clonazepam 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
17. acetaminophen 650 mg/20.3 mL Solution [**Hospital1 **]: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for fever, pain.
18. Fentanyl Citrate 25-100 mcg IV Q2H:PRN pain
19. Midazolam 0.5-2 mg IV Q2H:PRN anxiety
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Septic Shock
STEMI
Ventricular Tachycardia
Urinary Tract Infection
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You presented to the hospital with weakness and confusion. You
were found to have a severe heart attack and a blood infection.
You developed problems with your lungs related to fluid overload
and pneumonia. You were extubated, but need to have a breath
tube placed again. You also had several irregular heart rhythms
that required electric shocks. Eventually a tracheostomy and PEG
feeding tube were placed. Given your overall medical condition,
the decision was made to make your goals of care Do not
resuscitate. You are being discharged to a rehab facility in
order to continue your care.
Followup Instructions:
Please follow up with your primary care doctor as you see
necessary
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2131-4-20**]
ICD9 Codes: 5849, 2930, 2762, 4271, 5990, 5180, 2760, 2767, 5859, 2720, 496, 4280, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1020
} | Medical Text: Admission Date: [**2159-7-18**] Discharge Date: [**2159-7-23**]
Date of Birth: [**2088-5-19**] Sex: M
Service: MEDICINE
Allergies:
Amiodarone / Proscar / Sotalol
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
Arterial line
BiPAP
Continuous bladder irrigation
History of Present Illness:
Mr [**Known lastname 33474**] is a 71 year old man with history of severe COPD (on
2L NC at home), diastolic CHF, atrial flutter s/p AVJ ablation
presenting with fevers and respiratory distress. The patient was
last admitted [**Date range (1) 25250**] for SOB and treated for a COPD
exacerbation with nebs, clindamycin for 7 days (given concern
for prolonged QT wanted to avoid quinolones) and prednisone 60mg
prednisone with taper to 30mg daily. The patient was also
recently treated at S. [**Hospital **] Hospital for C. diff with a 10 day
course of flagyl and he finished last week. He reports he did
have some more diarrhea after stopping the flagyl and most
recently had loose stools yesterday.
.
The patient reports that he has been having progressive cough
for the past 3 days. There was increased sputum production
(greenish/white), but not a significant amount. He remained
afebrile, but took his temperature early this AM and it was 102F
with accompanying chills. He also reports that his cough was
worsening. This AM he reported worsening SOB and dyspnea that
prompted him to go to ED. He reports that prior to that his
breathing was at his baseline. The patient is on chronic
prednisone of 30mg daily.
.
In the ED, initial vs were: T:103.8 P 133 BP 125/69 R 30 O2 98%.
Pt was severely SOB, increased work of breathing and wheezy on
exam. ABG was 7.18/79/62/31, with a lactate of 4. He was placed
on BiPAP and reportly WOB and respiratory status improved. The
patient had been on BiPAP for 1.5 hrs at the time of signout and
per report appeared more comfortable with improved WOB and able
to speak in short, full sentences. Repeat ABG was 7.34/57/79/32.
His WBC on admission was 17.7, CEx1 neg and BNP: 380 (prior
398). Patient CXR did not show infiltrate, effusions or edema.
Pt was given albuterol/ipratropium nebs and levo 750mg IV, Vanco
1gm and flagyl 500mg (unclear per [**Name (NI) **] signout coverage for h/o C.
diff, but no complaints of diarrhea or risk of aspiration). He
was also given 125mg methylpred. The patient was given 1L of
IVF. Repeat lactate was 2.1. Blood and urine cultures were sent.
The patient was sent to the [**Hospital Unit Name 153**] for further management.
.
On the floor, the patient had increased WOB after being off the
BiPAP for transport. He reports cough, SOB and fever. He denied
any current abdominal pain or diarrhea. Pt was hypotensive with
SBP 85-90 and tachy to 110's. He was give 500cc IVF and
tachycardia improved.
.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denied
chest pain or tightness, palpitations. Denied nausea, vomiting,
abdominal pain. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
-Stage IV COPD requiring home oxygen (2 L NC during day, no
longer using bipap at night)
-Spirometry today shows an FEV1 0.72 (24% predicted) and FVC of
1.61 (37% predicted), with an FEV1/FVC ratio of 44.
-History of pulmonary nodules
(LLL nodule stable since [**11-26**], followed with yearly CT)
-History of atrial fibrillation s/p AV junction ablation &
[**Company 1543**] dual chamber pacer placement in [**2153**], on coumadin
-History of Aortic stenosis (valve area 1.0 on cath [**4-27**])
- Diastolic CHF (EF >55%)
-History of Arthritis
-History of Basal cell carcinoma
-History of migraines
-History of hemoptysis in [**11/2157**] s/p bronchoscopy at [**Hospital1 34**]
(non-TB mycobacteria per report)
Social History:
Previously worked as a travel [**Doctor Last Name 360**]. Prior smoker 68-pack-year
smoker, but quit in [**2140**]. Prior history of alcohol abuse, has
been abstinent for past 30 years.
Family History:
Father with CAD, mother with CVA
Physical Exam:
Admission physical exam:
Vitals: T:99.1 BP:93/58 P:119 R:29 O2: 95% on BiPAP
General: Alert, oriented, pt with increased WOB, pursed lip
breathing, accessory muscle use. Pt able to speak in short, full
sentences.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, unable to assess given body habitus and BiPAP
mask.
Lungs: Increased/labored breathing, tachypneic, Poor inspiratory
effort, clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Tachy, Regular rhythm, normal S1 + S2, II/VI SEM with
radiation to carotids, no rubs, gallops
Abdomen: ventral hernia, reducible, soft, non-tender,
non-distended, bowel sounds hypoactive, no rebound tenderness or
guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
trace edema
Neuro: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**12-22**]+ reflexes,
equal BL. Gait assessment deferred
Pertinent Results:
Admission laboratories:
[**2159-7-18**] WBC-17.7* RBC-4.02* Hgb-12.7* Hct-39.0* MCV-97 MCH-31.7
MCHC-32.7 RDW-16.7* Plt Ct-206
[**2159-7-18**] Neuts-80.0* Lymphs-12.9* Monos-5.7 Eos-0.9 Baso-0.5
[**2159-7-18**] PT-29.9* PTT-24.1 INR(PT)-3.0*
[**2159-7-18**] Glucose-113* UreaN-20 Creat-1.1 Na-143 K-4.0 Cl-99
HCO3-31 AnGap-17, Calcium-8.0* Phos-2.8 Mg-1.7
[**2159-7-18**] ALT-34 AST-28 LD(LDH)-356* CK(CPK)-110
[**2159-7-18**] 09:18AM BLOOD Lactate-4.0*
[**2159-7-18**] 11:11AM BLOOD Lactate-2.1*
[**2159-7-18**] 12:52PM BLOOD Lactate-1.6
[**2159-7-18**] 09:10AM BLOOD D-Dimer-<150
[**2159-7-18**] 09:48AM BLOOD Type-ART pO2-62* pCO2-79* pH-7.18*
calTCO2-31* Base XS-0
Cardiac enzymes:
[**2159-7-18**] 10:13PM BLOOD CK(CPK)-110 CK-MB-10 MB Indx-9.1*
cTropnT-0.20*
[**2159-7-19**] 03:36AM BLOOD CK(CPK)-107 CK-MB-10 MB Indx-9.3*
cTropnT-0.15*
[**2159-7-19**] 06:32AM BLOOD CK(CPK)-94, CK-MB-10 MB Indx-10.6*
cTropnT-0.16*
[**2159-7-19**] 08:58PM BLOOD CK(CPK)-91 CK-MB-8 cTropnT-0.11*
EKG ([**7-18**]):
The rhythm appears to be sinus as compared with previous tracing
of [**2159-6-5**] with atrial sensed and ventricular paced rhythm.
Compared to the previous tracing of [**2159-6-5**] sinus rhythm has
appeared.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
74 0 124 420/444 0 -74 80
Cultures:
Stool ([**7-19**]): C diff positive
Imaging:
CXR ([**7-18**]): IMPRESSION: No acute cardiopulmonary process.
Echo ([**7-19**]): The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and global systolic function (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. The aortic valve leaflets are mildly thickened
(?#). There is severe aortic valve stenosis (valve area
0.8-1.0cm2). Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild to moderate ([**12-22**]+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2158-5-12**],
findings are similar.
Brief Hospital Course:
This is a 71 year old man with severe chronic obstructive
pulmonary disease who presented with acute exacerbation and
hypercarbia. A low D dimer ruled out a PE as a cause of the
exacerbation. He was initiated on Albuterol and Ipratropium, IV
methyl prednisone 60 mg q6 hr, Levaquin to cover atypical
bacteria, and BiPap for respiratory support. He tolerated the
BiPap well and was quickly transitioned to nasal cannula, only
requiring BiPap at night. He then improved with less wheezing
and weaned back to his home oxygen requirement. His IV steroids
were tapered, and he was discharged on a slow taper of
prednisone starting at 60 mg daily. He is on chronic home
prednisone PO and atovaquone for PCP [**Name Initial (PRE) 1102**]. His Levaquin
was switched to doxycycline on [**7-20**] because Levaquin interacted
with his Dofetilide to prolong the QT interval. He will
complete a 7 day course of antibiotics. He will follow up with
Dr [**Last Name (STitle) **] (pulmonary) next week for further management of his
severe COPD and adjustment of his prednisone taper as needed.
.
C Diff Colitis: The patient was initially hypotensive and
responded to a bolus of normal saline. The patient was initially
covered with broad spectrum antibiotics including Vancomycin IV,
Levaquin IV, Flagyl PO, and Zosyn IV. Sputum, blood and urine
cultures were all negative. He had diarrhea; C. diff antigen
test in the stool was positive, so he was switched from Flagyl
PO to Vancomycin PO for the indication of disease severity.
Flagyl PO was started on [**7-18**] and replaced by Vancomycin PO on
[**7-20**]; he will complete a 2 week course. Once on the antibiotic
regimen, the patient remained hemodynamically stable.
.
NSTEMI: In the acute setting of respiratory distress, the
patient had a mild increase in his troponins, ruling in for
NSTEMI. In the ED, he was enrolled in a placebo trial which
either gave a placebo or statin for sepsis. Since he had demand
ischemia, the patient discontinued from the study and started on
a statin and aspirin. He was not started on a beta blocker due
to the severity of his COPD. An EKG revealed no signs of infarct
and an Echocardiogram was unchanged from prior with no new wall
motion abnormality. He will follow up with his cardiologist, Dr
[**Last Name (STitle) **] and his PCP, [**Name10 (NameIs) **] [**Last Name (STitle) 98034**] for further testing/management
of his CAD.
.
Atrial fibrillation: The patient has had a history of atrial
fibrillation and has been using diltiazem and dofetilide for
rate and rhythm control. An EKG on [**7-20**] showed that he had QT
prolongation, so dofetilide and Levaquin were discontinued.
Levaquin was switched to doxycycline. Upon correcting of his QT
interval, the patient was restarted on dofetilide on [**7-20**]. Since
his INR was initially supra therapeutic, Coumadin was held and
re-intiated once the INR was between [**1-23**].
.
Injury to urethra: The patient had gross hematuria likely
secondary to a traumatic Foley placement. He was told that he
had friable prostate veins and has had hematuria and a
cystoscopy in the past. He had clots in his Foley catheter, so
his bladder was irrigated. Urology saw the patient and
recommended CT pyelogram, which was unrevealing. His urine
cleared and he was voiding without difficulty on the day of
discharge. He will follow up with his outpatient urologist, Dr
[**Last Name (STitle) **], to complete the workup for hematuria.
Medications on Admission:
Medications:
Dofetilide 375 mcg Q12H
Albuterol prn
Diltiazem SR 180 mg daily
Docusate Sodium 100 mg [**Hospital1 **]
Mirtazapine 15 mg qhs
Atovaquone 1500 (1500) mg PO DAILY
Calcium Carbonate 500 mg daily
Guaifenesin Oral
Warfarin (5mg 5x/week and 6mg 2x/week).
Lasix 30mg daily
Spiriva Inhaler
Advair Diskus Inhalation
Prednisone 30mg daily
Discharge Medications:
1. Atovaquone 750 mg/5 mL Suspension Sig: 1500 (1500) mg PO
DAILY (Daily).
2. Dofetilide 250 mcg Capsule Sig: 1.5 Capsules PO Q12H (every
12 hours).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q2H (every 2 hours) as
needed for SOB.
4. Diltiazem HCl 180 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO once a day.
5. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 1 days.
Disp:*3 Capsule(s)* Refills:*0*
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Take 5 mg 5x/week and 6 mg 2x/week. .
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO once a
day as needed for constipation.
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
13. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 11 days.
Disp:*44 Capsule(s)* Refills:*0*
14. Furosemide 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
15. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) inhalation Inhalation once a day.
16. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
17. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a
day: Take 6 tablets (60 mg) daily x 5 days, then take 5 tablets
(50 mg daily) until you follow up with Dr [**Last Name (STitle) **]; discuss
further taper with him. .
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
1. Hypercapnic respiratory failure
2. COPD exacerbation.
3. C difficile colitis
4. Demand ischemia/troponin leak/ NSTEMI
Discharge Condition:
Stable on home oxygen level with appropriate follow up arranged.
Discharge Instructions:
You were admitted with a severe COPD exacerbation and C Diff
colitis. You were initially admitted to the ICU; your symptoms
improved with antibiotics, steroids and inhalers.
You also suffered from blood in your urine during this admission
which had resolved by the time of discharge. This was likely
due to irritation from the foley catheter.
Your bloodwork showed that you had a very mild NSTEMI (very mild
damage to your heart) however your electrocardiogram and
echocardiogram were unchanged which means that there was no
change in the function of your heart. You have been started on
atorvastatin (Lipitor) and low dose aspirin for this. You
should discuss with you PCP whether any further testing is
needed.
You refused to go to a rehab facility to continue your recovery;
we will arrange home services, physical therapy and outpatient
pulmonary rehab following discharge.
Please seek immediate medical attention if you develop chest
pain, worsening shortness of breath or cough, fevers, fatigue,
diarrhea or any other concerning symptoms.
It is essential that you continue to take your medications as
prescribed and follow up with your doctors as listed below.
Followup Instructions:
PRIMARY CARE:
Follow up with Dr [**Last Name (STitle) **] on [**7-30**] at 3:20 PM. Call
[**Telephone/Fax (1) 24396**] with questions.
UROLOGY:
Follow up with your Urologist, Dr [**Last Name (STitle) **], Wed [**8-1**] at
11:45 AM. Call ([**Telephone/Fax (1) 34886**] with questions.
PULMONARY:
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2159-8-1**] 2:30
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2159-8-1**] 2:50
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 91**] & DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2159-8-1**] 2:50
ICD9 Codes: 0389, 4280, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1021
} | Medical Text: Admission Date: [**2193-5-22**] Discharge Date: [**2193-5-28**]
Date of Birth: [**2149-9-12**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Iodine / Platinum Complexes / Aspirin / Shellfish
Derived
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Fever, chills, nausea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 43-year-old woman with a pmhx. of recurrent ovarian
carcinoma (s/p TAH-BSO, IV and intraperitoneal chemotherapy,
radiation, and microperforation of simoid colon requiring
sigmoid resection with end-colostomy) who presents from home
with fevers, chills, and nausea of one day.
Patient recently began ixabepilone chemotherapy on [**2193-5-2**] and since that time reports increased vaginal discharge,
which she describes as "yellow and brown debris." States that
she has been using about 2 pads per day, soaking through each,
and that discharge is "liquidy" in character. This is an
entirely new symptom for her. Also about one week ago patient
noticed that her stoma "looked different." It seemed retracted
into her abdominal wall, and there was increased "light pink
bubbles" at the opening. She went to see her ostomy nurse on
day prior to admission who told her to come into the hospital if
she developed fevers, chills, or increased abdominal pain. Ms.
[**Known lastname 45419**] woke up with these symptoms on day of admission and
came to the ED.
At [**Hospital1 18**] ED, patient had a CT which showed a small rectal stump
leak, locule of air near staple line of [**Doctor Last Name **] pouch, and a
colovaginal fistula, which had likely been developing over the
course of weeks (and was not likely the cause of her current
symptoms). Surgery was consulted and they felt that given the
contained leak and proximity of likely residual tumor, there
were no good (or safe) surgical options. It was recommended
that patient be treated with antibiotic coverage and remain NPO
for the time being.
In the ED initial vitals were: 100 136 134/77 20 100. Patient
was given vancomycin 1g, cefepime and metronidazole 500mg. Mag
was noted to be 1.2 and patient given 2g. Na was 128 (131 on
repeat) and k was 5.6 (4.2 on repeat). WBC 23. Also given 6L
of fluid. Patient remained tachy into the 130, SBP 97-120. A
U/A revealed trace modertate blood, trace leuks and glucosuria.
Zofran and tylenol were given symptomatically. On transfer, BP
was 125/80, HR 120, and she was satting 99%RA.
ROS: Chills, nausea, vomiting, abdominal pain in LLQ. Negative
for headache, trouble swallowing, shortness of breath, chest
pain, palpitations, dysuria, or any other concerning signs or
symptoms.
Past Medical History:
Past Oncologic history:
[**Known firstname **] is 43 yo woman with advanced ovarian ca. She is s/p
debulking surgery and hysterectomy and bilateral
salpingo-oopherectomy. She received iv and intraperitoneal
chemotherapy as part of her adjuvant chemotherapy ending in
[**2193**]7. She was enrolled in study getting oral [**Doctor Last Name 360**] AZD2171
until [**12-11**]. She resumed tx with single [**Doctor Last Name 360**] [**Doctor Last Name **] as of
[**2191-5-12**]; but had reaction with dose 6/08. Started doxil [**2191-7-21**].
Had evidence of disease progression so tx changed to Alimta on
[**2191-11-17**] till [**2-12**]. Tx changed to Weekly taxol with Avastin on
[**2192-3-8**]. Due to neuropathy from taxol; tx changed to weekly
taxotere on [**2192-6-28**]. She had sigmoid colon perforation and had
colon ressection and colonostomy on [**2192-7-6**]. She has been slow to
heal and resummed chemo with gemzar on [**2192-10-11**]. Tx changed to
Topotecan on
[**2192-12-14**].
.
Past Medical History:
Diabetes
Hypothyroidism
HTN (improved- no meds since [**Month (only) **])
Clear cell ovarian Cancer
s/p TAH-BSO, appendectomy, omentectomy [**2189**]
s/p sigmoid resection [**7-12**]
Social History:
Patient lives alone and is in the middle of a divorce. Her
father is her HCP. Does not smoke or drink. Continues to work
in fundraising at WGBH (send the flyers, doesn't do the radio
commercials).
Family History:
Mother with NHL, tongue CA, died of "strep throat." Father has
a pacemaker.
Physical Exam:
VS: Temp: 101.7, BP: 98/53, HR: 108, SPO2: 97% RA
GENERAL: Thin, chronically ill appearing woman, no acute
distress, lying in bed
CHEST: Clear to auscultation bilaterally
CARDIAC: RRR, II/VI systolic murmur throughout precordium
ABDOMEN: +BS, ostomy bag in place with gas, tenderness in LLQ
near ostomy site
EXTREMITIES: No edema bilaterally
SKIN: Warm, diaphoretic
NEURO: Alert and oriented to person, place, time, and event
Pertinent Results:
[**2193-5-22**] 09:00AM BLOOD WBC-23.2*# RBC-3.71* Hgb-10.5* Hct-31.1*
MCV-84 MCH-28.3 MCHC-33.8 RDW-15.7* Plt Ct-573*
[**2193-5-27**] 07:30AM BLOOD WBC-15.6* RBC-2.75* Hgb-7.3* Hct-23.4*
MCV-85 MCH-26.5* MCHC-31.3 RDW-15.6* Plt Ct-500*
[**2193-5-22**] 09:00AM BLOOD Glucose-412* UreaN-12 Creat-0.9 Na-128*
K-5.6* Cl-86* HCO3-26 AnGap-22*
[**2193-5-26**] 07:20AM BLOOD Glucose-96 UreaN-8 Creat-0.6 Na-135 K-4.3
Cl-102 HCO3-25 AnGap-12
[**2193-5-22**] 09:00AM BLOOD ALT-11 AST-32 AlkPhos-140* TotBili-0.4
[**2193-5-26**] 07:20AM BLOOD Phos-2.5* Mg-1.7
[**2193-5-22**] 02:15PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.024
[**2193-5-22**] 02:15PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2193-5-22**] 03:05PM URINE UCG-NEG
Micro:
[**2193-5-25**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2193-5-24**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2193-5-24**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2193-5-24**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2193-5-22**] Blood Culture, Routine-
{STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP}; Anaerobic Bottle Gram
Stain-
[**2193-5-22**] Blood Culture, Routine-{STREPTOCOCCUS ANGINOSUS
(MILLERI) GROUP}; Anaerobic Bottle Gram Stain
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP
CLINDAMYCIN----------- S
ERYTHROMYCIN----------<=0.25 S
LEVOFLOXACIN---------- 1 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
Radiology:
[**5-22**] CT ABDOMEN W/O CONTRAST IMPRESSION: (pt reports hx of
allergy to contrast)
1. Interval increase of left pelvic mass with close association
with the
bowel.
2. Enterovaginal fistula.
3. Locules of gas near the staple line of the Hartmann's pouch;
it is unclear if it is intra- or extra-luminal, infectious
process at this site not excluded. No evidence of parastomal
collection.
4. Gallbladder sludge without evidence of acute cholecystitis.
5. Bilateral hydronephrosis, stable from previous study.
6. Hepatic hypodensity, concerning for metastasis.
[**5-26**] KUB FINDINGS: Gas and stool are seen throughout the colon
to the region of the splenic flexure. Gas is seen in some mildly
dilated loops of small bowel measuring up to 4 cm, without
air-fluid level. This likely represents an ileus.
UNILAT LOWER EXT VEINS LEFT IMPRESSION: No evidence of DVT.
Brief Hospital Course:
43 yo femaled with advanced ovarian cancer, was admitted with
complaints of fever, chills, and was found to have SIRS/septic
shock, and was initially managed in the ICU. She was started on
empiric coverage with broad spectrum antibiotics. She was found
to be bacteremic with strep anginosus, which is likely d/t
intrabdominal fisulization/abscesses. A CT of her abdomen and
pelvis (without contrast due to allergy) showed significantly
worsening ovarian cancer, colovaginal fistulization, and
possible microperforation vs infection at her [**Doctor Last Name 3379**] pouch.
She clinically stabilized, however further discussion with her
oncologist and surgeon revealed that there are no further
therapeutic options to offer, and she is not a candidate for
surgery. Her primary oncologist is Dr. [**Last Name (STitle) **]. She
was transitioned to DNR/DNI, and she elected to go home with
hospice care.
Her blood cultures later revealed strep anginosus (milleri), and
her antibiotics were changed to oral flagyl and levofloxacin, as
she prefered an oral regimen for palliation. At the time of
discharge, she was still having low-grade temps, but seh was not
symptomatic from them. She will complete a 2 week course of
antibiotics on [**2193-6-5**].
.
* Colovaginal fistula - She has a known colovaginal fistula,
however there are no surgical options per GynOnc discussion. It
does appear that her vaginal discharge may be improving slightly
with antibiotic treatment.
.
* LLE Edema - She was noted to have some left sided edema
(LLE/LUE). THere was intially concern for possible DVT, however
LENI;s were negative. The edema is most likely related to =
tumor blocking lymphatic drainage. Elevation and LLE compression
hose were recommended for comfort.
.
* Ovarian cancer - Per primary oncologist, pt has no further
chemotherapy options. Transitioned to DNR/DNI and palliative
care consulted and assisted throughout the hospitalization.
-- Patient is being discharged to home with hospice
.
* DM -
Pt had several episodes of hypoglycemia on lantus due to
decreasing oral intake. Her lantus dose was serially
downtitrated. Tight glucose control not necessary at this time,
but would like to avoid extreme highs that may produce symptoms.
- Pt discharged on reduced lantus dose without sliding scale.
.
* Hypothyroidism - continue synthroid
.
* Hyperlipdemia - Hold statin and Tricor
.
* Ostomy Retraction - Ostomy is retracted as per ostomy nurse
and surgery consult. Now with resuming stool output. KUB showed
some stool c/w constipation. She was treated with Miralax with
some improvement in her stool output. She was recommened to
continue to take stool softeners and Miralax and to stay well
hydrated to prevent constipation in the future. She may also
use milk of magnesia as well as needed.
.
PPX: Pt is at high risk for DVT given ovarian cancer. Pt will be
discharged on daily dosing of lovenox to prevent DVT for
palliative benefit
[**Date Range **]: home today with hospice. She is DNR/DNI. Her oncologist,
Dr. [**Last Name (STitle) **] will be the contact person for the Hospice
agency.
Medications on Admission:
Tricor 145 QD
Crestor 40 QD
Lantus 80units QHS and Humalog sliding scale
Levothyroxine 100mcg QD
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Last Name (STitle) **]:*30 Tablet(s)* Refills:*0*
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
[**Last Name (STitle) **]:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
[**Last Name (STitle) **]:*60 Capsule(s)* Refills:*2*
4. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) inj Subcutaneous
once a day.
[**Last Name (STitle) **]:*30 inj* Refills:*0*
5. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
[**Last Name (STitle) **]:*30 packet* Refills:*0*
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 8 days.
[**Last Name (STitle) **]:*8 Tablet(s)* Refills:*0*
8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 8 days.
[**Last Name (STitle) **]:*24 Tablet(s)* Refills:*0*
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
[**Last Name (STitle) **]:*60 Tablet(s)* Refills:*0*
10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO four
times a day as needed for pain.
11. Insulin Glargine 100 unit/mL Solution Sig: Thirty Five (35)
units Subcutaneous once a day: please continue to follow your
blood sugars. Decrease your dose if you have low sugars, and
call your PCP.
[**Name Initial (NameIs) **]:*1 vial* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
# Recurrent ovarian cancer
# Bacteremia; Strep Anginosus
# Colovaginal fistula
# Diabetes, Type 2 on insulin
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with fevers, chills, and nausea, and you were
found to have bacteria in your blood, which is being treated
with antibiotics. After discussion with GYN-Oncology and
surgery, there are no further treatment options for your ovarian
cancer. You will be followed at home by Hospice, who will make
sure that any symptoms remain well managed.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2193-5-30**] at 2:00 PM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2193-5-30**] at 3:00 PM
With: [**Name6 (MD) 5338**] [**Name8 (MD) 5339**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2193-6-6**] at 2:00 PM
With: [**Name6 (MD) 5338**] [**Name8 (MD) 5339**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 2761, 2767, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1022
} | Medical Text: Admission Date: [**2172-5-12**] Discharge Date: [**2172-5-23**]
Date of Birth: [**2108-3-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Gastric carcinoma involving the gastroesophageal junction.
Major Surgical or Invasive Procedure:
[**2172-5-12**]: 1. Esophagogastroduodenoscopy. Left thoracoabdominal
incision. Total gastrectomy. Distal esophagectomy.
Roux-en-Y esophagojejunostomy. Placement of jejunostomy tube.
History of Present Illness:
Mr. [**Known lastname **] is a 64-year-old gentleman with a known diagnosis of
proximal gastric squamous cell carcinoma who has undergone 5
months of chemotherapy. He is admitted for a left
thoracoabdominal incision, total gastrectomy,
distal esophagectomy and placement of jejunostomy tube.
Past Medical History:
Gastric cancer
GERD
Anemia
Pseudogout
Social History:
Smoked 2 PPD until 8 years ago; smokes half a cigar almost
daily. Formerly drank 6-pack of beer nightly, now significantly
reduced and only occasional wine. Occassional marijuana use. He
is married and retired. Has had a variety of occupations
including biology teacher, real estate manager, taxi driver, and
chef.
Family History:
Mother had a heart attack at 58 and died of an MI at age 63.
Father died with gangrene and an unknown gastrointestinal
problem.
Physical Exam:
VS: T: 98.6 HR: 74 SR BP: 154/86 Sats: 95% RA
General: No apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopath
Card: RRR normal S1,S2 no murmur
Resp: decreased breath sounds on Left otherwise clear
GI: benign
Extr: warm no edema
Incsion: Left thoracotomy clean dry intact, mid abdominal
incision open, clean, pink granulated tissues
Neuro: non-focal
Pertinent Results:
[**2172-5-21**] WBC-14.1* RBC-2.35* Hgb-8.5* Hct-24.7* Plt Ct-316
[**2172-5-20**] WBC-17.4* RBC-2.51* Hgb-9.5* Hct-27.2* Plt Ct-312
[**2172-5-19**] WBC-13.2* RBC-2.51* Hgb-9.8* Hct-27.2* Plt Ct-241
[**2172-5-18**] WBC-11.2* RBC-2.32* Hgb-8.6* Hct-24.9* Plt Ct-172
[**2172-5-17**] WBC-9.4 RBC-2.41* Hgb-9.0* Hct-25.6* Plt Ct-134*
[**2172-5-16**] WBC-10.5 RBC-1.89* Hgb-7.6* Hct-21.2* Plt Ct-137*
[**2172-5-13**] WBC-6.1 RBC-2.21* Hgb-8.8* Hct-25.4* Plt Ct-114*
[**2172-5-12**] WBC-5.0 RBC-2.60* Hgb-10.6* Hct-29.9* Plt Ct-125*
[**2172-5-19**] Glucose-90 UreaN-26* Creat-1.1 Na-138 K-4.1 Cl-103
HCO3-25 AnGap-14
[**2172-5-16**] 07:45AM BLOOD Glucose-96 UreaN-21* Creat-1.2 Na-134
K-4.0 Cl-103 HCO3-24 AnGap-11
[**2172-5-15**] 09:45AM BLOOD Glucose-117* UreaN-20 Creat-1.1 Na-134
K-3.9 Cl-103 HCO3-23 AnGap-12
[**2172-5-19**] 06:50AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.0
[**2172-5-18**] Source: Abdominal Wound.
GRAM STAIN (Final [**2172-5-18**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2172-5-20**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
CXR:
[**2172-5-19**]:As compared to the previous radiograph, the left-sided
chest tube has been removed. There is a moderate left-sided
pleural effusion, but no pneumothorax is seen. The right lung is
unchanged.
[**2172-5-16**]: A drain is noted to the right of the trachea. Cardiac
and mediastinal contours are unremarkable. There has been
interval improvement in the extent of bibasilar atelectasis. No
pneumothorax is noted. Bony structures are unremarkable. Small
amount of residual subcutaneous emphysema is noted along the
right chest wall.
Esophagus [**2172-5-19**] IMPRESSION: No evidence of leak.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted on [**2172-5-12**] for
Esophagogastroduodenoscopy. Left thoracoabdominal incision.
Total gastrectomy. Distal esophagectomy. Roux-en-Y
esophagojejunostomy. Placement of jejunostomy tube. He was
transferred to the SICU intubated with a Bupivacaine/Dilaudid
Epidural with good pain control. The NGT to intermittent
suction, 2 chest tubes to suction. Overnight he episodes of
hypotension which responded to fluid boluses. On [**5-13**] he was
extubated, pulmonary toilet, the chest tube was removed. Trophic
tube feeds were started. He transferred to the floor. On
[**2172-5-15**] he was seen by physical therapy and nutrition. He was
started on pain medication via J-tube with good control. On
[**2172-5-16**] the epidural was removed. He was transfused 2 Units
PRBC for a HCT of 21 to a HCT 24. He developed cellulitis of the
abdominal wound. 0n [**5-17**] the foley was removed he voided. On
[**5-18**] the abdominal incision was open and packed with wet-dry.
He was started on Ancef. Wound cultures with no growth. On
[**5-19**] an esophagus study revealed no leak. The NGT was removed
and he started clear liquid diet. The [**Doctor Last Name **] drain was removed.
On [**5-20**] the white count was elevated, the wound was enlarged.
His bowel function returned, the tube feeds Replete with fiber
were advanced to Goal of 85/hr. He continued to ambulate, given
tube feed instructions and was discharged to home with VNA on
[**2172-5-22**]. He will follow-up as an outpatient.
Medications on Admission:
aspirin 325 daily, plavix 75 daily, lipitor 80 daily,
lansoprazole 30 mg daily
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid [**Date Range **]: Five (5) PO BID (2
times a day).
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Date Range **]: 5-10 MLs
PO Q3-4H () as needed for pain.
Disp:*400 ML(s)* Refills:*0*
3. Aspirin 325 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily):
crush.
4. Metoprolol Tartrate 25 mg Tablet [**Date Range **]: One (1) Tablet PO BID
(2 times a day): crush meds.
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] once a day.
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
6. Lipitor 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: crush
med.
7. Clopidogrel 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
8. Augmentin 400-57 mg/5 mL Suspension for Reconstitution [**Last Name (STitle) **]:
Five (5) ML PO Q8H (every 8 hours) for 6 days.
Disp:*90 ML* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Gastric cancer s/p chemo treatment
Myocardial Infarction [**10-20**] s/p 3 BMS LAD
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 4741**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough, or sputum production
-Chest pain
-J-tube site develops drainage
Should your feeding tube sutures become loose or break, please
tape tube securely and call the office [**Telephone/Fax (1) 170**].
If your feeding tube falls out, save the tube, call the office
immediately [**Telephone/Fax (1) 170**]. The tube needs to be replaced in a
timely manner because the tract will close within a few hours.
Completed by:[**2172-5-25**]
ICD9 Codes: 2859, 412, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1023
} | Medical Text: Admission Date: [**2143-8-26**] Discharge Date: [**2143-9-12**]
Date of Birth: [**2098-4-8**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Motor vehicle accident.
Major Surgical or Invasive Procedure:
- 3 Ex-Laps with Exploratory laparotomy.
Hepatorrhaphy.
Left chest tube placement.
Liver packing.
Ligation of the splenic artery and vein.
Enterorrhaphy.
Packing of the liver.
Insertion of Silastic patch closure.
Splenectomy, packing, and final closure
- Gelfoam embolization of right hepatic artery branch
- IVC filter
- Central line
- I&D closure left leg and right knee
- Initial I+D/ex fix L tibia, I&D closure left followed by
removal of ex-fix, ORIF left tibia and fibula MIPO-style
- Chest tube
History of Present Illness:
The patient was in a restrained motor vehicle accident head on
with truck at high speeds with prolonged extrication. Transfered
here on [**2143-8-26**] from outside hospital with GCS of 11 and
intubated and with obvious lower extremity injuries. Upon
arrival, the patient was noted to have blood
pressures 90's to over 50's, was saturating well. The patient
was a hemodynamic 'transient responder'. She was taken to CT
scan which revealed a grade 5 liver laceration. She was urgently
taken to the operating room. Patient was taken for exploratory
laporatory with continued care as contineud in "brief hospital
course".
Past Medical History:
Bipolar Disorder
Depression
Anxiety
Substance Abuse
Eating Disorder
Social History:
Patien is widowed with two children. Husband had successful
suicide attempt 2 years ago in patient's presence. As a result,
DSS is involved the life of her 13 yo daughter. She also has a
24 yo son. The patient's mother and sister-in-law are involved
in her life and have visited her at hospital.
Habits:
- smokes cigarettes
- substance and alcohol user (unclear to what extent)
Family History:
Family medical history: non-contributory.
Family psychiatric history:
Son and daughter with depression, son attempted suicide after
his step-father's death. Aunt with bipolar.
Physical Exam:
Physical Exam:
Vitals: T: 97.3 (max 100.9) P: 113-134 R: 20 BP: 98/60 - 102/60
SaO2: 94%2L
General: Awake, sitting in chair, cooperative, NAD. Mild
cachexia.
HEENT: NC/AT, no scleral icterus noted, dry MM, no lesions noted
in oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Bilateral rhonchi at bases.
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally. Both LEs in orthopedic devices.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 2 (states [**Month (only) **] rather than
[**Month (only) **], correctly identifies [**Hospital1 18**]). Unable to relate history
clearly. Grossly attentive, able to name [**Doctor Last Name 1841**] backward slowly
and
omitting [**Month (only) 359**], but unable to maintain thread of a moderately
long conversation. Language is sparse but fluent with intact
repetition and comprehension. There were no paraphasic errors.
Pt. was able to name both high and low frequency objects. Speech
was mildly dysarthric and hypophonic. Able to follow both
midline
and appendicular commands. Pt. was able to register 3 objects
and
recall [**1-13**] at 5 minutes, correctly selecting the third from a
list. There was no evidence of neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Diffuse atrophy, normal tone throughout. Motor exam
limited by multiple orthopedic injuries. No adventitious
movements, such as tremor, noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 4+ 5 4+ 5 5 4+ 5 5 5 5 Unable --------->
R 4+ 5 4+ 5 5 4+ 5 5 5 5 Unable --------->
-Sensory: No deficits to light touch throughout. No extinction
to
DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 3 3 3 2 -
R 3 3 3 2 -
Plantar response could not be tested due to injuries.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: Unable due to orthopedic injuries.
Pertinent Results:
[**2143-8-27**] 12:00AM TYPE-ART PO2-111* PCO2-41 PH-7.37 TOTAL
CO2-25 BASE XS--1
[**2143-8-27**] 12:00AM LACTATE-2.1*
[**2143-8-27**] 12:00AM freeCa-1.29
[**2143-8-26**] 11:56PM GLUCOSE-125* UREA N-14 CREAT-0.8 SODIUM-148*
POTASSIUM-3.4 CHLORIDE-117* TOTAL CO2-23 ANION GAP-11
[**2143-8-26**] 11:56PM ALT(SGPT)-372* AST(SGOT)-693* LD(LDH)-660*
ALK PHOS-57 TOT BILI-2.4*
[**2143-8-26**] 11:56PM LIPASE-69*
[**2143-8-26**] 11:56PM ALBUMIN-3.5 CALCIUM-9.4 PHOSPHATE-4.2
MAGNESIUM-1.8
[**2143-8-26**] 11:56PM WBC-1.8* RBC-3.61* HGB-10.3* HCT-30.2* MCV-84
MCH-28.6 MCHC-34.3 RDW-15.4
[**2143-8-26**] 11:56PM PLT COUNT-257
[**2143-8-26**] 11:56PM PT-12.5 PTT-34.5 INR(PT)-1.1
[**2143-8-26**] 11:56PM FIBRINOGE-605*
[**2143-8-26**] 09:28PM TYPE-ART PO2-96 PCO2-41 PH-7.33* TOTAL CO2-23
BASE XS--4
[**2143-8-26**] 09:28PM LACTATE-3.0*
[**2143-8-26**] 08:23PM TYPE-ART PO2-209* PCO2-56* PH-7.25* TOTAL
CO2-26 BASE XS--3
[**2143-8-26**] 08:23PM LACTATE-3.5*
[**2143-8-26**] 08:23PM freeCa-1.27
[**2143-8-26**] 08:11PM GLUCOSE-118* UREA N-13 CREAT-0.8 SODIUM-149*
POTASSIUM-3.3 CHLORIDE-116* TOTAL CO2-23 ANION GAP-13
[**2143-8-26**] 08:11PM ALT(SGPT)-271* AST(SGOT)-431* ALK PHOS-55
AMYLASE-46 TOT BILI-1.7*
[**2143-8-26**] 08:11PM LIPASE-42
[**2143-8-26**] 08:11PM ALBUMIN-3.5 CALCIUM-9.9 PHOSPHATE-4.6*
MAGNESIUM-2.1
[**2143-8-26**] 08:11PM TRIGLYCER-65
[**2143-8-26**] 08:11PM WBC-2.1* RBC-3.12*# HGB-9.0* HCT-26.8* MCV-86
MCH-28.8 MCHC-33.5 RDW-15.1
[**2143-8-26**] 08:11PM NEUTS-77.9* LYMPHS-17.3* MONOS-4.2 EOS-0.2
BASOS-0.3
[**2143-8-26**] 08:11PM PLT COUNT-252#
[**2143-8-26**] 08:11PM PT-12.6 PTT-42.1* INR(PT)-1.1
[**2143-8-26**] 08:11PM FIBRINOGE-624*#
[**2143-8-26**] 05:03PM WBC-2.1* RBC-2.44* HGB-7.5* HCT-22.1* MCV-91
MCH-30.9 MCHC-34.2 RDW-14.6
[**2143-8-26**] 05:03PM PLT COUNT-103*
[**2143-8-26**] 05:03PM PT-12.5 PTT-77.5* INR(PT)-1.1
[**2143-8-26**] 05:02PM TYPE-[**Last Name (un) **] PO2-34* PCO2-67* PH-7.07* TOTAL
CO2-21 BASE XS--12 INTUBATED-INTUBATED COMMENTS-PERIPHERAL
[**2143-8-26**] 05:02PM GLUCOSE-237* LACTATE-3.9* NA+-143 K+-5.4*
CL--116*
[**2143-8-26**] 05:02PM HGB-7.7* calcHCT-23
[**2143-8-26**] 05:02PM freeCa-0.74*
[**2143-8-26**] 04:08PM TYPE-[**Last Name (un) **] PO2-29* PCO2-69* PH-7.06* TOTAL
CO2-21 BASE XS--13 INTUBATED-INTUBATED
[**2143-8-26**] 04:08PM GLUCOSE-183* LACTATE-3.2* NA+-141 K+-4.6
CL--112
[**2143-8-26**] 04:08PM HGB-8.0* calcHCT-24
[**2143-8-26**] 04:08PM freeCa-0.63*
[**2143-8-26**] 04:08PM WBC-3.5*# RBC-2.44* HGB-7.8* HCT-22.2* MCV-91
MCH-31.8 MCHC-35.0 RDW-13.6
[**2143-8-26**] 04:08PM PLT SMR-LOW PLT COUNT-96*
[**2143-8-26**] 04:08PM PT-19.6* PTT-80.7* INR(PT)-1.8*
[**2143-8-26**] 03:11PM TYPE-[**Last Name (un) **] PO2-33* PCO2-66* PH-7.03* TOTAL
CO2-19* BASE XS--15 INTUBATED-INTUBATED
[**2143-8-26**] 03:11PM GLUCOSE-116* LACTATE-2.3* NA+-140 K+-3.2*
CL--120*
[**2143-8-26**] 03:11PM HGB-8.3* calcHCT-25
[**2143-8-26**] 03:11PM freeCa-1.03*
[**2143-8-26**] 02:46PM TYPE-[**Last Name (un) **] PO2-44* PCO2-69* PH-7.09* TOTAL
CO2-22 BASE XS--11 INTUBATED-INTUBATED
[**2143-8-26**] 03:11PM freeCa-1.03*
[**2143-8-26**] 02:46PM TYPE-[**Last Name (un) **] PO2-44* PCO2-69* PH-7.09* TOTAL
CO2-22 BASE XS--11 INTUBATED-INTUBATED
[**2143-8-26**] 02:46PM GLUCOSE-102 LACTATE-1.5 NA+-139 K+-3.5
CL--118*
[**2143-8-26**] 02:46PM HGB-6.9* calcHCT-21
[**2143-8-26**] 02:46PM freeCa-0.95*
[**2143-8-26**] 02:40PM WBC-10.0 RBC-2.18*# HGB-6.7*# HCT-20.2*#
MCV-92 MCH-30.8 MCHC-33.4 RDW-13.7
[**2143-8-26**] 02:40PM PLT COUNT-121*#
[**2143-8-26**] 02:40PM PT-23.9* PTT-103.7* INR(PT)-2.3*
[**2143-8-26**] 01:12PM GLUCOSE-158* LACTATE-2.2* NA+-139 K+-3.8
CL--105 TCO2-24
[**2143-8-26**] 01:06PM LACTATE-1.4
[**2143-8-26**] 01:06PM O2 SAT-97
[**2143-8-26**] 01:00PM UREA N-16 CREAT-1.0
[**2143-8-26**] 01:00PM estGFR-Using this
[**2143-8-26**] 01:00PM AMYLASE-110*
[**2143-8-26**] 01:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2143-8-26**] 01:00PM WBC-16.2* RBC-3.63* HGB-11.1* HCT-33.2*
MCV-91 MCH-30.6 MCHC-33.5 RDW-13.8
[**2143-8-26**] 01:00PM PLT COUNT-272
[**2143-8-26**] 01:00PM PT-15.8* PTT-38.5* INR(PT)-1.4*
[**2143-8-26**] 01:00PM FIBRINOGE-254
Brief Hospital Course:
The patient was in a restrained motor vehicle accident head on
with truck at high speeds with prolonged extrication and was
transfered here on [**2143-8-26**]. She was taken to the OR by trauma
surgery for exploratory laporatomy which was repeated twice
resulting in a liver hepatorrhaphy, chest tube placement, liver
packing, ligation of the splenic artery and vein, enterorrhaphy.
acking of the liver, insertion then removal of Silastic patch
closure, passage of long intestinal feeding tube, splenectomy,
packing, and final closure on [**2143-8-26**]. Given her
multiple lower extremity injuries, an IVC filter was placed on
[**2143-8-29**]. She was treated for a left pneumothorax which was
treated with a chest tube. She was admitted to the intensive
care unit with intubation and was later weaned and transfered to
the floor. All tubes including chest tube and JP drains have
been removed as have abdominal staples.
Consults:
Orthopedic surgery was consulted for numerous leg fractures
including Ortho Inj: Open L distal tibial pilon fx, R knee
degloving wound, R ankle fx/ talus fx
Procedures peformed and care given by orthopedics included
[**8-26**]: I+D/ex fix L tibia, washout + closure R knee wound.
[**8-27**]: I&D closure left leg and right knee. Right knee lac did
not violate the joint.
[**8-29**]: Aircast boot to R ankle fx
[**9-5**]: Removed ex-fix, ORIF left tibia and fibula MIPO-style
Neurosurgery found no urgent/emergent neurosurgical issues at
time of presentation and with ongoing assessment found evidence
of traumatic brain injury.
Psychiatry was consulted to assess mental status and manage
behavior finding that her signs and symptoms are most consistent
with a organic syndrome relating to her brain injury, with
resolving toxic-metabolic encephalopathy. While her untreated
bipolar disorder may be contributing somewhat to her mood
lability, it is unlikely to be the primary cause of her
symptoms.
Neurology was consulted to evaluate confusion and odd behavior
finding that the most likely cause of these signs and symptoms
was a toxic-metabolic encephalopathy that will simply clear with
time but additonally recommeded limiting sedating mediations.
Medications on Admission:
Alprazolam.
Discharge Medications:
1. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain for 10 days.
Disp:*30 Tablet(s)* Refills:*1*
3. Megestrol 40 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day) for 10 days.
Disp:*40 Tablet(s)* Refills:*0*
4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain or fever.
8. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Olanzapine 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
10. Thiamine HCl 100 mg/mL Solution Sig: One (1) Injection TID
(3 times a day).
11. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
Liver laceration
Open L distal tibial pilon fx, R knee degloving wound, R ankle
fx/ talus fx
Bilateral Subarachnoid Hemorrhage
Left pneumothorax
Discharge Condition:
Stable vital signs. Weight bearing on right LE as tolerated.
Non-weight bearing on left LE.
Discharge Instructions:
You were in a motor vehicle accident requiring your admission
the the hospital including the intensive care unit after several
abdominal operations for injuries to your liver. Therefore it is
very important to carefully monitor your condition and return to
the Emergency Department immediately if you have any of the
warning signs listed below.
* Rest: You should restrict your activities until you are
completely better.
* Acceptable liquids include: water, tea, broth, ginger ale,
jello, diluted Gatorade, diluted apple juice or ice chips.
Avoid milk, ice cream and other dairy products.
* When your abdominal pain is gone, start a light diet in
addition to the fluids above. Good choices include: bananas,
rice, applesauce, toast, and crackers. Avoid milk products
(such as cheese) as well as spicy, fatty or fried foods.
* Do not consume alcohol or caffeine until you are completely
better.
* Continue your prescribed medications unless instructed to do
otherwise.
You had leg fractures requiring orthopedic surgery. Return to
the Emergency Department or see your own doctor right away if
any problems develop, including the following:
* Swelling, pain or redness getting worse.
* Pain not much better within 3 days.
* Fingers or toes become pale (whiter) or become dark or
blue.
* Numbness, tingling or coldness of your fingers or toes.
* Loss of movement.
* Rubbing sensation, burning or soreness of your skin,
especially under a cast.
* Chest pain, shortness of breath or trouble breathing.
* Fever or shaking chills.
* Headache, confusion or any change in alertness.
* Anything else that worries you.
<B>Warning Signs:</B>
Call your doctor or return to the Emergency Department right
away if any of the following problems develop:
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 100.4 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Given the extent of injuries and low-nutrition status, please
call back if you have any difficulty eating.
Followup Instructions:
Follow-up with the following services within the next two weeks
available at the following numbers:
- Trauma surgery: [**Telephone/Fax (1) 6429**]
- Orthopedic surgery: [**Telephone/Fax (1) 1228**]
- Neurology: [**Telephone/Fax (1) 44**]
Completed by:[**2143-9-12**]
ICD9 Codes: 496, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1024
} | Medical Text: Admission Date: [**2133-1-12**] Discharge Date: [**2133-1-17**]
Date of Birth: [**2092-2-26**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 40 year old
gentleman with known bicuspid aortic valve and hepatitis A.
The patient had an echocardiogram previously done in [**2125**]
which showed mild aortic stenosis and no aortic
insufficiency. On a recent visit with his primary care
physician he was noted to have a new heart murmur. The
patient had an echocardiogram done at an outside hospital on
[**2132-9-12**] which demonstrated a moderately dilated
left aorta and left ventricle with an ejection fraction of
approximately 60%. The patient also had moderately severe
aortic insufficiency and mild aortic stenosis. As a result
of this echocardiogram the patient underwent a cardiac
magnetic resonance imaging scan on [**2132-11-12**]. The
results of the study were as follows: 1. Bicuspid aortic
valve with moderate severe aortic regurgitation; 2. Moderate
dilation of aortic root and ascending aorta; 3. Severely
dilated left ventricular cavity size with normal regional and
global left ventricular systolic function; 4. Left
ventricular ejection fraction normal at 66%; 5. Normal right
ventricular cavity size and function; 6. Moderately dilated
main pulmonary artery; 7. Bilateral enlargement. This study
was ordered by Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **]. The patient was referred
for a cardiac catheterization to determine the central need
for surgery. On [**2133-1-6**], the patient underwent a
cardiac catheterization. The cardiac catheterization
revealed normal coronary arteries; severe aortic
regurgitation with aortic root dilation; mild aortic
stenosis; preserved systolic ventricular function. Following
the cardiac catheterization the patient was referred to Dr.
[**Last Name (STitle) **] for aortic valve replacement.
PAST MEDICAL HISTORY:
1. The patient's past medical history is significant for
aortic valve disease.
2. Hepatitis A.
3. Allergic rhinitis.
4. Status post vasectomy.
SOCIAL HISTORY: The patient is married, lives with his wife
three children. The patient works as a medical technician at
[**Hospital6 2910**].
ALLERGIES: The patient is allergic to Penicillin.
MEDICATIONS ON ADMISSION:
1. Zestril 10 mg q.d.
2. Multivitamin q.d.
REVIEW OF SYSTEMS: The patient denied any visual changes,
dysphagia, shortness of breath, hematochezia, melena,
dysuria, transient ischemic attack symptoms. The patient did
describe feeling palpitations with exertion.
PHYSICAL EXAMINATION: On presentation the patient's physical
examination revealed that he was a pleasant male in no
apparent distress who was alert and oriented times three. He
was afebrile. The heart rate was 76 in sinus rhythm. Blood
pressure was 89/53. Respiratory, breathing 20 breaths/minute
with a saturation of 100% on room air. The patient's head,
eyes, ears, nose and throat examination, pupils equal, round
and reactive to light, extraocular movements intact,
oropharynx was clear with good dentition, no jugulovenous
distension, no bruits. Neck was supple. Carotid artery
pulses were 2+ bilaterally. The patient's lung examination
was even and unlabored, clear to auscultation bilaterally.
The patient's cardiac examination revealed a regular rate and
rhythm with a III/VI systolic ejection murmur; the patient's
abdominal examination revealed positive bowel sounds, soft,
nontender, nondistended. The patient's extremity examination
showed 2+ bilateral pulses, dorsalis pedis and posterior
tibialis. The patient's extremities were not erythematous or
edematous. Neurological examination, the patient was alert
and oriented times three. Cranial nerves II through XII were
grossly intact.
HOSPITAL COURSE: The patient was admitted and underwent an
aortic root and transverse arch replacement with aortic valve
replacement with aortic valve replacement on [**2133-1-12**].
An aortic valve replacement was done with a 29 mm CV
pericardial valve. The aortic root and transverse arch
replacement was done with 28 mm gel-weave graft. The
procedure was done by Dr. [**Last Name (STitle) **] and assisted by Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 12373**], MD [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], PA Cardiac. The patient was
placed on a pulmonary bypass time of 185 minutes and a
crossclamp time of 139 minutes. The patient was under
complete circulatory arrest for 14 minutes. The patient
tolerated the procedure well and was transferred to the
Intensive Care Unit with Levophed, Epinephrine, and Propofol
drips. The patient also had two atrial and two ventricular
pacing wires.
Over the postoperative night the patient was extubated
without complications and remained on Levophed and
Epinephrine drips to keep the systolic blood pressure 95 to
110. That evening was only complicated by one small run of
atrial fibrillation which converted without any intervention.
Following expiration the patient's lung fields were clear
with diminished bases bilaterally but was able to maintain
oxygen saturations at 100% while on 2 liters of nasal
cannula. The patient's chest tube had minimal serosanguinous
drainage and no air leak noted.
On postoperative day #1 the patient was successfully weaned
off of his Levophed and Epinephrine drips. The patient's
pulmonary status continued to improve, he was able to
maintain oxygen saturation while being weaned off of 2 liters
of nasal cannula. The patient was transferred out of the
Cardiac Surgery Recovery Unit to the Surgical Floor. The
patient was transferred with two atrial and two ventricular
pacing wires as well as two [**Doctor Last Name 406**] chest Tubes. The chest
tubes were draining a small amount of serosanguinous fluids.
The patient continued to have an uncomplicated postoperative
course. Both of his chest tubes were removed on
postoperative day #2. The patient tolerated the procedure
well. The patient was seen and evaluated by physical therapy
and it was determined that after one more session the patient
would be cleared to go home. The patient had her pacing
wires discontinued on postoperative day #3. The patient
remains in sinus rhythm with a rate of approximately 70 to
90.
The patient had a serial hematocrit performed throughout his
postoperative course and noticed that hematocrit level had
dropped to a nadir of 19.6. The patient was offered the
choice of transfusion versus medication with iron and Vitamin
C. The patient refused the transfusion, having concerns over
the transition of hepatitis. The patient was started on
SeFO4 325 mg p.o. q.d. and ascorbic acid 500 mg p.o. b.i.d.
Hematocrit levels taken the following day showed an increase
of 21.4. The patient stated that he felt considerably
better, less lethargic, and more energetic. By postoperative
day #5, it was felt that the patient was ready and stable to
be discharged to home for further continuation of recovery of
the cardiac surgery.
The remainder of this dictation will be completed when the
patient leaves in the morning.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 846**]
MEDQUIST36
D: [**2133-1-16**] 14:41
T: [**2133-1-16**] 15:42
JOB#: [**Job Number 12374**]
ICD9 Codes: 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1025
} | Medical Text: Admission Date: [**2192-6-20**] Discharge Date: [**2192-6-22**]
Date of Birth: [**2140-8-7**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
altered mental status, hypotension
Major Surgical or Invasive Procedure:
central line placement
History of Present Illness:
51 yo M with history of ETOH abuse, CHF with EF 10-15%, HTN,
Vpacer for bradycardia, CAD s/p MI in [**2189**], who presents after
found intoxicated and hypotensive outside of [**Hospital3 74487**].
.
Of note patient was recently admitted to [**Hospital 3278**] Medical Center
and discharged on day of presentation. Per [**Hospital1 3278**] nursing staff,
patient was admitted intoxicated after losing all his
belongings. He reported chest pain and was admitted for rule out
MI. Patient was ruled out for MI with serial troponins. He
expressed no desire to stop drinking and to be discharged. He
was discharged on his heart failure regimen, however
anticoagulation was discontinued given frequent intoxication and
history of subdural and subarachnoid hemorrhage.
.
After discharge from [**Hospital1 3278**], patient was subsequently found on
the VA steps intoxicated. EMS was called and then he was
transported to [**Hospital1 18**]. Patient was found to be hypotensive in the
field with systolics in the 60s-70s. The patient had some
bruising to his abdomen from injections of lovenox vs insulin.
He was otherwise nonfocal.
.
In the ED, initial VS were: 60s/40s 101 18 100%. Rectal temp was
103. On arrival patient was intoxicated and responsive to voice.
His neurologic exam was nonfocal. Abdomen was soft and he was
guiac negative. He had a CT scan of his head, cspine, chest,
abdomen, and pelvis which were unremarkable. His labs were
significant for ETOH level of 239. He had a normal WBC count,
HCT of 29, Chem 7, LFTs unremarkable and troponin negative x1.
Serum and urine tox negative. UA negative. ABG 7.36/47/64 with
lactate of 2. Patient was initially volume recussitated with 4L
of NS with improvement of blood pressures to the 80s. He was
started of levophed and RIJ was placed with improvement of
pressures to 90s/50s (MAP of 60). LP was attempted but aborted
after learned of AM administration of 80 mg lovenox. Patient was
started on vancomycin, ceftriaxone and acyclovir and 4g of mag
IV. Repeat rectal temp 37 prior to transfer.
.
On arrival to the MICU, patient intoxicated but able to follow
commands. He has no complaints. Blood pressures improved. In the
morning, he was afebrile. There was no nuchal rigidity or sign
of infection, so antibiotics were all stopped. CVL was removed.
Has been on CIWA, but has not been [**Doctor Last Name **]. Metoprolol and
digoxin were restarted. Still holding lasix and spironolactone.
.
EP should be involved in AM as he is getting paced fast
.
Review of systems: unable to obtain
Past Medical History:
# Hypercholesterolemia
# V-pacer for bradycardia (?sick sinus), AICD for HF
Device: [**Company 1543**] Secura
Pacer last interrogated [**2192-5-25**]
setting: D-D-D-R
low rate: 70
upper rate: 140
tachyarrhythmias: none
therapies delivered: none
A-P: 2%
v-pace: 99.5%
V-sense response: on
[**Hospital1 **]-V paced
mode switch episodes: none
# CAD s/p MI [**7-14**] "100% occlusion, no stents, ?appropriate for
CABG
# CHF with EF 10-15%
# DM2
# BPH
# Depression
# Alcohol abuse
# hilar adenopathy
# hx of PE
# hx of resolved LV thrombus
# apical aneurysm
# hx of subdural and subarachnoid hemorrhages
Social History:
# Personal: Homeless, living in a veterans' shelter. Used to
work in business, but lost everything [**3-8**] alcohol.
# Alcohol: drinks 1 pint 3 times per week
# Recreational drugs: Denies
# Tobacco: denies.
Family History:
# Father: Unknown
# Mother: [**Name (NI) **] cancer
Physical Exam:
admission exam
Vitals: T: 98.2 BP: 104/67 P: 92 R: 16 O2: 96% RA
General: somnolent but in NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Neck: supple, JVP difficult to interpret, no LAD. RIJ in place
CV: Regular rate and rhythm, normal S1 + S2, no murmurs
Lungs: Decreased breath sounds at bases, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, trace LE edema
Neuro: somnolent but arousable. A&Ox person, year, president
(thinks at [**Hospital1 **]), able to respond to commends, moving all
extremities. no nuchal rigidity.
.
discharge exam
97.7 111/75 102 22 96%ra
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-9**] throughout, sensation grossly intact throughout, gait
deferred. No tremor or asterixes
Pertinent Results:
admission labs
[**2192-6-20**] 03:00PM BLOOD WBC-5.9 RBC-3.59* Hgb-9.1* Hct-29.0*
MCV-81*# MCH-25.2*# MCHC-31.3# RDW-16.4* Plt Ct-285#
[**2192-6-20**] 03:00PM BLOOD Neuts-74.2* Lymphs-17.7* Monos-4.2
Eos-3.3 Baso-0.6
[**2192-6-20**] 04:32PM BLOOD PT-12.8* PTT-41.0* INR(PT)-1.2*
[**2192-6-20**] 03:00PM BLOOD Glucose-152* UreaN-20 Creat-1.2 Na-137
K-4.0 Cl-103 HCO3-24 AnGap-14
[**2192-6-20**] 03:00PM BLOOD ALT-25 AST-33 AlkPhos-62 TotBili-0.3
[**2192-6-20**] 03:00PM BLOOD Lipase-56
[**2192-6-20**] 03:00PM BLOOD cTropnT-<0.01
[**2192-6-20**] 03:00PM BLOOD Albumin-3.7 Calcium-8.2* Phos-2.8 Mg-1.4*
[**2192-6-20**] 03:00PM BLOOD ASA-NEG Ethanol-239* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2192-6-20**] 03:22PM BLOOD Type-[**Last Name (un) **] pO2-64* pCO2-47* pH-7.36
calTCO2-28 Base XS-0 Comment-GREEN TOP
[**2192-6-20**] 03:22PM BLOOD Lactate-2.0
[**2192-6-20**] 11:48PM BLOOD O2 Sat-74
.
Discharge labs
[**2192-6-22**] 08:20AM BLOOD WBC-4.5 RBC-3.94* Hgb-10.0* Hct-32.3*
MCV-82 MCH-25.4* MCHC-30.9* RDW-16.5* Plt Ct-229
[**2192-6-22**] 08:20AM BLOOD Glucose-198* UreaN-13 Creat-0.9 Na-134
K-4.0 Cl-98 HCO3-25 AnGap-15
[**2192-6-22**] 08:20AM BLOOD Calcium-8.6 Phos-2.6* Mg-1.7
Studies:
CXR:
1) Right-sided internal jugular central venous line terminating
at the mid to distal SVC without evidence of pneumothorax.
2) Cardiomegaly.
.
Radiology Report CT C-SPINE W/O CONTRAST Study Date of [**2192-6-20**]
4:04 PM
IMPRESSION:
1. No acute cervical spine fracture or dislocation.
2. Multilevel degenerative changes of the cervical spine as
detailed above.
.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2192-6-20**]
4:04 PM
IMPRESSION:
1. No acute intracranial process.
2. Left maxillary sinus disease.
.
Radiology Report CT ABD & PELVIS WITH CONTRAST Study Date of
[**2192-6-20**] 4:05 PM
IMPRESSION:
1. No evidence of pulmonary embolism although evaluation of
subsegmental
arteries in right lower lobe is suboptimal due to patient
respiratory motion.
2. Prominent bilateral hilar and mediastinal lymph nodes some
of which are enlarged. Recommend clinical correlation with
history of prior infection, inflammatory process, or concern for
malignancy and further evaluation per clinical history.
Findings should be followed-up.
3. Cardiomegaly without pericardial effusion or acute aortic
syndrome.
4. Thickened-appearing bladder wall. Correlate with urinalysis.
.
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2192-6-20**] 4:05 PM
IMPRESSION:
1. No evidence of pulmonary embolism although evaluation of
subsegmental
arteries in right lower lobe is suboptimal due to patient
respiratory motion.
2. Prominent bilateral hilar and mediastinal lymph nodes some
of which are enlarged. Recommend clinical correlation with
history of prior infection, inflammatory process, or concern for
malignancy and further evaluation per clinical history.
Findings should be followed-up.
3. Cardiomegaly without pericardial effusion or acute aortic
syndrome.
4. Thickened-appearing bladder wall. Correlate with urinalysis.
Brief Hospital Course:
51 yo M with hx of ETOH abuse, CHF with EF 10-15%, HTN, Vpacer
for bradycardia, CAD s/p MI in [**2189**] who presented intoxicated,
febrile, and hypotensive. He had a unit stay for the hypotension
where he received IV fluid resuscitation overnight and pressors,
and was weaned off by the morning.
# Altered mental status - Patient found to be intoxicated with
ETOH level of 239, hypotensive with blood pressures in the 60s,
and initial rectal temp of 103. Mental status improved overnight
as patient sobered up. There was initial concern for meningitis
given febrile with altered mental status and patient was started
on vancomycin, ceftriaxone and acyclovir at meningitis dosing.
Patient was monitored overnight and given afebrile, improvement
in mental status, lack of nuchal rigidity and photophobia
antibiotics were discontinued. He had return of normal mental
status at time of transfer from the unit. He remained stable and
intact once on the floor.
.
# Shock - Patient had presenting blood pressures in the 60s and
was febrile to 103. There was initial concern for distributive
shock due to possible sepsis and he was started on vancomycin,
ceftriaxone, and acylovir for potential meningitis. He was going
to get an LP, but then MICU team learned he had gotten lovenox
earlier that AM, so this was deferred. However infectious workup
negative and patient was afebrile, without leukocytosis, and
clinically improved with IV fluids. He was started on levophed
in the ED which was quickly weaned off overnight. He was likely
volume depleted in the setting of acute intoxication. There was
no clinical evidence to suggest primary distributive or
cardiogenic process leading to his hypotension. He responded to
IVF to normotension, and was stable on the floor.
.
# ETOH abuse - Patient was placed on valium CIWA scale. He was
given MVI, thiamine, and folate. Given his ETOH use and social
situation, social work was consulted. However, patient declined
these interventions. States that he has an outpatient rehab he
is working with, and is not interested in alternatives.
.
# CHF with EF 10-15% - Home antihypertensives including toprol,
lisinopril, lasix and spironolactone initially held. His digoxin
was continued. As his blood pressures stabilized, patient was
restarted on all his home meds by time of discharge
- his pacer appearred to be pacing at ~100bpm. W/ low EF, this
seems to be too fast. We offerred patient electrophysiology to
look at pacer, but he declined and will f/u with his
cardiologist.
.
# hx of PE and LV thrombus - previously on warfarin/lovenox.
Patient discharged from [**Hospital1 3278**] off all anticoagulation due to
noncompliance, history of ETOH abuse and subdural/subarachnoid
bleeds. INR subtherapeutic on admission. Lovenox and warfarin
were held during admission given risk of bleed due to history of
intracranial bleed.
His primary cardiologist was contact[**Name (NI) **] and agreed w/ this plan.
If patient can get sober, restarting coumadin would make more
sense.
.
# CAD ?????? PO medications intially held. Patient restarted on ASA
and beta blocker. His ACE and beta blocker were initially held
due to hypotension, but restarted by time of discharge.
.
# Type 2 DM - Home metformin and glyburide held. Blood sugars
were well controlled with insulin sliding scale. PO meds
restarted at discharge.
.
====================================================
TRANSITIONAL ISSUES
# Prominent bilateral hilar and mediastinal lymph nodes some of
which are
enlarged on CTA. Pt was informed, and should pursue further
work-up in outpatient setting.
# EtOH management: pt declined intervention this admission, has
outpatient rehab at [**Last Name (un) **] VA that he would like to f/u at.
# his pacer appearred to be pacing at ~100bpm. W/ low EF, this
seems to be too fast. We offerred patient electrophysiology to
look at pacer, but he declined and will f/u with his
cardiologist.
Medications on Admission:
aspirin 81 mg po
budesonide 80 mcg/4.5mcg 2 puffs [**Hospital1 **]
digoxin 0.125 mcg daily
lasix 20 mg [**Hospital1 **]
glyburide 5 mg [**Hospital1 **]
lisinopril 2.5 mg
metformin 500 mg [**Hospital1 **]
toprol XL 25 mg daily
multivitamin
omeprazole 20 mg daily
simvastatin 40 mg daily
sublingual nitro as needed
aldactone 25 mg daily
coumadin 5 mg every evening --> 1 tab SWF and 1.5 tabs MTThSat
(not getting during recent hospitalization)
lovenox 80 every 12 hours
terazosin 1 mg qhs
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
2. budesonide-formoterol 80-4.5 mcg/actuation HFA Aerosol
Inhaler Sig: Two (2) Inhalation twice a day.
Disp:*1 inhaler* Refills:*0*
3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
5. glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
6. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
9. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
11. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
12. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual Q5 minutes, take as needed for chest pain, call 911
after 2nd dose.
Disp:*5 * Refills:*0*
13. Aldactone 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
14. terazosin 1 mg Capsule Sig: One (1) Capsule PO at bedtime.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hypovolemia, alchohol intoxication
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname **],
It was a pleasure taking [**Doctor Last Name **] of you at [**Hospital1 18**]. You were
admitted for fever and low blood sugars. This was thought to be
from alcohol intake. It is crtically important that you stop
drinking alcohol. Please continue to see your outpatient rehab
providers to assist you with this.
Because of your heart failure, weight yourself daily. If weight
increases by 3 lbs, [**Name6 (MD) 138**] your MD right away.
No changes have been made to your medications.
Followup Instructions:
You should see your PCP, [**Name10 (NameIs) **] Cardiologist, and your
rehabilitation team within 1 week of discharge.
You have an appointment with your Cardiology team for next week:
[**Location 1268**], VA
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], NP
Wednesday, [**6-27**], at 8:00am.
ICD9 Codes: 4254, 4280, 412, 4019, 2720, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1026
} | Medical Text: Admission Date: [**2183-2-11**] Discharge Date: [**2183-2-16**]
Date of Birth: [**2127-11-28**] Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
s/p cardiac cath with BMS to prox RCA, hypertensive urgency
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
55 yo W with Hx of CAD s/p PCI with BMS to RCA in [**4-13**], also PVD
s/p R SFA stenting, dCHF, IDDM, HTN, HLD and active tobacco use
who presented to OSH on [**2183-2-7**] with acute dyspnea and chest
discomfort, had pulmonary edema on CXR and elevated troponins
(peak at 0.67). Treated with IV Lasix 40 [**Hospital1 **] with resolution of
symptoms, and began on heparin gtt (which was d/c in setting of
g+ stools). Per report, repeat echo revealed preserved EF.
.
At OSH Pt had one episode of agitation and disorientation the
morning of transfer. Head CT was negative for ICH. She was
brought to [**Hospital1 18**] where she underwent cardiac catheterization and
had BMS placed to a 60% proximal RCA lesion with positive
resting gradient by pressure wire. During the procedure her
blood pressure was extremely difficult to control. She was
started on a Nitroglycerin gtt at 180 mcg, then Nipride gtt, as
well as given IV labetalol bolus (dose unspecified) to keep her
sBP<180. She had normal b/l renal arteries. She required 4L of
O2 by facemask to keep her oxygen saturations in the mid 90s.
Her LVEDP was 30. She is being transferred to the CCU for
management of her hypertension and CHF.
.
Currently she reports feeling well. She denies any chest pain,
dyspnea, fever or chills. No abdominal pain or pain at cath
site.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, or
red stools. She denies recent fevers, chills or rigors. She
denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY: prior Non-Q wave MI in [**4-13**]
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: Cardiac cath in [**4-13**] with
BMS placed to RCA (severe mid 90% lesion and diffuse 70% mid
disease)
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY: as above, additionally
-peripheral neuropathy
-bilateral carotid stenosis (50-60%)
-osteomyelitis/gangrene of right fourth toe s/p amputation in
[**2182-5-4**]
-s/p right SFA stenting in [**4-13**]
-s/p L iliac angioplasty in [**2167**]
-cataract surgery
Social History:
- Retired nurse
- Exercises daily
- Tobacco history: currently uses [**2-6**] pack/week since age 16
- ETOH: denies
- Illicit drugs: denies
Family History:
- Father had CAD, MI in 60s, died from complications of cancer
Physical Exam:
VS: 98.2, 69, 174/50, 23, 97%
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP at angle of mandible while supine.
CARDIAC: RR, normal S1, S2. No S3 or S4. +SEM loudest @ LUSB, +
carotid bruits
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB of anterior fields
ABDOMEN: Soft, NTND. Abd aorta not enlarged by palpation. No
abdominial bruits.
EXTREMITIES: No c/c/e, + right femoral bruit
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas
Pulses: faint DP & PT pulses b/l
Pertinent Results:
Right and Left Heart Catheterization:
1. Selective coronary angiography of this right dominant system
demonstrated single vessel coronary artery disease. The LMCA was
free of angiographically significant disease. There was mild
paquing of the LAD with a 60% ostial stenosis leading to a small
D2. The LCx had diffuse insignificant plaquing. The RCA had a
40% ostial lesion and a 60% proximal stenosis. Pressures were
damped with a 5-Fr catheter. The gradient across the lesion by
pressure wire was hemodynamically significant at rest (32mmHg).
2. Limited resting hemodynamics revealed elevated right and left
heart filling pressures. There was moderate pulmonary artery
hypertension. The cardiac output and index were normal as was
the SVR. The PVR was slightly elevated. There was severe
systemic arterial hypertension despite aggressive IV vasodilator
therapy (SBP=184mmHg). On careful pullback from the LV there was
no pressure gradient across the aortic valve.
3. Selective angiography of the bilateral renal arteries
revealed no angiographically significant disease.
4. Successful PCI with BMS to RCA.
5. [**Hospital **] medical therapy and BP control.
6. Watch renal function closely.
.
FINAL DIAGNOSIS:
1. NSTEMI with one vessel coronary artery disease.
2. Severe systemic arterial hypertension
3. Moderate diastolic dysfunction
4. No renal artery stenosis
5. Successful FFR guided PCI to proximal RCA.
.
LOWER EXTREMITY ULTRASOUND: Targeted Grayscale and Doppler
son[**Name (NI) **] of the right common femoral artery and vein was
performed. There is normal flow and waveforms within the veins.
There is no evidence of pseudoaneurysm.
Brief Hospital Course:
55 yo W with PMHx of CAD s/p POBA to LAD in 99, BMS to RCA in
[**4-13**], PVD (s/p L iliac angio & R SFA stenting), HTN, HLD, IDDM
presenting to OSH with elevated troponins and acute on chronic
diastolic CHF, transferred for cath where she received BMS to
prox RCA, and had significantly elevated blood pressures
necessitating nitroglycerin and nipride gtts
.
# Hypertensive Urgency: Patient had been receiving her home
antihypertensive medication regimen at the OSH. Per report, the
day prior to transfer her pressures were elevated and
supplemental labetalol was given. During catheterization the
patient was maxed on a nitroglycerin gtt, then started on a
nitroprusside gtt to keep her SBPs <180. Her renal arteries
appeared normal. Based on the patient's description of the
procedure, a component of her elevated BPs was likely secondary
to anxiety. On arrival to the CCU she denied any symptoms of end
organ damage. Given her baseline poor renal function we
discontinued the Nipride gtt and re-started the Nitroglycerin
gtt, as well as re-started her outpatient antihypertensive
regimen (except for Lisinopril during [**Last Name (un) **]). She was easily
weaned off the Nitroglycerine gtt and her blood pressure
remained well controlled. On discharge we asked the patient to
hold her Lisinopril until she follows up with her providers.
.
# Acute on chronic diastolic CHF: Patient presented to OSH with
acute dyspnea, and had CXR findings of pulmonary edema and
elevated troponin (peak 0.6, CKMB flat). She was diuresed with
IV Lasix 40 [**Hospital1 **] with subsequent improvement in her symptoms. An
echocardiogram obtained at the OSH revealed preserved EF of 55%,
mild MR, mild TR, mod elevated PAP, and mild LVH. Unclear
trigger as the patient denied medication non-compliance, dietary
indiscretion, or symptoms to suggest infection. She was
transferred to our hospital and underwent cardiac
catheterization where her LVEDP was noted to be 30. BNP was
elevated at 2891. Clinical exam revealed bibasilar rales. She
was given IV Lasix boluses and diuresed over her hospital
course. She initially required supplemental oxygen to maintain
adequate oxygen saturations, but that improved with diuresis.
She was continued on Metoprolol, but Lisinopril was held given
her acute on chronic kidney injury. She was discharged on a
decreased dose of Lasix 40 mg PO daily.
.
# Acute on Chronic Kidney Injury: Likely secondary to contrast
nephropathy given her baseline poor renal function and history
of diabetes, despite pre and post-cath hydration. She received
160 cc dye load during the catheterization. Her ace-inhibitor
was held. Her creatinine was 1.2 on admission (baseline likely
1.5 based on OSH records), peaked at 4.3, and began to trend
down. Her creatinine was 3.3 at discharge. She was making good
urine output, and will follow up for a lab check as outpatient.
.
# CAD/PVD: The patient has a long history of diffuse vascular
disease. She presented to OSH with elevated troponins (peak
0.62) in setting of CHF and chest discomfort. CKMBs remained
flat. She was transferred for cardiac catheterization which
revealed diffuse, but non-critical plaquing of LAD and LCx, and
60% proximal RCA stenosis, for which a BMS was placed. Her EKG
remained stable from baseline. Post-cath check was notable for a
bruit at entry site not documented on admission physical.
Ultrasound was obtained and negative for pseudoaneurysm. She was
continued on ASA 325, Plavix 75, and Atorvastatin 80 daily. She
was also given a prescription for SL Nitro to take for chest
pain in the future.
.
# Agitated Delirium: The patient had one episode of agitation
and disorientation during her stay at the OSH. Given she had
been on a heparin gtt, a head CT was obtained and negative for
ICH. During her stay in the ICU she had a few episodes of
transient disorientation (often after awakening), and became
quite tearful, agitated, and distrustful of the care she was
receiving. We performed a delirium work up (B12, folate, TSH,
RPR), as well as obtained a urinalysis, which were negative for
gross abnormalities. According to her family members, this was
new behavior; however, they had been noticing mild increased
confusion for some time now. Psychiatry was consulted and
recommended delirium work-up, frequent reorientation, transfer
out of ICU, and Haldol if needed for agitation. Haldol was not
needed. Her symptoms improved.
.
# Rhythm: Monitored on telemetry. Remained in sinus rhythm,
occasionally asymptomatic sinus bradycardia with rate in the
50s.
.
# IDDM: Diagnosed at age 14. Has many microvascular and
macrovascular complications including retinopathy, neuropathy,
nephropathy, CAD and PVD. Hgb A1c of 9.9 indicating need for
tighter control. We monitored her FSBG levels, provided
diabetic, consistent-carbohydrate diet, and continued her on her
outpatient regimen of Glargine and Humalog SSI.
.
# Chronic Normocytic Anemia: History of guaiac + stools, but
prior evaluation of GI tract has been negative. Takes Fe
supplement as outpatient, which was held on admission, and
re-started at discharge. Her hematocrit was closely monitored
and remained relatively stable. Given that her Fe studies
reflected iron deficiency, this should continued to be monitored
and evaluated by her Primary Care Physician after discharge.
.
# HLD: Continued Atorvastatin 80 daily.
.
# Peripheral Neuropathy: Initially continued Lyrica 100 TID,
then discontinued it in the setting of her acute kidney injury.
Her pain was controlled with tramadol and low dose oxycodone.
Upon discharge she was given a two day prescription for Percocet
for pain relief, then told to re-start her Lyrica.
.
# GERD: We initially held her outpatient Omeprazole and started
renally-dosed Famotidine given the patient's history of being on
Plavix. Famotidine was discontinued in the setting of acute
kidney injury. Upon discharge she was restarted on Omeprazole.
This should be discussed with her outpatient Cardiologist.
.
# Risk Factor Modification: The patient was encouraged to stop
smoking tobacco. We provided her with a nicotine patch to reduce
cravings. Social Work was consulted for smoking cessation
counseling.
Medications on Admission:
-Metoprolol 75 [**Hospital1 **]
-Lisinopril 10 [**Hospital1 **]
-Norvasc 30 AM, 60 PM
-Prilosec 40 qd
-Lantus 26 units
-Novolog SSI
-Aspirin 325 daily
-Plavix 75 qd
-Lasix 80 daily
-Lipitor 80 daily
-Percocet 5/325 q6
-Lyrica 100 TID
-Slow Fe daily
Discharge Medications:
1. Outpatient Lab Work
Please have Chemistry 7 drawn (sodium, potassium, chloride,
bicarbonate, BUN, creatinine and glucose). Please fax these
results to Dr. [**Last Name (STitle) 39822**] [**Name (STitle) **] at fax # [**Telephone/Fax (1) 19406**] (phone #
[**Telephone/Fax (1) 8506**])
2. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
4. Lantus 100 unit/mL Solution Sig: 26 units daily Subcutaneous
once a day.
5. Novolog 100 unit/mL Solution Sig: One (1) Subcutaneous once
a day: Use per home insulin sliding scale.
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
8. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual once a day as needed for chest pain: [**Month (only) 116**] repeat two
times. If you need to use this medication more than once, please
call your physician.
[**Name Initial (NameIs) **]:*30 tablets* Refills:*0*
9. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**4-9**]
hours for 2 days: Please continue for two days.
[**Month/Day (3) **]:*10 Tablet(s)* Refills:*0*
10. iron 325 mg (65 mg Iron) Capsule, Extended Release Sig: One
(1) Capsule, Extended Release PO once a day: please restart home
dose of iron supplement.
11. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
12. furosemide 40 mg Tablet Sig: One (1) Tablet PO ONCE (Once).
[**Month/Day (3) **]:*30 Tablet(s)* Refills:*0*
13. Lyrica 100 mg Capsule Sig: One (1) Capsule PO three times a
day: please start in two days.
14. nifedipine 30 mg Tablet Extended Release Sig: 1 in the
morning, 2 in the evening Tablet Extended Release PO twice a
day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
acute on chronic diastolic congestive heart failure
hypertensive urgency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for management of heart failure. On transfer
to [**Hospital1 69**], a cardiac
catheterization revealed coronary artery disease. A bare metal
stent was placed in one of the arteries supplying your heart.
You were admitted to cardiac intensive care unit for management
of elevated blood pressures after your procedure. You were given
diuretics to help relieve some of the excess fluid that had
collected while in heart failure. While admitted, you developed
acute kidney injury likely from the contrast dye that was
injected into your arteries during the catheterization, a not
uncommon side effect. Your renal function was
improving at the time of discharge. It will be important for
you to follow-up closely with your primary care physician this
week regarding your hospitalization and kidney function.
The following medication changes were made:
1. Please STOP taking Lisinopril until your primary care
physician or cardiologist allows you to restart. This medication
was held due to your acute kidney injury.
2. Please DECREASE your dose of Lasix to 40mg daily and discuss
this change with your physicians.
3. Please take Percocet for pain management for 2 more days
4. Please RESTART Lyrica in 2 days.
5. Please START sublingual nitroglycerin for management of chest
pain. If you need to use this medication more than once in a
row, or with increasing frequency, please contact your physician
[**Name Initial (PRE) 2227**].
4. Please DISCONTINUE Norvasc
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please call your cardiologist Dr. [**First Name11 (Name Pattern1) 518**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 8579**] to schedule
an appointment within the next 1-2 weeks for a follow-up
appointment.
Address: [**State **], [**Apartment Address(1) 39823**], [**Location (un) **], [**Numeric Identifier 23881**]
Phone: ([**Telephone/Fax (1) 39824**]
Please call your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] for
follow-up this week. It will be important to have your blood
drawn on Tuesday for monitoring of your kidney function and have
these results faxed to Dr. [**Last Name (STitle) **] if you are unable to see her
before Tuesday.
Name: [**Doctor Last Name **],[**Doctor Last Name **] C.
Location: [**Hospital **] MEDICAL ASSOC-[**Location (un) **]
Address: [**Location (un) 11898**], [**Location (un) **],[**Numeric Identifier 9310**]
Phone: [**Telephone/Fax (1) 8506**]
Fax: [**Telephone/Fax (1) 19406**]
ICD9 Codes: 5849, 4439, 4280, 3572, 2724, 3051, 2859, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1027
} | Medical Text: Admission Date: [**2116-7-19**] Discharge Date: [**2116-7-22**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
bleed tranferred from OSH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 83237**] is an 88 yo RH woman with a pMH remarkable for HTN,
CHF and LBD on coumadin (parox AF) p/w a fall 24h prior to
admission at [**Hospital1 18**].
She fell from her rocking chair and struck the LEFT side of her
head and LEFT hand yesterday at noon. She did not loose her
consciousness (as per nurse who saw her in her chair 1 minute
prior to falling). She is usually having falls when attempting
to
walk with her walker. She did have a bilateral hip replacement
and a subsequent LEFT femoral fracture (with residual internal
hip rotation) that impairs her gait (for 2 years).
She remained in the [**Hospital3 **] facility, but started to
become confused. She was taken to [**Hospital3 4107**] today at
around
11:00 am, where she received a CT scan that showed a small (1.
3cm) left frontal intraparenchimal bleed without a midline
shift,
not open to the ventricles, no data of hydrocephalus. At [**Hospital1 **]
her VS were stable. At the time she was confused. She had an
INR
of 2.97 and received vitamin K 10 mg iv without complications.
Once at [**Hospital1 18**] ED, her VS were 98.6F, 70 bpm, 161/ 71, 16RR, So2
100% in RA. She was alert and oriented *3. Pleasant and
cooperative with the ED team. She received FFP and a new CT CNS
and C-spine scan w/o contrast that showed.
The family denies any previous episodes with focal deficits
eventually resolving. Sh ehas been having viual hallucinations
for 24 months. Those are well formed (people). She talks to
them,
but they do not reply. She has been seeing her husband lately
(he
passed the way 6 months ago).
Past Medical History:
PMH: PCP:[**Telephone/Fax (1) 83238**]
HTN
Paroximal CHF (unknown EF and diastolic function)
LBD
Depression??
Urinary incontinence
No previous strokes or spontaneous bleeds/ coagulopathy or brain
tumors. No Hx of seizure
Social History:
Lives in [**Location 10549**] living facility
Family History:
no hx of early strokes, or spontaneous bleeds/ coagulopathy,
brain tumors. No Hx of seizures.
Physical Exam:
VS: 98.6F, 70 bpm, 161/ 71, 16RR, So2 100% in RA.
Gen: Lying in bed, NAD.
HEENT: NC/AT, moist oral mucosa
Neck: supple, no carotid or vertebral bruit
Back: No point tenderness or erythema
CV: Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Abd: Soft, nontender, non-distended. No masses or
megalies.Percussion within normal limits. +BS.
Ext: no edema, no DVT data. Pulses ++ and symmetric.
Neurologic examination:
No meningismus. No photophobia.
MS:General: alert, awake, normal affect
Orientation: oriented to person, place, date, situation
Attention: 20 to 1 backwards +. Follows simple/complex commands.
Speech/Language: fluent w/o paraphasic errors;
comprehension,repetition, naming: normal. Prosody: normal.
Memory: Registers [**3-24**] and Recalls [**2-25**] when given choices at 5
min
Praxis/ agnosia: Able to brush teeth. No field cuts.
CN:I: not tested
II,III: VFF to confrontation, PERRL 3mm to 2mm, fundus w/o
papilledema.
III,IV,VI: EOMI, no ptosis. No nystagmus
V: sensation intact V1-V3 to LT
VII: Facial strength intact/symmetrical
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midlineXI:
SCM/trapezeii [**5-26**] bilaterally
XII: tongue protrudes midline, no dysarthria
Rinne: R ear: AC>BC, LEFT ear AC> BC
[**Doctor Last Name 15716**]: central.
Motor: Normal bulk. Tone: Coughweeling in both arms. No tremor,
no asterixis or myoclonus. No pronator drift:
Delt;C5 bic:C6 Tri:C7 Wr ext:C6 Fing ext:C7
Left 5 5 5 5 5
Right 5 5 5 5 5
IP: Quad: Hamst: Dorsiflex: [**Last Name (un) 938**]:Pl.flex
Left internal rotation and antigravity (not new).
Right 5 5 5 5 5
Deep tendon Reflexes:
Bicip:C5 Tric:C7 Brachial:C6 Patellar:L4 Toes:
Right 1 1 1 1 DOWNGOING
Left 1 1 1 1 DOWNGOING
Sensation: Intact to light touch, vibration, and
temperature.Propioception: normal.
Coordination:
*Finger-nose-finger normal.
*Rapid Arm Movements bl clumsy
*Fine finger tapping: no decrement
Pertinent Results:
[**2116-7-19**] 05:35PM GLUCOSE-85 UREA N-19 CREAT-1.0 SODIUM-141
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-31 ANION GAP-11
[**2116-7-19**] 05:10PM WBC-6.1 RBC-3.67* HGB-10.6* HCT-31.5* MCV-86
MCH-28.9 MCHC-33.6 RDW-15.0
[**2116-7-19**] 05:10PM NEUTS-71.9* LYMPHS-20.7 MONOS-5.3 EOS-1.9
BASOS-0.3
[**2116-7-19**] 05:10PM PT-27.9* PTT-38.3* INR(PT)-2.7*
[**2116-7-20**] 02:32AM BLOOD CK-MB-3 cTropnT-0.04*
[**2116-7-20**] 08:35AM BLOOD CK-MB-5 cTropnT-0.05*
[**2116-7-20**] 02:32AM BLOOD Triglyc-80 HDL-51 CHOL/HD-4.0
LDLcalc-135*
[**2116-7-20**] 02:32AM BLOOD TSH-1.6
Wrist x ray: No acute fracture. Old distal radious and ulnar
styloid fractures.
CNS scan without contrast: LEF frontal bleed. no mas effect, not
open to ventricles.
Brief Hospital Course:
Mrs.[**Last Name (un) 83239**] INR was corrected with vitamin K at OSH and
Profilnine and FFP here. Ms [**Known lastname 83237**] was admitted to the
neurologic ICU service overnight for observation for her left
frontal intraparechymal hemorrhage. Her ICH was thought to
represent a traumatic contusion. She remained stable and her
neurologic exam was normal other than a slight right facial
droop. No repeat imaging or further work up was felt to be
necessary. Fasting lipid panel w/ LDL 135, total Chol 202.
Discharged on ASA 81 qd with plans to re-start coumadin in [**7-31**]
days. When therapeutic on coumadin, ASA will be discontinued.
Cards: Telemetry unremarkable
No ID, Endo, GI, Resp issues this admission
Medications on Admission:
Coumadin 5mg qhs, but Tuesday and Friday 7 mg qhs
ASA 81 mg qd.
Metoprolol 25 mg [**Hospital1 **], verapamil 240 qd, lisinopril 20 qd.
Furosemide 20 mg qd
Sinemet/ carbidopa: 25/ 100 tid
Aricept 5 mh qd. Celexa 20 qd.
Bactrim SS 100/ 80, Tolterodine (antimuscarinic) 7.5 qd
MVI
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Carbidopa-Levodopa 25-100 mg Tablet Sustained Release Sig:
One (1) Tablet PO TID (3 times a day).
5. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily): This medication is to be stopped when coumadin
reaches therapeutic dose. Coumadin to be started [**7-27**].
11. Verapamil 240 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Hospital **] Nursing Home - [**Location (un) 5087**]
Discharge Diagnosis:
Primary:
traumatic left frontal intaparychymal hemorrhage (contusion)
Secondary:
Paroxysmal atrial fibrilation treated with coumadin
CHF
Hypertension
[**Last Name (un) 309**] Body Dementia
Discharge Condition:
She is at her baseline. Still mild rigth sidede droop. Otherwise
her neurological examination is normal.
Discharge Instructions:
You were admitted to the ICU with bleeding in the front left
part of your brain after a fall. The bleeding has stabilized
and your coumadin was reversed
.
Please take all medications as perscribed. If you have concerns
about the medications, please call your PCP before changing the
doses.
.
Please call your PCP or return to the emergency room if you
experience any worsening in your symptoms or have other concerns
Please note that coumadin was reversed and stopped because of
hemorrhage. Aspirin has been started in meantime. Coumadin
should be resumed at prior dose on [**7-27**], and titrate to goal INR
[**2-25**]. Aspirin to be discontinued once INR therapeutic.
Followup Instructions:
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2116-9-8**] 1:00
PCP: [**Name10 (NameIs) 9529**],[**Name11 (NameIs) **] [**Telephone/Fax (1) 17503**]
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
ICD9 Codes: 2930, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1028
} | Medical Text: Admission Date: [**2138-8-21**] Discharge Date: [**2138-8-29**]
Date of Birth: [**2064-5-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
OSH transfer for cardiogenic shock
Major Surgical or Invasive Procedure:
Cardiac Catheterization with POBA to OM1 and no stents
History of Present Illness:
74M with h/o OSA on CPAP, HLD, HTN and no known cardiac history
confirmed with partner and family, admitted to [**Name (NI) 8125**] on for
spinal surgery [**1-9**] severe spinal stenosis, had L3-L5 laminectomy
with decompression on [**8-19**]. On [**8-21**] (POD #2) pt was difficult to
arouse at 6:30am. RN removed CPAP (for OSA) -> resp distress
with SaO2 70-80s, hypotensive, and unresponsive -> given 40mg IV
Lasix, intubated and transferred to ICU. In ICU given more
lasix. Then at 9:00 PEA code called, CPR x5 mins with 1mg Epi,
Dopamine, and Phenylephrine started. Pt returned to sinus rhythm
within 10 minutes with BP 120s/60s. OGT placed and EKG was done
that was interpreted as RV Infarct prompting transfer.
- CXR was done that showed Right lung white out and left lung
pulm edema.
- Bedside echocardiogram was performed which demonstrated
inferobasal and posterior wall hypokinesis and an LV ejection
fraction of 45-50%. The right ventricle was mildly dilated with
moderate hypokinesis. Estimated pulmonary artery pressure was 35
mmHg.
.
On transfer here, the pt was intubated, was put on phenylephrine
and dopamine and given a 3000U Heparin bolus.
.
OSH Labs showed Trop 4.21 BNP 232 wbc 19 plt 428, INR 1.1 Crt
0.9 Gluc 188.
.
In [**Hospital1 18**] Cath Lab - Bolused with Heparin 2000U, ASA 325, no
plavix.
Results showed: (1) LCx 90% stenosis, (2) 99% OM1 stenosis, with
POBA to OM1 no stents.
- Dye Load = 185 mL
- Fick CO: 5.08, CI: 2.30
- RA Mean: 18
- RV: 55/13
- PCWP: 25
- PAP: 50/28
- AO: 117/65
.
On arrival to CCU - Pt was intubated on CPAP FiO2 100 with
20PEEP SaO2 92, On Dobutamine @ 2, Fentanyl at .5, Midaz at 4.
Vitals were HR 90, BP 94/53, and Febrile to 101.9.
Past Medical History:
HTN
Mild AS
DM2 - diet controlled
OSA with CPAP
Hyperlipidemia
Restless leg syndrome, s/p normal ST recently
Chronic back pain (now s/p fusion)
BPH
GERD
Social History:
-Lives at home, retired, with male partner, former Episcopalian
minister
-Tobacco history: former smoker, quit 20 [**Last Name (un) **], smoked for 20
years 1ppd
-ETOH: [**2-9**] scotch / week
-Illicit drugs: none.
Family History:
- father died at 60 ? heart issues (had pacemaker)
- mother died at 62
- brother [**Name (NI) **] alive
- no other heart fam history
Physical Exam:
Admission Exam:
Ht 5'7", Wt 250 lbs
VS: 101.9, HR 90, BP 94/53 (66) - aLine, SaO2 92% on CPAP FiO2
100, 20 PEEP
GENERAL: Obese caucasian male intubated.
NEURO: pinpoint pupils, squeezed hands, no wiggle of toes,
opened eyes to nurse.
[**Last Name (Titles) 4459**]: Pickwikian neck habitus, OGT and ETT in place. Difficult
to appreciate JVP
CARDIAC: Distant heart sounds, RR. No m/r/g.
LUNGS: Ausculated anteriorly, decreased breath sounds on the
right. No crackles.
ABDOMEN: Obese, soft, no bowel sounds.
BACK: serosanginous output from drain of lower back
EXTREMITIES: Dopplerable DP/PT.
LINES: Right IJ, Right A Line.
.
Discharge Exam:
GENERAL: Obese caucasian male A+Ox3.
NEURO: non-focal
[**Last Name (Titles) 4459**]: Pickwikian neck habitus, no JVD appreciated.
CARDIAC: Distant heart sounds, RR. No m/r/g.
LUNGS: CTAB. No crackles.
ABDOMEN: Obese, soft, no bowel sounds.
GU: Foley in place
EXTREMITIES: Palpable DP/PT.
Pertinent Results:
[**2138-8-21**] 02:30PM PT-13.4* PTT-47.0* INR(PT)-1.2*
[**2138-8-21**] 02:30PM PLT COUNT-324
[**2138-8-21**] 02:30PM NEUTS-87.1* LYMPHS-9.1* MONOS-3.6 EOS-0.1
BASOS-0.1
[**2138-8-21**] 02:30PM WBC-17.8* RBC-3.48* HGB-11.1* HCT-32.4*
MCV-93 MCH-32.0 MCHC-34.3 RDW-13.8
[**2138-8-21**] 02:30PM CALCIUM-7.0* PHOSPHATE-3.4 MAGNESIUM-1.9
[**2138-8-21**] 02:30PM CK-MB-104* MB INDX-1.5 cTropnT-0.78*
[**2138-8-21**] 02:30PM CK(CPK)-6930*
[**2138-8-21**] 02:30PM GLUCOSE-195* UREA N-26* CREAT-0.8 SODIUM-137
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-24 ANION GAP-12
[**2138-8-21**] 02:40PM URINE MUCOUS-RARE
[**2138-8-21**] 02:40PM URINE HYALINE-4*
[**2138-8-21**] 02:40PM URINE RBC-15* WBC-8* BACTERIA-NONE YEAST-NONE
EPI-<1 RENAL EPI-<1
[**2138-8-21**] 02:40PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-TR
[**2138-8-21**] 02:40PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.050*
[**2138-8-21**] 02:40PM freeCa-1.01*
[**2138-8-21**] 02:40PM LACTATE-1.8
[**2138-8-21**] 02:40PM TYPE-ART PO2-71* PCO2-41 PH-7.35 TOTAL CO2-24
BASE XS--2
[**2138-8-21**] 04:04PM TYPE-ART PO2-77* PCO2-40 PH-7.38 TOTAL CO2-25
BASE XS-0
[**2138-8-21**] 07:54PM O2 SAT-98
[**2138-8-21**] 07:54PM TYPE-ART PO2-175* PCO2-42 PH-7.38 TOTAL
CO2-26 BASE XS-0
[**2138-8-21**] 08:58PM CALCIUM-7.5* PHOSPHATE-3.0 MAGNESIUM-2.8*
[**2138-8-21**] 08:58PM CK-MB-87* MB INDX-1.2 cTropnT-1.33*
[**2138-8-21**] 08:58PM CK(CPK)-7363*
[**2138-8-21**] 08:58PM GLUCOSE-177* UREA N-29* CREAT-0.8 SODIUM-137
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-26 ANION GAP-10
[**2138-8-21**] 09:12PM O2 SAT-98
[**2138-8-21**] 09:12PM TYPE-ART PO2-121* PCO2-44 PH-7.38 TOTAL
CO2-27 BASE XS-0
[**2138-8-21**] 11:54PM O2 SAT-97
[**2138-8-21**] 11:54PM TYPE-ART PO2-111* PCO2-44 PH-7.36 TOTAL
CO2-26 BASE XS-0
[**2138-8-21**] 12:32PM TYPE-ART RATES-/16 TIDAL VOL-500 O2 FLOW-100
PO2-88 PCO2-41 PH-7.37 TOTAL CO2-25 BASE XS--1 -ASSIST/CON
INTUBATED-INTUBATED
[**2138-8-21**] 12:32PM HGB-10.8* calcHCT-32 O2 SAT-96
.
EKG: STD V4-V6, I, aVF
.
CXR: RIJ in proximal SVC, ETT proximal to carina, OGT in
stomach, right lung with significant mid opacification, left
lung with three areas of opacification laterally.
.
CARDIAC CATH: Bolused with Heparin 2000U, ASA 325, no plavix.
Results showed: (1) LCx 90% stenosis, (2) 99% OM1 stenosis, with
POBA to OM1 no stents.
- Dye Load = 185 mL
- Fick CO: 5.08, CI: 2.30
- RA Mean: 18
- RV: 55/13
- PCWP: 25
- PAP: 50/28
- AO: 117/65
.
ECHO [**8-21**]:
The left ventricle is not well seen. Right ventricular chamber
size is normal. with borderline normal free wall function. The
aortic valve is not well seen. The mitral valve leaflets are
mildly thickened. The mitral valve leaflets are not well seen.
Trivial mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Limited study. Mild
pulmonary artery systolic hypertension.
.
ECHO [**8-22**]:
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF 70%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
is not well seen. Aortic stenosis is present (not quantified).
There is an anterior space which most likely represents a
prominent fat pad.
.
DISCHARGE:
[**2138-8-29**] 07:20AM BLOOD WBC-18.1* RBC-3.18* Hgb-10.0* Hct-29.8*
MCV-94 MCH-31.3 MCHC-33.5 RDW-13.5 Plt Ct-616*
[**2138-8-29**] 07:20AM BLOOD Glucose-116* UreaN-19 Creat-0.6 Na-139
K-3.7 Cl-105 HCO3-23 AnGap-15
[**2138-8-29**] 07:20AM BLOOD ALT-141* AST-56*
Brief Hospital Course:
74 yo male with PEA arrest and NSTEMI (LCx/OM1) on POD #2 after
spinal surgery at OSH. He was transferred to [**Hospital1 18**] and admitted
to the CCU.
.
# Hypoxic Respiratory Failure : Patient developed hypoxic
respiratory failure, likely secondary to aspiration pneumonia
vs. pneumonitis. He was intubated and ventilated on ARDS net
protocol. He was treated with vancomycin and Zosyn. We
diuresed the patient >1L net negative per day. On [**8-25**], the
patient was extubated. He did well from a respiratory
stand-point following extubation. He continued to have an
elevated WBC count during his hospital stay, likely due to
resolving pneumonitis. It was 18 on [**8-29**]. He was afebrile and
otherwise without evidence of infection. His WBC count should
be checked at the rehabilitation facility every 48 hours to
ensure that the leukocytosis resolves.
.
# PEA Arrest: Patient had PEA arrest at OSH secondary to hypoxia
in the setting of aspiration and MI. By [**8-24**], he was without
pressor support and was in sinus rhythm. He did not have
significant ectopy or arrhythmia.
.
# NSTEMI: EF 45%. Wt at discharge = 110kg. Patient had a RV MI
and had a catheterization with POBA to distal LCx. The patient
was treated with aspirin and atorvastatin. He initially needed
pressors for cardiogenic shock, but pressors were weaned off by
[**8-24**]. Metoprolol was initiated on [**8-24**]. Troponin peaked at
1.33 and CK-MB at 104. Plavix was held given the recent spinal
surgery. Follow-up ECHO showed on [**8-22**] showed normal LV
function. The patient was discharged on aspirin, metoprolol,
losartan, and low-dose atorvastatin (due to transaminitis).
.
# Anemia: HCT dropped from 32 on [**8-21**] to 24 on [**8-23**] with no
clear source of bleeding. On [**8-24**], HCT stabilized at 26. We
monitored spine and retroperitoneum by exam to evaluate for
bleeding. No evidence of GI bleed or hemolysis. We followed
HCT daily. At time of discharge, HCT was 29.8.
.
# Spinal Surgery: Patient continued to recover well from the
surgery he had at [**Hospital6 **]. Our spine surgery team
followed the patient while he was an inpatient here at [**Hospital1 18**] and
allowed full activty privileges. His back drain was removed on
[**8-22**]. He should follow up with the spine surgeons at NEBH as
scheduled.
.
# Hypertension: Home amlodipine was held in the setting of
cardiogenic shock. When BP improved, metoprolol was initiated
instead of home amlodipine. Losartan was also initiated.
.
# Hyperlipidemia: Patient was put on atorvastatin 80mg daily
initially. However, he developed transaminitis; his ALT peaked
at 181 and AST at 223 (which likely occurred secondary to
cardiogenic shock). Therefore, his atorvastatin was
discontinued until [**8-29**], when it was re-initiated at 10mg daily.
LFTs should be followed by the rehabilitation facility. At
discharge, ALT was 141, and AST was 56. His cardiologist may
wish to consider increasing his statin in the future.
.
# Diabetes: Patient was treated with insulin sliding scale.
.
# GERD: Patient was continued on H2 blocker.
.
# Urinary Retention: Patient had a Foley catheter for UOP
monitoring while in the CCU. It was removed on [**8-27**], and on
[**8-28**], he was found to have urinary retention. Foley was
replaced on [**8-28**], and his home tamsulosin was was restarted.
The rehab facility should remove the Foley and evaluate whether
the patient is able to urinate on or around [**9-3**].
.
Transitional Issues:
- For Rehab Facility: Check LFTs and WBCs every other day to
ensure resolution of transaminitis and leukocytosis; Remove
Foley any day after [**8-31**] after pt is on Tamsulosin and
Oxybutynin and re-evaluate for urinary retention
.
- For Cardiology Follow-Up: Consider increasing atorvastatin
from 10mg/day to at least 30m/day, enforce to the patient that
he should NOT use NSAIDs, Stress Test in [**2-9**] months, consider
diuretics.
.
- For PCP: [**Name Initial (NameIs) **] HgbA1C to consider Metformin, patient was
controlled on sliding scale in the hospital and diet controlled
at home
.
- CODE: FULL confirmed
- EMERGENCY CONTACT: Partner and HCP [**Name (NI) **] [**Telephone/Fax (1) 112477**]
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from OSH records.
1. Naproxen 220 mg PO Q8H:PRN pain
2. Losartan Potassium 100 mg PO DAILY
3. Duloxetine 30 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Ferrous Gluconate 325 mg PO DAILY
6. Tamsulosin 0.4 mg PO HS
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. Clonazepam 1 mg PO QHS
9. Lactaid *NF* (lactase) 3,000 unit Oral TID: PRN dairy
10. Vitamin B Complex 1 CAP PO DAILY
11. Atorvastatin 30 mg PO HS
12. Psyllium 1 PKT PO HS
13. NexIUM *NF* (esomeprazole magnesium) 20 mg Oral [**Hospital1 **]
14. Amlodipine 10 mg PO DAILY
15. Oxybutynin 5 mg PO HS
16. Multivitamins 1 TAB PO DAILY
17. Vitamin D 1000 UNIT PO DAILY
18. Vitamin E 400 UNIT PO DAILY
19. ZYRtec *NF* 10 mg Oral daily
20. melatonin *NF* 10 mg Oral HS
21. Osteo [**Hospital1 **]-Flex *NF*
(gluc-[**Doctor Last Name 2871**]-msm#1-C-[**Last Name (un) **]-bos-bor;<br>glucosamine-D3-boswellia
[**Last Name (un) **]) 1,[**Telephone/Fax (3) 112478**] mg-unit-mg Oral as directed
22. Krill Oil (Omega 3 & 6) *NF*
(krill-om3-dha-epa-om6-lip-astx) 1000-130(40-80) mg Oral as
directed
23. coenzyme Q10 *NF* UNKNOWN Oral as directed
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clonazepam 1 mg PO QHS:PRN insomnia
3. Duloxetine 30 mg PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Losartan Potassium 100 mg PO DAILY
6. NexIUM *NF* (esomeprazole magnesium) 20 mg ORAL [**Hospital1 **]
7. Psyllium 1 PKT PO HS
8. Tamsulosin 0.4 mg PO HS
9. Vitamin B Complex 1 CAP PO DAILY
10. Acetaminophen 650 mg PO Q6H
11. Docusate Sodium 100 mg PO BID
12. Ferrous Sulfate 325 mg PO DAILY
13. Metoprolol Succinate XL 25 mg PO DAILY
Hold for SBP<90, HR<60
14. Senna 1 TAB PO BID
hold for loose stool
15. TraMADOL (Ultram) 100 mg PO Q6H:PRN back pain
16. Krill Oil (Omega 3 & 6) *NF*
(krill-om3-dha-epa-om6-lip-astx) 1000-130(40-80) mg Oral as
directed
17. Lactaid *NF* (lactase) 3,000 unit Oral TID: PRN dairy
18. melatonin *NF* 10 mg Oral HS
19. Multivitamins 1 TAB PO DAILY
20. Osteo [**Hospital1 **]-Flex *NF*
(gluc-[**Doctor Last Name 2871**]-msm#1-C-[**Last Name (un) **]-bos-bor;<br>glucosamine-D3-boswellia
[**Last Name (un) **]) 1,[**Telephone/Fax (3) 112478**] mg-unit-mg Oral as directed
21. Oxybutynin 5 mg PO HS
22. Vitamin D 1000 UNIT PO DAILY
23. Vitamin E 400 UNIT PO DAILY
24. ZYRtec *NF* 10 mg Oral daily
Discharge Disposition:
Extended Care
Facility:
[**Hospital 31356**] Healthcare Center - [**Location (un) 730**]
Discharge Diagnosis:
- Ventilator dependent hypoxemic respirator failure
- NSTEMI (99% occluion of OM1)
- Pulseless Electrical Activity
- Aspiration pneumonitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr [**Known lastname **],
You were admitted to [**Hospital1 18**] from [**Hospital6 **] after
difficulty breathing, and temporary stopped heart. You required
intubation there. During this event you also had a heart attack.
At [**Hospital1 18**] cardiologist performed a heart catheterization with
angioplasty, and without placement of stents. You were extubated
and treated with IV antibiotics for an infection of your lungs.
Your clinical status improved significantly and our physical
therapists recommend that you continue rehabilitation as an
inpatient. We started you several new medications for your heart
attack, please see below. We have also set up an appointment
with a Cardiologist, Dr. [**First Name4 (NamePattern1) 2174**] [**Last Name (NamePattern1) 2912**], who saw you while
you were at [**Hospital6 **]. (See info below)
.
MEDICATIONS:
- STOP Naproxen - avoid all NSAIDs as they can be detrimental to
your heart
- START Metoprolol succinate XL 25mg/day
- Decrease Atorvastatin from 30mg/day to 10mg/day (increase this
back to 30mg/day after your liver enzymes normalize)
- Continue Aspirin 81mg/day
- Contine Losartan 100mg/day
- continue diet control of your diabetes
Followup Instructions:
Cardiologist Dr. [**Last Name (STitle) **] (he saw you in the hospital at [**Hospital1 18**]) will
set up an appointment for you. Please call his office next week
on [**2138-9-3**] to confirm date and time of the appointment.
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
[**Apartment Address(1) 98993**]
[**Location (un) 86**], [**Numeric Identifier 112479**]
Phone: [**Telephone/Fax (1) 7960**]
ICD9 Codes: 5070, 4019, 2724, 2859, 4168, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1029
} | Medical Text: Admission Date: [**2103-6-2**] Discharge Date: [**2103-6-8**]
Service: MED
HISTORY OF PRESENT ILLNESS: An 83-year-old female with a
history of interstitial pulmonary fibrosis on six liters of
oxygen and 10 mg of prednisone at baseline, congestive heart
failure, hypertension, was found by primary care physician on
[**5-29**] to have ambulatory sats of 70 percent. The patient
was admitted to [**Hospital 1562**] Hospital and started on Solu-Medrol
and levofloxacin. The patient underwent CT of chest at
outside hospital which showed ground glass opacities
bilaterally and no PE. The patient was transferred to [**Hospital1 1444**] for lung biopsy and
intubated. Lung biopsy only showed pulmonary congestion
consistent with congestive heart failure and interstitial
pulmonary fibrosis. The patient was eventually extubated on
[**6-5**] and a transesophageal echocardiogram was performed
which showed severe left ventricular global hypokinesis,
ejection fraction 20 percent, 1 plus mitral regurgitation, PA
pressure not estimated because of size of patient. In the
Medical Intensive Care Unit the patient was empirically
treated for PCP with Bactrim and pneumonia with Levaquin and
diuresed with modest improvement in breathing. The patient
states she still gets very short of breath with any movement
such as moving in bed. The patient cannot move to commode
without shortness of breath. The patient also just denies
any chest pain, no cough or fever, no abdominal or urinary
symptoms.
PAST MEDICAL HISTORY: Interstitial pulmonary fibrosis since
[**2097**]. Requires six liters of oxygen at home. Essentially
any movement makes the patient desaturate. Chronically on
steroids. Congestive heart failure. Had clean cardiac
catheterization in [**2086**]. Question of viral etiology of
cardiomyopathy. Hypertension. Hyperlipidemia.
ALLERGIES: Procardia, Voltaren.
PHYSICAL EXAMINATION: Afebrile, 80, 127/51, 22, 94 percent
on six liters face mask. No apparent distress. Alert and
oriented times three. Moist mucus membranes. Oropharynx
clear. Jugular venous pressure difficult to assess because
of neck size. Regular rate without murmur. Distant S1, S2.
Diffuse crackles and bronchial sounds in upper airways. No
wheezes. Soft, obese, positive bowel sounds, non-tender, non-
distended. No clubbing, cyanosis or edema, warm.
She gave sputum, oropharynx on [**6-3**]. Biopsy consistent with
IPF and pulmonary edema.
LABORATORY: White count 11.8, hematocrit 30.9, platelet
count 202,000. Electrolytes unremarkable.
HOSPITAL COURSE: Respiratory failure: The patient's biopsy
was consistent with end-stage interstitial pulmonary fibrosis
that might have been exacerbated by congestive heart failure.
The patient was also empirically treated for PCP and
pneumonia with ten days of Levaquin and Bactrim. The patient
was on 40 mg of prednisone and this should be tapered down to
10 mg q. day which is her home dose. After discussions with
the patient and her family, the Pulmonary team felt that this
was end-stage interstitial pulmonary fibrosis that would have
a progressive course regardless of any treatment modalities.
The patient and family then spoke with the Palliative Care
team at [**Hospital1 69**] and it was felt
that she should go to rehab for one week to try to build up
strength and ability to walk and then to go home with hospice
care. The patient felt that bronchodilators were of no
benefit so these were discontinued upon her discharge.
Morphine sulfate IV was used as needed for shortness of
breath and dyspnea. She will be sent out on oxycodone 5 mg
to 10 mg orally q. 4h. as needed for dyspnea. This may be
increased upward as you see fit to treat her dyspnea.
Cardiovascularly, cardiomyopathy with ejection fraction of 20
percent most likely viral etiology with clean cardiac
catheterization in [**2096**]. She will be restarted on her Bumex
0.5 mg q. day as diuresis. She appeared slightly dry on
discharge. An ACE inhibitor was also initiated here in the
hospital 10 mg q. day.
Code Status: After discussions with the family she will
become DNR. Her code status was changed to DNR/DNI. The
patient has elected that with no further treatment modalities
to enter hospice after rehab.
DISPOSITION: Discharge to rehab and then to hospice care.
DISCHARGE STATUS: Poor. Unable to do any activities of
daily living. Saturations 98 percent with six liters oxygen
but decreases upon minimal movement including her activities
of daily living.
DISCHARGE MEDICATIONS:
1. Oxazepam 15 mg q. hs. as needed for sleep.
2. Zoloft 100 mg q. day.
3. Protonix 40 mg q. day.
4. Prednisone 40 mg q. day that should be tapered over one
week to 10 mg q. day.
5. Lisinopril 10 mg q. day.
6. Oxycodone 5-10 mg q. 4h., save for shortness of breath or
wheezing.
7. Bumex 0.5 mg q. day.
FOLLOW UP: The patient after rehab stay will be discharged
to hospice care.
[**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], [**MD Number(1) 15911**]
Dictated By:[**Last Name (NamePattern1) 14382**]
MEDQUIST36
D: [**2103-6-8**] 13:13:46
T: [**2103-6-8**] 13:51:34
Job#: [**Job Number 56154**]
ICD9 Codes: 4280, 4254, 5849, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1030
} | Medical Text: Admission Date: [**2155-4-18**] Discharge Date: [**2155-4-25**]
Date of Birth: [**2081-10-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Bacteremia
Major Surgical or Invasive Procedure:
Central Venous Catheter
History of Present Illness:
73 yo female transferred from [**Hospital 8629**] to [**Hospital1 18**] for
intermittent fevers. Pt initially admitted to [**Hospital1 **] on [**2155-3-17**]
after being discharged from [**Hospital1 18**] after prolonged
hospitalization. Initially, the pt underwent CABG, prosthetic
MVR, and closure of foramen ovale on [**2155-2-21**]. Post-op course
complicated by mediastinal hemorrhage, prolonged shock, renal
failure. The pt failed to recover neurologically, and the family
decided to pursue trach and PEG. HD was initiated, and the pt
was transferred to [**Hospital1 **] for rehab. Since admission, she has
had intermittent fevers and leukocytosis, and recurrent
infections. She initially was treated with a course of Vanc,
Zosyn, and Flagyl. She was then started on Fluconazole for
fungus in the urine, and [**Female First Name (un) 564**] bacteremia. This was changed to
Caspofungin when the patient failed to respond to treatment. The
pt also grew [**Female First Name (un) **] out of her blood and was started on Linezolid.
She also had new bilateral pulmonary infiltrates on CXR, and was
started on Imipenem for broad coverage. She developed fever and
hypotension requiring pressors off and on from the 20th to the
24th. She underwent a TTE that showed no vegetations, EF 40%.
Surveillance cultures have been NGTD. She was started on
steroids empirically, and a random cortisol level returned at 3.
She is transferred to [**Hospital1 18**] for further evaluation including
TEE, CT, ID consult, and infected lined change.
Past Medical History:
1. CAD, s/p CABG for 2VD
2. Cardiomyopathy, EF 40% on echo [**2155-4-8**]
3. anoxic encephalopathy
4. ESRD, on HD tues/thurs/sat
5. a-fib
6. trach/peg on [**2155-3-12**]
7. stent to LAD 97
8. htn
9. hypercholesterolemia
10. insulin dependent diabetes
11. spinal stenosis
12. COPD
Social History:
no ETOH, previous 20 pack year smoking history, quit 20 years
ago, previously lived w/ daughter, [**Name (NI) 13788**] who is HCP
Family History:
nc
Physical Exam:
vitals: wt 72/ 95.2/ bp 107/72/ pulse 89/
vent: AC .40/ 500/ 14/5
GEN: comatose
HEENT: conjunctiva injected, dry mucosa, OP clear
NECK: no LAD. Trach in place
CV: RRR, 2/6 systolic murmur
LUNGS: bronchial BS
ABD: distended, soft, hypoactive BS
EXT: 3+ pitting edema B/L, symmetric up to knees and on UE.
Multiple areas of skin breakdown. R PICC site clean, HD site
clean
NEURO: sluggish pupillary reflex, no corneal reflex, no
spontaneous movement of extremities, no response to voice,
minimal response to pain. Muscles contracted.
Pertinent Results:
[**2155-4-19**] 02:35a
142 110 32 120 AGap=12
3.5 24 0.5
Ca: 7.2 Mg: 1.7 P: 3.7
ALT: 22 AP: 99 Tbili: 0.2 Alb: 1.5
AST: 20 LDH: 235 Dbili: TProt:
[**Doctor First Name **]: 82 Lip: 16
mcv 95 wbc 10.4 hgb 8.3 plts 196 hct 25.5
PT: 12.2 PTT: 28.1 INR: 1.0
.
[**2155-4-19**] 12:38a
pH 7.49 pCO2 35 pO2 33 HCO3 27 BaseXS 3
.
blood cx [**4-18**], [**4-19**] from picc pending
.
cxr:
Right lower lobe/right infrahilar opacity. Differential includes
asymmetrically distributed alveolar edema or consolidation,
possibly
aspiration related. Mild vascular conjestion.
.
TEE - Conclusions:
No spontaneous echo contrast or thrombus is seen in the body of
the left
atrium/left atrial appendage or the body of the right
atrium/right atrial
appendage. A small left-to-right shunt across the interatrial
septum is seen
at rest consistent with a small secundum atrial septal defect.
There is
regional left ventricular systolic dysfunction with basal
inferior akinesis.
There are simple atheroma in the ascending aorta. There are
complex (>4mm,
non-mobile) atheroma in the aortic arch and scending thoracic
aorta. The
aortic valve leaflets (3) appear structurally normal with good
leaflet
excursion. No masses or vegetations are seen on the aortic
valve. Trace aortic
regurgitation is seen. A well seated mitral valve annuloplasty
ring is
present. The leaflets are mildly thickened with normal gradient.
No mass or
vegetation is seen on the mitral valve. Very mild mitral
regurgitation is
seen. There is no pericardial effusion.
IMPRESSION: Normal functioning mitral annuloplasty ring with
very mild mitral
regurgitation. No vegetations identified. Complex (non-mobile)
aortic
atherosclerosis. Small secundum type atrial septal defect.
Regional left
ventricular systolic dysfunction c/w CAD.
Brief Hospital Course:
73 YOF with anoxic brain injury, renal failure and line
infection.
.
Line infection - [**Female First Name (un) 564**] and [**Female First Name (un) **] grown at Rehab. Treated with
caspofungin, linezolid, and meropenem. Hemodialysis and PICC
lines removed, tip cultures negative. Left subclavian line
placed. Repeat cultures neagative. TEE done which showed no
vegetation or abcess. New PICC line placed [**2155-4-24**], left
subclavian d/c'd. To complete a 14 day course of Meropenem,
Linezolid, Caspofungin to end on [**2155-5-2**].
.
Renal failure - Patient was on dialysis after prolonged
hypotension leading to ATN. HD catheter removed at time of
admission. Cr and electrolytes remained stable. Patient making
~1L of urine a day. Hemodialysis discontinued indefinetly.
.
Hypotension - Patient transiently hypotensive. Hypovolemia vs
sepsis. Responded to fluids.
.
Anoxic Encephalopathy- secondary to prolonged shock, evaluated
by neurologist at [**Hospital1 **], poor prognosis for recovery based on
prolonged state of neurological decline. No change in neuro exam
during hospitalization.
.
Respiratory Failure- trached. Per outside hospital physician,
[**Name10 (NameIs) **] to wean from vent. Attempted to wean while here, but
failed PS.
- continue vent at current settings AC 500 x 12/PEEP 5/ FiO2 40%
- MDIs standing
- Growing pseudomonas in sputum, being treated with Meropenem x
2 weeks
- VBG showed near normal pH with low pCO2 and low bicarb.
pH 7.43 pCO2 29 pO2 38
Medications on Admission:
500 ml NS Bolus 500 ml Over 15 mins
500 ml NS Bolus 500 ml Over 15 mins
Qvar *NF* 160 mcg IH [**Hospital1 **] 1 inhalation delivers 80 mcg of
beclomethasone.
Azithromycin 500 mg IV Q24H
Meropenem 500 mg IV ONCE
Meropenem 500 mg IV Q6H
Pantoprazole 40 mg IV Q24H
Linezolid 600 mg IV ONCE
Albuterol-Ipratropium [**11-26**] PUFF IH Q4H
Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
Aspirin 81 mg NG DAILY
Artificial Tears 1-2 DROP BOTH EYES PRN
Linezolid 600 mg IV Q12H
Caspofungin 50 mg IV Q24H
Dexamethasone 2 mg IV Q12H
Heparin 5000 UNIT SC TID
Insulin SC
Docusate Sodium (Liquid) 100 mg PO BID
Senna 1 TAB PO BID:PRN
Bisacodyl 10 mg PO/PR DAILY:PRN
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary -
Line infection ([**Last Name (LF) **], [**First Name3 (LF) 564**])
Pseudomonas in sputum
Secondary -
1. CAD, s/p CABG for 2VD
2. Cardiomyopathy, EF 40% on echo [**2155-4-8**]
3. anoxic encephalopathy
4. ESRD, on HD tues/thurs/sat
5. a-fib
6. trach/peg on [**2155-3-12**]
7. stent to LAD 97
8. htn
9. hypercholesterolemia
10. insulin dependent diabetes
11. spinal stenosis
12. COPD
Discharge Condition:
Stable, normotensive and afebrile
Discharge Instructions:
Please continue course of antibiotics as specified in the
dischartge summary for treatment of Pseudomonas, [**Date Range **], and
[**Female First Name (un) 564**].
Continue medications as detailed.
Wound care as directed, continue tube feeds.
Vent settings as specified.
Followup Instructions:
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2155-4-29**] 11:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1989**] Date/Time:[**2155-6-4**]
1:40
Completed by:[**2155-4-25**]
ICD9 Codes: 4254, 5856, 496, 4589, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1031
} | Medical Text: Admission Date: [**2158-3-21**] Discharge Date: [**2158-3-28**]
Date of Birth: [**2158-3-21**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby girl [**Known lastname 22771**] is the first
born of spontaneous twin gestation born to a 19-year-old G2,
P1 woman, gestational age was 35 and 1/7 weeks.
Prenatal screens: Blood type O+, antibody negative, rubella
immune, RPR nonreactive, hepatitis B surface antigen negative,
group B Strep status unknown. This was a spontaneous
dichorionic diamniotic pregnancy. The mother was transferred from
[**Name (NI) 1474**] Hospital on the day of delivery with preterm labor.
She proceeded to cesarean section delivery, thus twin #1
emerged vigorous with good tone and cry, Apgars were 8 at one
minute and 9 at 5 minutes. She was admitted to the neonatal
intensive care unit for treatment of prematurity.
PHYSICAL EXAM UPON ADMISSION: Weight 1.955 kg 25th
percentile, length 42.5 cm 10-25th percentile, head
circumference 31.5 cm 25th percentile.
PHYSICAL EXAM AT DISCHARGE: Weight 1.86 kg. General: Non
distressed, growing preterm female in no acute distress.
Color pink on room air. Head, eyes, ears, nose and throat:
Anterior fontanelle level and soft, sutures opposed, palate
intact. Chest: Breath sounds clear and equal, easy
respirations. Cardiovascular: Regular rate and rhythm, no
murmur, heart rate 140-160 beats per minute. Blood pressure
66/42 with a mean of 51. Abdomen: Soft, nontender,
nondistended, positive bowel sounds, cord on and drying. Anus
patent, small anal fissure noted. GU: Normal female.
Extremities: Moving all well, straight with normal digits,
nails and creases. Hips stable. Spine intact. Neurological:
Appropriate tone and reflexes.
HOSPITAL COURSE BY SYSTEM INCLUDING PERTINENT LABORATORY
DATA: Respiratory: This infant has been on room air since
admission to the neonatal intensive care unit. She has had
infrequent oxygen desaturations. She has not had any episodes
of spontaneous apnea or bradycardia.
Cardiovascular: This baby has maintained normal heart rates
and blood pressures. No murmurs have been noted.
Fluids/electrolytes/nutrition: This baby has been on full
enteral feeds of breast milk or Similac 20 calorie per ounce.
She has been mostly ad lib p.o. taking approximately 120 mL
per kg per day. On [**2158-3-28**] she was increased to 24
calories per ounce. Weight on the day of discharge is 1.86
kg.
Infectious disease: Due to the unknown group beta Strep
status of the mother and the preterm labor, this baby was
evaluated for sepsis upon admission to the neonatal intensive
care unit. A complete blood count was within normal limits. A
blood culture was obtained and was no growth at 48 hours.
This infant was not treated with antibiotics.
Hematology: Hematocrit at birth was 48.2%. The baby did not
receive any transfusions of blood products.
Gastrointestinal: Peak serum bilirubin occurred on day of
life 3, a total of 6.1 mg per dL. A repeat bilirubin on day
of life 6 was 5.5 mg per dL total.
Neurology: This baby has maintained a normal neurological
exam during admission and there were no neurological concerns
at the time of discharge.
Sensory: Audiology hearing screening is recommended prior to
discharge.
Psychosocial: [**Hospital1 **] social work has been
involved with this family, the contact social worker is
[**Name (NI) 46381**] [**Name (NI) 6861**] and she can be reached at [**Telephone/Fax (1) 8717**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Transferred to [**Hospital 1474**] Hospital for
continuing level II care.
PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 60719**] in [**Hospital1 1474**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feeding. Ad lib p.o. feeding breast milk or Similac 20
calorie per ounce.
2. Medications: Goldline baby vitamins 1 mL p.o. once daily,
ferrous sulfate 0.2 mL of 25 mg per mL dilution p.o. once
daily.
3. Iron and vitamin D supplementation:
Iron supplementation is recommended for preterm and low birth
weight infants until 12 months corrected age.
All infants taking predominantly breast milk should receive
vitamin D supplementation at 200 International Units which
may be provided as a multivitamin preparation daily until 12
months corrected age.
1. Car seat position screening is recommended prior to
discharge.
2. State newborn screen was sent on [**2158-3-24**] with no
notification of abnormal results to date. A followup
screen is recommended at 2 weeks of age.
3. No immunizations have been received.
4. Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]-
[**Month (only) 958**] for infants who meet any of the following 4 criteria.
1st: Born at less than 32 weeks; 2nd: Born between 32-35
weeks with 2 of the following: Daycare during RSV season, a
smoker in the household, neuromuscular disease, airway
abnormalities, or school age siblings; 3rd: Chronic lung
disease; or 4: Hemodynamically significant congenital heart
disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out of home caregivers.
This infant has not received Rota virus vaccine. The American
Academy of Pediatrics recommends initial vaccination of
preterm infants at/or following discharge from the hospital
if they are clinically stable and at least 6 weeks, but fewer
than 12 weeks of age.
DISCHARGE DIAGNOSES:
1. Prematurity at 35 and 1/7 weeks gestation.
2. Twin #1 of twin gestation.
3. Suspicion for sepsis ruled out.
4. Mild hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55750**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2158-3-28**] 14:12:04
T: [**2158-3-28**] 15:58:02
Job#: [**Job Number 72393**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1032
} | Medical Text: Admission Date: [**2118-7-21**] Discharge Date: [**2118-7-26**]
Date of Birth: [**2077-5-2**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
Supraventricular Tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mrs. [**Known lastname 96136**] is a 41 yo woman with a h/o hypogammaglobulinemia
who presented from her hematology clinic with tachycardia. She
had been getting IVIG every 3 weeks for her
hypogammaglobulinemia. Prior to each treatment she starts to
feel "congested", develops a cough and feels fatigued. She was
feeling these symptoms over the last day and presented to clinic
where she was supposed to get IVIG today. On initial evaluation
in the clinic she was found to be tachycardic to 180 (regular)
and hypotensive with BP 72/52 and febrile 99F. O2 sat 88-95% on
RA. She was given adenosine 6 mg which did not change her HR and
then diltiazem 5mg IV x 1. After this her SVT broke to sinus
tachy with rate in 130s. She was then sent to ED.
In the ED her initial vs were: T 101.0 132 (sinus tach) 100/57
20 100. On exam she had crackles on the right. She denied
symptoms aside from the cough she normally gets prior to IVIG
treatments. A CXR revealed likely PNA. She was given
vanc/levoquin/flagyl and 4L NS. Her BPs remained 80s systolic so
she was started on levoquin. She remained asymptomatic from her
hypotension specifically she had no dizziness, lightheadedness,
chest pain, or headache.
.
On admission, she had no complaints aside from the cough. She
denied palpitations, chest pain, abdominal pain, diarrhea,
nausea, vomiting, dysuria, sick contacts, recent travel. She has
an indwelling port that had been accessed in ED but before then
not since she had her last IVIG treatment 3 weeks ago. No
rashes. No chills/fevers/weight changes.
Past Medical History:
(per patient and atrius records)
- Hypogammaglobulinemia diagnosed at age 18 after her first
pregnancy when she presented with severe PNA and complicated by
4 port infections, sepsis from possible spinal abscess s/p
drainage (at T4 only neurologic deficit is numbness on her feet
but was transiently paralyzed from "armpits down" per patient),
- Osteomyelitis of finger
- Squamous cell CA of the left middle finger requiring removal
of distal tip in [**2109**]
- Celiac Sprue
- Osteopenia
- ITP
Social History:
She lives at home. Works as CNA. Has one son (age 24)
- Tobacco: Denies
- Alcohol: denies
- Illicits: denies
Family History:
Son is healthy without immunodeficiency. No other family members
with immunodeficiency.
Physical Exam:
Vitals: T:99.1 BP:90/53 on 0.1 levophed P:86 R: 18 O2: 100 on 2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: crackles and diminished airmovement on the right
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, trace lower extremity edema
bilaterally
Neuro: A+OX 3, moving all four extremities
Skin: no rashes
Pertinent Results:
[**2118-7-21**] 04:20PM BLOOD WBC-5.6 RBC-3.53* Hgb-11.3* Hct-33.5*
MCV-95 MCH-32.0 MCHC-33.8 RDW-14.3 Plt Ct-166
[**2118-7-21**] 04:20PM BLOOD Neuts-71.4* Lymphs-23.3 Monos-4.6 Eos-0.3
Baso-0.4
[**2118-7-21**] 04:20PM BLOOD Plt Ct-166
[**2118-7-21**] 04:20PM BLOOD PT-18.7* PTT-150* INR(PT)-1.7*
[**2118-7-21**] 04:20PM BLOOD Glucose-120* UreaN-6 Creat-0.5 Na-141
K-3.1* Cl-109* HCO3-23 AnGap-12
[**2118-7-22**] 03:31AM BLOOD ALT-47* AST-50* LD(LDH)-247 AlkPhos-115*
TotBili-0.2
[**2118-7-22**] 03:31AM BLOOD Albumin-2.4* Calcium-7.2* Phos-2.9
Mg-1.3*
[**2118-7-21**] 09:50PM BLOOD TSH-2.8
[**2118-7-21**] 04:20PM BLOOD HCG-<5
[**2118-7-21**] 04:25PM BLOOD Glucose-107* Lactate-2.6* K-3.0*
-----------
[**2118-7-21**] ECG: Sinus tachycardia with non-diagnostic
repolarization abnormalities.
.
[**2118-7-21**] CXR: CXR: Left-sided portacath tip ends in superior
right atrium. mild CM. Blunting of right costophrenic angle may
represent effusion. rLL atelectasis vs consolidation and
increased retrocardiac density likely atelectasis but infection
can't be ruled out.
.
[**2118-7-22**] TTE: The left atrium is mildly dilated. The estimated
right atrial pressure is 0-5 mmHg. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
There is no pericardial effusion.
IMPRESSION: Vigorous global and regional biventricular systolic
function. No pulmonary hypertension or clinically-significant
valvular disease seen. Low estimated intracardiac filling
pressures.
Brief Hospital Course:
Ms. [**Known lastname 96136**] was a 41 yo woman with a h/o hypogammaglobulinemia
admitted s/p an episode of SVT. Brief hospital course was as
follows:
.
# SVT: Ms. [**Known lastname 96136**] was found to be in asymptomatic SVT with
hypotension of 72/52 at her [**Hospital 108307**] clinic. Her SVT
rapidly converted to sinus rhythm following 6 mg adenosine and 5
mg diltiazem. In the ED, she was found to be in sinus
tachycardia with a fever to 101F and because of a concern for
PNA on CXR she was started on vancomycin, levofloxacin, and
azithromycin for empiric coverage of pneumonia. She was also
given 4L of NS and required pressors to maintain her systolic BP
above 90, thus she was admitted to the MICU. In the MICU she was
weaned off pressors successfully after approximately 12 hours. A
TTE was performed which showed normal cardiac function and was
significant for low filling pressures consistent with
hypovolemia. She was initially kept on vanc/levo/azithromycin,
however she remained afebrile throughout her MICU course (36
hours) and her antibiotics were discontinued given her lack of
symptoms, fever, white count, and a CXR that showed chronic
changes seen on prior CXRs. Following her transfer to the
general medicine floor, she was continued on telemetry and
remained in NSR. A review of her prior EKGs revealed paroxysmal
AVRT or AVNRT and an electrophysiology consult was obtained with
reommendation for outpatient monitoring with an event monitor
and ablation if paroxysms persists. On the day of discharge, she
remained hemodynamically stable and was in NSR.
.
# Hypotension: Ms. [**Known lastname 96136**] was initially found to hyptotensive
to 72/52 with fever to 101F, leukocytopenia, and an opacity
noted on CXR concerning for PNA in the ED. However, she remained
afebrile following admission and review of outpatient records
revealed chronic leukocytopenia and chronic CXR finding beleived
to be scarring from multiple episodes of PNA. In addition, it
was discovered that her baseline systolic blood pressure was in
the 90s with isolated clinic readings as low as 82. It was
likely that her normal systolic blood pressure at rest was in
the 80s, especially considering the fact that she remained
asymptomatic and had excellent urine output with systolic blood
pressure readings in the 80s. On the day of discharge, she was
walked up a flight of stairs and around the unit with excellent
oxygen saturation and appropriate increase in blood pressure
following activity noted to be 104/72.
.
# Coagulopathy : She was followed by her hematologist for
suspected factor deficiency and received vitamin K periodically
as an outpatient. This appeared to be a chronic issuse and she
received 5mg of vitamin K daily for three days prior to dischare
with appropriate INR change from 1.8 to 1.2. Ongoing outpatient
follow up with hematologist was advised.
Medications on Admission:
Ketoconazole shampoo
Nuvaring
Traimcinolone ointment
Terconazole vaginal cream
IVIG Q3weeks
Discharge Medications:
1. Ketoconazole Topical
2. NuvaRing 0.12-0.015 mg/24 hr Ring Vaginal
3. Triamcinolone Acetonide Topical
4. Terconazole Vaginal
5. IVIG
Please Continue to follow with your primary physcian as to
frequency of your IVIG treatments.
Discharge Disposition:
Home
Discharge Diagnosis:
Supraventricular Tachycardia
Hypogammaglobulinemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 96136**]
You were admitted to the hospital for an episode of fast heart
rate with low blood pressure that was identified at your
physcian's office. You were found to be febrile to 101.0F in the
emergency department and you received antibiotics for two days,
while you were evaluated and treated by the emergency department
and medical intensive care unit. Following you transfer to the
general medicine floor, you were evaluated and treated by the
medicine service. You were found to have experienced an abnormal
heart rhythm called supraventricular tachycardia. Your heart was
monitored throughout your admission in the hospital and a heart
rhythm specialist, Dr. [**First Name (STitle) **], arranged extended monitoring for
you. You should follow up with Dr. [**First Name (STitle) **] at the appointment
below.
No changes have been made to your home medications please keep
the appointment below with your primary care physcian and please
return to the hospital promply if you should experiance fever,
chills, fatigue, shortness of breath, lightheadedness or other
signs of infection.
Followup Instructions:
Name:Dr [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Specialty: Primary Care
When: [**Last Name (LF) 2974**], [**7-29**] at 3:20pm
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2261**]
Dr [**Last Name (STitle) **] is on vacation so this appointment is booked with a
colleague on her team.
Name: [**Last Name (LF) **], [**Name8 (MD) **] MD
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 6425**]
Phone: [**Telephone/Fax (1) 2258**]
Appointment: Monday [**2118-9-19**] 11:10am
**Life Watch will be contacting you at home within 24-48 hours
to explain the event monitor and will mail out the package to
your home. If you have not heard by next Tuesday please call Dr.
[**Last Name (STitle) 30448**] office at [**Telephone/Fax (1) 2258**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
ICD9 Codes: 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1033
} | Medical Text: Admission Date: [**2153-6-6**] Discharge Date: [**2153-6-23**]
Date of Birth: [**2083-5-16**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
altered mental status/hepatic encephalopathy
Major Surgical or Invasive Procedure:
diagnostic paracentesis
therapeutic paracentesis
tunneled HD catheter
hemodialysis
History of Present Illness:
Mr. [**Known lastname **] is a 70 year old man with ETOH cirrhosis complicated
by HCC s/p RFA, DM2, CAD, PVD and CRI admitted from clinic on
[**2153-6-6**] with general debility, hepatic encephalopathy, dyspnea
on exertion, abdominal ascites and peripheral edema. Patient was
seen by Dr. [**Last Name (STitle) 497**] who determined that he has slow onset
encephalopathy grade I based on the symptoms he has described
over the few days prior to admission. Patient stateed that he
has felt more confused for the week prior to admission, as well
as more argumentative. Also states that one of his children was
concerned about his driving. Reports very poor appetite because
"food does not taste good". He had a CT chest on [**2153-6-6**] which
showed bilateral upper lobe opacities concerning for infection.
REVIEW OF SYSTEMS: Positive per HPI. Also reports having
hemorrhoids with occasional bright red blood when he wipes after
a BM. Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
1. HCC: CT abdomen [**2151-9-23**] revealed a segment IV 2.2
x 2.2 cm enhancing lesion concerning for HCC. This was confirmed
by [**Year (4 digits) 950**] on [**2151-10-1**], demonstrating a segment IV
hypoechoic 2.3 x 1.7 x 2.6 cm, hypovascular mass. He underwent
RFA of this lesion on [**2151-10-27**] without complications. s/p RFA
[**2151-10-27**].
2. ETOH cirrhosis
3. DM2: was on oral hypoglycemics but these were discontinued
with no need for further intervention at this time.
4. CAD: Radionucleotide cardiac perfusion study done [**2151-12-23**]
demonstrating normal LV myocardial perfusion and LV systolic
function with LVEF of 61%
5. PVD with left iliac stenting and fem-fem bypass in [**Month (only) 116**] and
[**2150-8-25**]. These were infected and patient had two surgeries in
[**2150-11-24**] to remove the fem-fem bypass graft and had left
femoral angioplasties.
- hx of infected femoral graft for which he is on
dicloxacillin suppression
6. Hypertension.
7. Bell's palsy: unclear etiology; reports noting a tick on his
body after walking in the [**Doctor Last Name 6641**] while on [**Location (un) **] 2 months prior
to the onset of the Bell's Palsy; Lyme serologies were negative
at the time; no further manifestations of Lyme disease and near
resolution of the [**Name (NI) 14245**] ptosis from the Bell's.
8. CCY in [**2114**]
9. Cystoscopy in [**2148**] showed a bladder polyp that was
premalignant. This was removed and followup cystoscopy in
[**2150-1-25**] was negative.
Social History:
Previous significant alcohol use, but quit drinking in [**2149-6-24**]
after a GI bleed. He is a former smoker (reports that he quit in
the [**2120**]) and denies any illicit substance use. He works as a
computer facilities control person. He lives with his wife and
adult autistic son. [**Name (NI) **] 2 daughters.
Family History:
Liver disease in his grandfather, which was not thought to be
related to alcohol. He also reports multiple nieces and nephews
with cognitive issues without a clear diagnosis.
Physical Exam:
Physical Exam on Admission:
VS: 97.2, 113/51, 66, 20, 99%RA
GENERAL: NAD, tired appearing M who appears stated age
HEENT: Sclerae anicteric. PERRL, EOMI.
NECK: Supple, did not appreciate elevated JVP
CARDIAC: RRR, no M/R/G, nl S1, S2
LUNGS: CTAB, no crackles, wheezes or rhonchi. No chest wall
deformities, scoliosis or kyphosis. Resp were unlabored, no
accessory muscle use, moving air well and symmetrically.
ABDOMEN: obese, distended, soft, non-tender to palpation.
Dullness to percussion over dependent areas but tympanic
anteriorly. No HSM or tenderness. +fluid wave c/w ascites
EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 3+
LE pitting edema bilaterally to knees. 1+ DP/PT pulses
bilaterally.
NEURO: A+O x 3, slow to respond to questions with somewhat
slurred speech, +asterixis, slight R-sided facial droop c/w
known Bell's palsy
.
Pertinent Results:
Labs on Admission:
[**2153-6-7**] 05:14AM BLOOD WBC-1.8* RBC-2.94* Hgb-9.9* Hct-30.0*
MCV-102* MCH-33.8* MCHC-33.2 RDW-16.9* Plt Ct-81*#
[**2153-6-7**] 05:14AM BLOOD PT-23.7* PTT-41.1* INR(PT)-2.3*
[**2153-6-7**] 05:14AM BLOOD Glucose-100 UreaN-44* Creat-2.2* Na-135
K-3.8 Cl-106 HCO3-23 AnGap-10
[**2153-6-7**] 05:14AM BLOOD ALT-37 AST-99* LD(LDH)-140 AlkPhos-118
TotBili-8.4* DirBili-5.6* IndBili-2.8
[**2153-6-7**] 05:14AM BLOOD Albumin-2.5* Calcium-8.0* Phos-3.6 Mg-1.9
[**2153-6-7**] 05:14AM BLOOD Ammonia-133*
[**2153-6-8**] 05:45AM BLOOD AFP-2.5
Peritoneal fluid
[**2153-6-6**] 11:47PM ASCITES TOT PROT-1.5 ALBUMIN-LESS THAN
[**2153-6-6**] 11:47PM ASCITES WBC-35* RBC-235* POLYS-8* LYMPHS-28*
MONOS-7* MACROPHAG-57*
[**2153-6-6**] 01:07PM CREAT-2.2*
Microbiology:
[**2153-6-6**] 11:47 pm PERITONEAL FLUID
**FINAL REPORT [**2153-6-13**]**
GRAM STAIN (Final [**2153-6-7**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2153-6-10**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2153-6-13**]): NO GROWTH.
[**2153-6-7**] 8:23 am [**Month/Day/Year 14246**] Source: CVS.
**FINAL REPORT [**2153-6-9**]**
[**Month/Day/Year 14246**] CULTURE (Final [**2153-6-9**]):
Culture workup discontinued. Further incubation showed
contamination
with mixed fecal flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 0.5 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2153-6-9**] 10:00 pm [**Month/Day/Year 14246**] Source: CVS.
**FINAL REPORT [**2153-6-12**]**
[**Month/Day/Year 14246**] CULTURE (Final [**2153-6-12**]):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 256 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
[**2153-6-13**] 3:11 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT [**2153-6-19**]**
GRAM STAIN (Final [**2153-6-13**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2153-6-16**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2153-6-19**]): NO GROWTH.
[**2153-6-13**] 3:11 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
**FINAL REPORT [**2153-6-19**]**
Fluid Culture in Bottles (Final [**2153-6-19**]): NO GROWTH.
Imaging:
[**2153-6-6**] CT CHEST W/O CONTRAST
FINDINGS:
New consolidations in the posterior segment left upper lobe (4,
53), in the right upper lobe (4: 52, 91), are most likely
infectious in etiology. Pericardial opacities in the right
middle lobe could be atelectasis or infection. 1 mm right upper
lobe lung nodule (4, 35) is stable, 1 mm lung nodule in the
right middle lobe is also stable. Subpleural 3 mm lung nodule in
the right upper lobe is new (4, 95). There are scattered
calcified granulomas. Small right pleural effusion and adjacent
atelectasis is new. There are few calcified pleural plaques (4,
118).
There is gynecomastia. Mediastinal lymph nodes do not meet CT
criteria for pathologic enlargement. Dense calcifications are
again noted in all coronary arteries. Mild calcification of the
aortic valve is of unknown hemodynamic significance. Trace
pericardial effusion is unchanged and physiologic. Tiny
epicardiac lymph nodes are again noted. This examination is not
tailored for subdiaphragmatic evaluation. For a more detailed
description of abdominal findings, please refer to concurrent MR
of the abdomen. There are no bone findings of malignancy.
IMPRESSION:
1. Multifocal bilateral opacities mostly likely infectious in
etiology. Other tiny lung nodules are stable.
2. Coronary calcifications.
[**2153-6-6**] BONE SCAN
INTERPRETATION: Whole body images of the skeleton obtained in
anterior and posterior projections show no abnormal areas of
tracer uptake. On the anterior projection, there is reduced
uptake in the spine and kidneys, unchanged, secondary to large
volume ascites as seen on the MRI of the abdomen done today. The
kidneys and urinary bladder are visualized, the normal route of
tracer excretion.
IMPRESSION:
No evidence of osseous metastatic disease.
[**10/2152**] EGD
- One column of nonbleeding grade I varices were seen in the
lower esophagus.
- There was erythematous and nodular mucosa at the antrum. There
was no evidence of active bleeding. No ulcer was seen.
- Mild non-bleeding portal hypertensive gastropathy was seen in
the body of stomach. There was no gastric varices.
- The mucosa at the duodenal bulb appeared erythematous and
nodular. There was no evidence of active bleeding. There was no
evidence of varices.
- Otherwise normal EGD to third part of the duodenum.
MRI abd w/ and w/o contrast:
1. Nodular cirrhotic liver with evidence of portal hypertension
with splenomegaly, ascites, recanalization of paraumbilical
vein.
2. 12-mm focus of arterial enhancement with washout and T2
correlate, lateral to the previously ablated lesion within
segment [**Doctor First Name **], which is concerning for a focus of HCC. A 7 mm
nodule within segment II, which demonstrates arterial
enhancement and washout but without T2 correlate is also very
suspicious. Close surveillance of these lesions is recommended.
3. New multiple nodular foci within segment VI with arterial
enhancement, no T2 correlate or washout identified. These arhave
intermediate concern given nodular nature. Continued
surveillance recommended.
4. Simple bilateral renal cysts.
Renal US [**2153-6-9**]
1. No evidence of hydronephrosis. Right renal cysts,
characterized as simple on MR exam of [**2153-6-6**].
2. Large amount of ascites.
Urinalysis:
[**2153-6-11**] 05:40PM [**Month/Day/Year 14246**] Color-DkAmb Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2153-6-9**] 10:00PM [**Month/Day/Year 14246**] Color-DkAmb Appear-Clear Sp [**Last Name (un) **]-1.015
[**2153-6-7**] 08:23AM [**Month/Day/Year 14246**] Color-AMBER Appear-Clear Sp [**Last Name (un) **]-1.014
[**2153-6-11**] 05:40PM [**Month/Day/Year 14246**] Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-5.5 Leuks-NEG
[**2153-6-9**] 10:00PM [**Month/Day/Year 14246**] Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-5.5 Leuks-NEG
[**2153-6-7**] 08:23AM [**Month/Day/Year 14246**] Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-4* pH-5.5 Leuks-NEG
[**2153-6-11**] 05:40PM [**Month/Day/Year 14246**] RBC-1 WBC-26* Bacteri-FEW Yeast-NONE
Epi-<1
[**2153-6-9**] 10:00PM [**Month/Day/Year 14246**] RBC-<1 WBC-2 Bacteri-FEW Yeast-NONE
Epi-<1
[**2153-6-11**] 05:40PM [**Month/Day/Year 14246**] CastGr-29* CastHy-28*
[**2153-6-9**] 10:00PM [**Month/Day/Year 14246**] CastHy-18*
[**2153-6-11**] 05:40PM [**Month/Day/Year 14246**] Eos-NEGATIVE
Discharge Labs:
[**2153-6-23**] 05:20AM BLOOD WBC-1.5* RBC-2.56* Hgb-8.7* Hct-26.2*
MCV-102* MCH-34.2* MCHC-33.4 RDW-18.1* Plt Ct-84*
[**2153-6-23**] 05:20AM BLOOD PT-23.6* PTT-46.8* INR(PT)-2.3*
[**2153-6-23**] 05:20AM BLOOD Glucose-92 UreaN-38* Creat-3.2* Na-135
K-4.0 Cl-98 HCO3-27 AnGap-14
[**2153-6-23**] 05:20AM BLOOD ALT-27 AST-104* AlkPhos-99 TotBili-6.1*
[**2153-6-23**] 05:20AM BLOOD Albumin-3.8 Calcium-8.8 Phos-3.7 Mg-2.0
Brief Hospital Course:
Mr. [**Known lastname **] is a 70 year old man with ETOH cirrhosis complicated
by HCC s/p RFAk encephalopathy, ascites, grade I varices, DM2,
CAD, PVD and CRI admitted from clinic today with hepatic
encephalopathy and acute kidney injury.
.
# Hepatic Encephalopathy: Patient presented with increased
irritability for 1 week and determined to have slow onset grade
I encephalopathy. He was found to have community-acquired
pneumonia given bilateral upper lobe opacities seen on [**2153-6-6**]
CT chest. Diagnostic para ruled out SBP. U/A neg but [**Date Range **]
culture + proteus, treated CAP with levofloxacin, and proteus
was sensitive to that as well. Continued home lactulose 30mg PO
TID and 30mg PO Q4H and rifaximin 550mg [**Hospital1 **]. Encephalopathy
cleared on lactulose and rifamixin over the course of the
hospital stay.
.
# ETOH Cirrhosis: Complicated by hepatic encephalopathy,
ascites, portal hypertensive gastropathy and HCC s/p RFA. Was
found to have non-bleeding grade 1 varices on EGD 11/[**2151**]. Does
have what is concerning for HCC recurrence in several regions on
MRI abd. AFP 2.5. Patient was discussed and tumor board and was
approved to be placed on transplant list. Transplant surgery was
following. Initially, diuretics (lasix and spironolactone) were
held in setting of [**Last Name (un) **] as below. Continued home pantoprazole
40mg [**Hospital1 **]. Of note, had therapeutic para on [**6-13**], removed 3 L.
MELD of 36 at time of discharge.
.
# Community-acquired pneumonia: Patient had CT chest [**2153-6-6**]
which showed bilateral upper lobe opacities concerning for
infection. Denied any fever, cough, or increased sputum
production. However, given hepatic encephalopathy was likely
related to infection, treated for CAP with levofloxacin 750mg
Q48h x 5 days (last day [**6-11**])
.
# UTI: Patient with proteus on [**Month/Year (2) **] culture on admission
despite neg U/A. Asymptomatic. This was sensitive to
levofloxacin which was already being used to treat CAP as above.
Completed 7 day course for complicated UTI.
.
# Acute on chronic kidney injury: Patient has chronic renal
insufficiency with baseline Cr ~1.5-1.7. Presented with Cr 2.2,
initially thought it may be prerenal pre-renal given poor PO
intake. However, did not respond to albumin challenge x2 days,
Cr continued to rise. Renal US on [**6-9**] ruled out
hydronephrosis. Started ocreotide and midodrine for HRS on [**6-12**],
albumin was also given daily. However, renal function continued
to decrease. A suspected cellulitis developed on the LLE which
was started on vanco. It was thought that the cellulitis would
not resolve with LE edema and thus would not qualify patient for
transplant. Because the edema would not resolve with diuretics,
Lasix 80mg daily was started with the understanding that the
patient's renal function would likely deteriorate and HD would
be required. This was discussed with the patient and he agreed
on this plan despite the risk for HD. On [**6-18**] an HD catheter
was placed and dialysis was started on [**6-19**]. He was discharged
on HD on a T/TH/SA scheduled to be continued at an out patient
dialysis center.
.
# PVD/Chronic Infected Femoral Graft. Consulted vascular
surgery to comment on status of PVD and ability to tolerate
transplant. Noninvasive vascular studies showed patent
bilateral external iliac and common femoral arteries with
monophasic waveforms and no focal velocity step-up.
Dicloxacillin [**Hospital1 **] was continued for suppression. He will follow
up with Vascular surgery 1 mo post discharge.
.
# LLE Extremity cellulitis: The patient was found to have
erythema on distal LLE extremity. Initially, it was thought that
it might be a cellulitis. It was treated with vancomycin, dosed
by daily troughs, for 5 days. On [**6-18**], Dr. [**Last Name (STitle) 497**] recommended
discontinuing the vancomycin as cellulitis seemed less likely
once some of the LE edema resolved.
.
# Malnutrition: Patient reported very poor appetite at home and
appeared somewhat debilitated. Nutrition consulted, followed.
Pt had better appetite in house.
.
# DM2: Diet-controlled.
.
# Hypertension: Continued home carvedilol.
# CAD: Continued home carvedilol, rosuvastatin.
# PVD: Continued home Plavix.
.
TRANSITIONS OF CARE:
-will f/u with vascular surgery as outpatient
-with f/u with nephrology as outpt at dialysis center three
times per week T/TH/SA
-will be contact[**Name (NI) **] by [**Name (NI) 6177**] from Transplant center about
arranging follow up to clinic and out pt lab work that will need
to be completed
-CONTACT: patient, daughter ([**Name (NI) **], [**Telephone/Fax (1) 14247**])
Medications on Admission:
- allopurinol 300 mg Tablet daily
- carvedilol 12.5 mg Tablet twice a day
- clopidogrel [Plavix] 75 mg Tablet daily
- dicloxacillin 500 mg Capsule [**Hospital1 **]
- furosemide 40 mg Tablet daily
- pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]
- rifaximin [Xifaxan] 550 mg Tablet [**Hospital1 **]
- rosuvastatin [Crestor] 40 mg Tablet daily
- spironolactone 50 mg Tablet daily
- ferrous sulfate 325 mg (65 mg iron) Tablet, Delayed Release
(E.C.) 1 Tablet by mouth once a day
- multivitamin Capsule daily
- omega-3 fatty acids-fish oil [Fish Oil] 360 mg-1,200 mg
Capsule, Delayed Release(E.C.) daily
Discharge Medications:
1. Allopurinol 150 mg PO DAILY
RX *allopurinol 300 mg 0.5 (One half) Tablet(s) by mouth daily
Disp #*15 Tablet Refills:*1
2. Clopidogrel 75 mg PO DAILY
3. Clotrimazole 1 TROC PO 5X PER DAY
4. DiCLOXacillin 500 mg PO BID
5. Pantoprazole 40 mg PO Q12H
6. Rosuvastatin Calcium 40 mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. Fish Oil (Omega 3) 1000 mg PO DAILY
9. Lactulose 30 mL PO TID
RX *lactulose 20 gram/30 mL 1 capsule by mouth three times a day
Disp #*90 Bottle Refills:*1
10. Multivitamins 1 TAB PO DAILY
11. Lanthanum 500 mg PO TID W/MEALS
RX *FOSRENOL 500 mg 1 Tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*1
12. Midodrine 10 mg PO TID
RX *midodrine 10 mg 1 Tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
13. Nephrocaps 1 CAP PO DAILY
RX *Nephrocaps 1 mg 1 Capsule(s) by mouth daily Disp #*30 Tablet
Refills:*1
14. Rifaximin 550 mg PO BID
RX *Xifaxan 550 mg 1 Tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Encephalopathy
Pneumonia
Urinary tract infection
Cellulitis
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to the hospital with confusion and a decline
in your kidney function. Your confusion was due to a pneumonia
and urinary tract infection, which we treated with antibiotics.
The poor kidney function was caused by worsening liver function.
We tried a number of treatments, but they did not improve your
kidney function and you were started on dialysis after
consultation with the kidney specialists.
Of note, when the kidney doctors examined your [**Name5 (PTitle) **] under the
microscope, they saw cells which can be seen with a bladder
lesion. Since you have had a bladder mass removed in the past,
you had a cystoscopy performed to look in the bladder. No signs
of cancer were found.
You also had an infection of your left leg which we treated with
antibiotics. During the admission, the vascular surgeons saw
you to evaluate the extent of your peripheral vascular disease
and your ability to withstand a liver transplant. They
recommended seeing you in clinic 1 month after discharge.
You are starting on dialysis as an outpatient. Your schedule is
Tuesday/Thursday/Saturday. It is very important that you don't
miss any sessions as it can lead to serious heart and kidney
problems. Please notify your kidney doctor if you will not be
able to make a session.
The following changes have been made to your medications:
STOP: Furosemide, Spironolactone, Carvedilol
DECREASE: Allopurinol to 150mg daily
START:
Lactulose and take enough to achieve [**2-25**] bowel movements per day
to prevent confusion
Lanthanum for your kidney disease
Nephrocaps for your kidney disease
Xifaxan for your liver disease
Please see below for follow up appointment information
Followup Instructions:
Please call to schedule follow up with Dr. [**Last Name (STitle) **] (Vascular
Surgery) 1 month after discharge for your peripheral vascular
disease at ([**Telephone/Fax (1) 2867**].
[**Location (un) 6177**] from the Liver Transplant Center will be in contact
with you on [**2153-6-25**] to set up a follow up appointment with you.
If you do not hear from her by the afternoon please give the
transplant center a call at ([**Telephone/Fax (1) 3618**].
You will have to continue Hemodialysis following discharge the
from hospital. Your hemodialysis will take place at:
[**Location (un) 14248**]Dialysis Center [**Street Address(2) 14249**] [**Location (un) 5871**], [**Numeric Identifier 12701**]
#[**Telephone/Fax (1) 14250**]. HD nephrologist Dr. [**Last Name (STitle) 14251**] [**Name (STitle) 14252**]
Dialysis Schedule: Tuesday, Thursday and Saturday. First
outpatient session is [**6-26**] @ 6am
ICD9 Codes: 5845, 5856, 9971 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1034
} | Medical Text: Admission Date: [**2194-9-9**] Discharge Date: [**2194-9-11**]
Date of Birth: [**2133-7-4**] Sex: F
Service: NEUROSURGERY
Allergies:
Clindamycin
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
Right suboccipital craniotomy with excision of mass
History of Present Illness:
: 61 y/o woman with PMH significant for DCIS in right breast
(s/p lumpectomy [**2183**]), bronchoalveolar carcinoma [**2190**] and [**2193**]
(s/p thorascopic resection of lesions), melanoma of left eye
(follwed my [**Hospital **], has proton therapy Q6 months),
melanoma in right ankle (s/p wide local excision with
reconstruction), and squamous cell CA in left hand. Presents
with
HA for last month, increasing in severity in past 48 hours.
+nausea, no vomiting, no visual changes, no dizziness, no
difficulty ambulating. Given 10 of decadron x1 in ED.
Past Medical History:
: HTN, chronic sinus congestin, obesity, depression, ductal
carcinoma in situ, bronchoalveolar carcinoma, melanoma of left
eye and right ankle, squamous cell ca.
Social History:
no smoking, no alcohol, no I.V. drug use
Family History:
M- dx'd with breast Ca at 39 s/p mastectomy. Died at 83 yo
Maternal aunts/uncles - [**10-23**] have died of cancer (lung, liver,
melanoma, stomach)
Brothers - 2 have died of melanoma, both started in the eye and
spread to the liver.
Physical Exam:
PHYSICAL EXAM:
O: T:97.3 BP:165 / 83 HR: 72 R 16 O2Sats 100 RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: left pupil larger than right pupil (has had this
finding since the [**2168**]'s), reactive to light L 4mm-3mm, R 3mm to
2mm EOMs: no nystagmus, intact bilaterally.
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-14**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils round and reactive to light. Left pupil larger than
right pupil. Left pupil 4mm to 3mm, right pupil 3mm to 2mm
(stable finding since [**2168**]'s). Visual fields are full to
confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical, uvula midline.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-16**] throughout. No pronator drift
Sensation: Intact to light touch, proprioception, pin prick
bilaterally.
Reflexes: biceps, triceps brisk and equal bilaterally
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin.
Pertinent Results:
[**2194-9-8**] 07:00PM GLUCOSE-95 UREA N-16 CREAT-0.9 SODIUM-137
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-25 ANION GAP-15
[**2194-9-8**] 07:00PM WBC-10.3 RBC-4.29 HGB-13.3 HCT-38.5 MCV-90
MCH-31.0 MCHC-34.6 RDW-13.2
[**2194-9-8**] 07:00PM NEUTS-64.2 LYMPHS-29.3 MONOS-3.8 EOS-2.3
BASOS-0.4
[**2194-9-8**] 07:00PM PLT COUNT-333
[**2194-9-8**] 07:00PM PT-12.2 PTT-28.3 INR(PT)-1.0
CT: Enhancing hyperdense mass within the right cerebellum
producing mass effect on the fourth ventricle. The other
ventricles appear prominent in this patient, though there are no
prior studies for comparison.
Brief Hospital Course:
Pt was admitted to the ICU for close neurologic monitoring, she
was intact and remained so. She was taken to the OR [**9-9**] where
under general anesthesia she underwent right suboccipital
craniotomy with excision of mass. She tolerated this procedure
well, was extubated and returned to the SICU for recovery and
monitoring. Post op she remained neurologically intact. Her
vital signs were stable. Post op CT showed : Postoperative
changes of the right cerebellar hemisphere with a small amount
of hemorrhage in the resection bed. Unchanged appearance of the
ventricles compared to yesterday. She also underwent post op
MRI which was reveiwed by Dr. [**Last Name (STitle) 739**] which showed no
residual tumor. She was also seen in consult by Dr. [**Last Name (STitle) 4253**]
from neurooncology. Foley was removed.Her diet and activity
were advanced. She was evaluated by PT and found to be safe for
home.
Medications on Admission:
HCTZ 12.5mg qd
Discharge Medications:
1. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day:
take while on steroids.
Disp:*60 Tablet(s)* Refills:*2*
5. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO three times
a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Cerebellar mass
Discharge Condition:
Neurologically stable
Discharge Instructions:
Keep incision dry until staples removed. Call for fever or any
signs of infection - redness, swelling or drainage from wound.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 4253**] in Brain [**Hospital 341**] Clinic - [**Hospital Ward Name 23**] 8
[**2194-9-22**] at 2:30pm. You need to have bone scan prior to this
appt - Dr[**Name (NI) 4674**] office will schedule this - call
[**Telephone/Fax (1) 1669**] for appt time.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2194-9-11**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1035
} | Medical Text: Admission Date: [**2164-1-24**] Discharge Date: [**2164-1-24**]
Date of Birth: [**2105-2-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
found down
Major Surgical or Invasive Procedure:
central line placement
History of Present Illness:
58M w/ hx Down's who was found to be in respiratory arrest at
home in setting of several days of diarrhea. He has been in his
USOH until the morning of admission when he awoke with N/V and
diarrhea. He was complaining of SOB and chest pain and then
rapidly arrested. He was intubated at the scene and received 7L
IVF. In the ED, he was noted to have a distended abd, to be
profoundly acidotic 6.82/85/151, lactate 12.8, and in PEA
arrest. He was given bicarb, 4 rounds of epi/atropine with
return of pulses and started on a dopamine gtt. He was then
transferred to ICU.
No further history was able to be obtained.
Past Medical History:
Down's Syndrome
Porcelain Gallbladder
Celiac Sprue
Social History:
not obtained
Family History:
not obtained
Physical Exam:
PE in ICU
BP 60/34 P 75 22 27 75% on AC 500X30 Peep 10 100% FiO2
GEN: Intubated, non-responsive
COR: irreg. irreg, distant heart sounds
PULM: [**Last Name (un) 28015**], decrease BS bilat
ABD: soft, distended, guaiac positive (per surgery)
EXT: 2+ edema, oozing from numerous stick sites
Pertinent Results:
[**2164-1-24**] 11:38AM BLOOD Glucose-189* Lactate-12.8* K-4.9
[**2164-1-24**] 12:01PM BLOOD Lactate-12.2*
[**2164-1-24**] 01:16PM BLOOD Lactate-11.9*
[**2164-1-24**] 02:25PM BLOOD Glucose-88 Lactate-12.8*
[**2164-1-24**] 11:38AM BLOOD Type-ART O2 Flow-90 pO2-151* pCO2-85*
pH-6.82* calTCO2-16* Base XS--23 -ASSIST/CON Intubat-INTUBATED
Comment-GREEN
[**2164-1-24**] 12:01PM BLOOD Type-ART pO2-209* pCO2-93* pH-7.00*
calTCO2-25 Base XS--10 -ASSIST/CON Intubat-INTUBATED
[**2164-1-24**] 01:16PM BLOOD Type-ART pO2-168* pCO2-48* pH-7.17*
calTCO2-18* Base XS--10
[**2164-1-24**] 02:25PM BLOOD Type-ART pO2-58* pCO2-62* pH-7.35
calTCO2-36* Base XS-5
[**2164-1-24**] 11:30AM BLOOD CK-MB-5 cTropnT-0.04*
[**2164-1-24**] 01:10PM BLOOD CK-MB-37* MB Indx-2.8 cTropnT-0.12*
[**2164-1-24**] 11:30AM BLOOD Amylase-114*
[**2164-1-24**] 01:10PM BLOOD ALT-623* AST-393* LD(LDH)-893*
CK(CPK)-1322* AlkPhos-46 Amylase-179* TotBili-0.3 DirBili-0.1
IndBili-0.2
[**2164-1-24**] 01:10PM BLOOD Glucose-110* UreaN-24* Creat-2.1* Na-151*
K-4.1 Cl-116* HCO3-17* AnGap-22*
[**2164-1-24**] 01:10PM BLOOD WBC-1.8*# RBC-3.22* Hgb-11.0* Hct-32.4*
MCV-101* MCH-34.1* MCHC-33.9 RDW-14.6 Plt Ct-182
[**2164-1-24**] 01:10PM BLOOD PT-20.4* PTT-150* INR(PT)-2.0*
[**2164-1-24**] 01:10PM BLOOD Fibrino-113* D-Dimer->[**Numeric Identifier 961**]*
Brief Hospital Course:
The hospital course for this 58 y/o M with sudden onset resp
failure and PEA arrest is as follows:
.
# Hemodynamic instability: Patient arrived on the floor
hemodynamically unstable with BP 60/40 while on dopamine gtt. He
was started on levophed and vasopressin gtt as well, but
remained hypotensive despite being on maximum pressors. His
heart rate was between 80-140's with frequent PVCs. Echo
revealed no tamponade, RV or LV dilatation. The decision was
made with the pts sister to continue medical care, but CPR was
felt to be not indicated.
.
# Resp Failure: Pt was intubated at the scene and was intially
oxygenating well; however, over the course of the hosp day, his
sats fell to the 70's despite being on AC 100% FiO2 and 10 PEEP.
He was found on CXR to have severe pulm edema felt to be [**1-13**]
aggressive fluid rescusitation.
.
# Septic Shock/Acidosis: Source remains unclear, but may be GI
in origin. Patient reeived 12 amps of Bicarb to help correct his
acidosis and was started on Vanc/Levo/Flagyl empirically. He was
also given stress dose steroids.
.
# Distended Abd: Pt was noted to have a distended abd on arrival
and there was concern for perforated bowel. Surgery was
consulted and felt that there was no acute GI process to warrant
surgical intervention. It was felt that the guaiac positive
stool could be a component of ischemic bowel compounded by DIC.
.
.
At 4:50PM on [**2164-1-24**], patient was pronounced dead of cardiac
arrest and resp failure. The discussion was made with family,
who felt that they would like an autopsy. The proper
arrangements were made.
Medications on Admission:
Zyprexa
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
n/a
ICD9 Codes: 0389, 5845, 2762, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1036
} | Medical Text: Admission Date: [**2186-1-25**] Discharge Date: [**2186-1-31**]
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Ciprofloxacin
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Observation s/p trach change
Major Surgical or Invasive Procedure:
Tracheostomy change
Hemodialysis
History of Present Illness:
Ms. [**Known lastname 4318**] is a 89yo female with PMH significant for chronic
ventilator support, ESRD on HD, atrial fibrillation, and AS s/p
AVR. She is being admitted to the ICU for observation after
undergoing replacement of her tracheostomy tube earlier today.
The patient was first admitted to [**Hospital1 18**] on [**12-17**] after she
presented to an OSH with ventilator dyssynchrony, thick
secretions, increasing peak pressures, and hypoxia. Sputum
cultures at this time supposedly grew pseudomonas and she was
treated with Aztreonam. On transfer to [**Hospital1 18**] bronchoscopy showed
tracheomalacia. Her tracheostomy tube was exchanged for a longer
one; no stent was placed at the time. She was readmitted on [**12-28**]
for reoccurring hypoxia. She underwent flexible bronchoscopy
which revealed severe tracheomalacia obstructing her
tracheostomy tube. She was taken back to the OR for insertion of
a Y stent across the area of tracheomalacia and her tracheostomy
was replaced as well.
.
The patient presented to the [**Hospital **] clinic for routine follow-up for
evaluation of her tracheostomy and Y stent. Per daughter, the
patient has had increased secretions and alarms from the
ventilator. The patient also admits to feeling more SOB
recently. She denies any fevers, chills, dizziness, chest pain,
abdominal pain, or any other concerning symptoms. On further
examination, her tracheostomy tube was found to be displaced
proximally. As a result, she underwent change of her tube this
afternoon. She is being admitted to the MICU for observation.
Past Medical History:
Past Medical History:
Respiratory failure requiring mechanical ventilator support
Tracheal stenosis
Chronic kidney disease on hemodialysis
Diabetes mellitus (per OSH H+P, daughter denies)
COPD (per OSH H+P, daughter denies)
Hypertension, but now requires midodrine to maintain BPs
s/p CVA (per OSH H+P, daughter denies)
Aortic stenosis s/p aortic valve replacement in [**2181**]
Hypothyroidism per OSH record however pt. recently on
methimazole
Paroxysmal atrial fibrillation
CAD
Dementia (given med list although daughter denies)
Hyperlipidemia
CHF
Osteoarthritis
.
Past surgical history:
CABG in [**2181**] w/ AVR; mosaic porcine valve
AVR [**2181**]
Hip surgery
Hemodialysis catheter placement placed [**10/2184**] at [**Hospital 1281**]
Hosp,[**Location (un) **], MA
Social History:
No smoking, no alcohol, no drug use. Lives with daughter, bed
bound.
Family History:
Non-contributory
Physical Exam:
vitals T 98.3 BP 150/57 AR 93 RR 21
vent settings: AC/450/15/0.30/8
Gen: Patient lying in bed, does not appear acutely ill
HEENT: MMM
Heart: RRR, +2-3 systolic murmur
Lungs: CTAB
Abdomen: soft, NT/ND, +BS
Extremities: 1+ bilateraly edema, 2+ DP/PT pulses
Pertinent Results:
[**2186-1-25**] 02:03PM BLOOD WBC-13.1* RBC-3.57* Hgb-9.4* Hct-31.1*
MCV-87 MCH-26.5* MCHC-30.4* RDW-21.1* Plt Ct-379#
[**2186-1-27**] 04:10AM BLOOD WBC-12.5* RBC-3.21* Hgb-8.5* Hct-28.3*
MCV-88 MCH-26.4* MCHC-30.0* RDW-19.6* Plt Ct-360
[**2186-1-30**] 03:06AM BLOOD WBC-11.1* RBC-3.27* Hgb-8.8* Hct-28.9*
MCV-88 MCH-26.8* MCHC-30.3* RDW-17.8* Plt Ct-261
[**2186-1-25**] 02:03PM BLOOD Neuts-87.6* Lymphs-7.1* Monos-3.6 Eos-1.2
Baso-0.5
[**2186-1-28**] 03:25AM BLOOD Neuts-77.0* Bands-0 Lymphs-13.7*
Monos-6.2 Eos-2.2 Baso-0.8
[**2186-1-28**] 03:25AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-OCCASIONAL Ovalocy-OCCASIONAL Tear
Dr[**Last Name (STitle) 833**] [**Name (STitle) 12188**]1+
[**2186-1-25**] 02:03PM BLOOD Plt Ct-379#
[**2186-1-26**] 05:18AM BLOOD PT-14.7* PTT-29.7 INR(PT)-1.3*
[**2186-1-25**] 02:03PM BLOOD Glucose-116* UreaN-18 Creat-1.7* Na-140
K-4.1 Cl-100 HCO3-29 AnGap-15
[**2186-1-27**] 04:10AM BLOOD Glucose-88 UreaN-32* Creat-3.1* Na-137
K-4.7 Cl-101 HCO3-21* AnGap-20
[**2186-1-30**] 03:06AM BLOOD Glucose-125* UreaN-37* Creat-3.5* Na-132*
K-4.6 Cl-97 HCO3-24 AnGap-16
[**2186-1-25**] 02:03PM BLOOD ALT-13 AST-16 AlkPhos-126* TotBili-0.3
[**2186-1-25**] 02:03PM BLOOD Albumin-3.4 Calcium-9.2 Phos-2.0* Mg-2.2
[**2186-1-28**] 03:25AM BLOOD Calcium-9.4 Phos-2.9# Mg-1.9
[**2186-1-30**] 03:06AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.0
[**2186-1-27**] 04:10AM BLOOD Vanco-14.9
[**2186-1-28**] 03:25AM BLOOD Vanco-19.4
[**2186-1-30**] 03:06AM BLOOD Vanco-14.8
.
GRAM STAIN (Final [**2186-1-27**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2186-1-30**]):
OROPHARYNGEAL FLORA ABSENT.
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
GRAM NEGATIVE ROD(S). RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| KLEBSIELLA PNEUMONIAE
| |
AMIKACIN-------------- 16 S
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 8 S R
CEFTAZIDIME----------- 16 I =>64 R
CEFTRIAXONE----------- R
CEFUROXIME------------ 32 R
CIPROFLOXACIN--------- 2 I =>4 R
GENTAMICIN------------ 4 S =>16 R
MEROPENEM------------- 4 S <=0.25 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- 64 S 8 S
TOBRAMYCIN------------ <=1 S =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
.
CXR [**1-26**] - Reoccurring complete left-sided pulmonary whiteout
developing during the last four hours interval. Consider mucous
plugging as cause.
CXR [**1-30**] - Portable AP chest radiograph compared to [**2186-1-27**].
Worsening of left retrocardiac opacities consistent with again
worsened left retrocardiac atelectasis. No change in the
appearance of the endotracheal Y stent is demonstrated. The
tracheostomy is at the midline with tip just above the upper
margin of the stent. There is no change in the dialysis central
venous line with its tip in the right atrium. There is no
failure. Bilateral small pleural effusions are unchanged.
Brief Hospital Course:
Ms. [**Known lastname 4318**] is an 89yo female with PMH as listed above who
presented for observation after changing of her tracheostomy
tube, with course complicated by lung white out, thought
secondary to mucus plugging, initiated on antibiotic therapy for
presumptive ventilator associated pneumonia.
.
# Chronic respiratory failure - Patient had tracheostomy tube
changed by interventional pulmonology without complication.
Patient was continued on AC ventilator support with good
respiratory function. Patient had cxr findings of left lung
white out with concern for ventilatory associated pneumonia
given secretions, and was started initially on vanco and
cefepime. Sputum culture grew pseudomonas sensitive to cefepime
and sparse klebsiella bacteria with resistances, without
evidence of gram positive cocci. Her antibiotics were changed
to only cefepime on [**1-30**], with decision to not treat sparse esbl
klebsiella. Plan to complete two-week course of cefepime, to
end [**2-9**]. Patient was continued on mucinex and NAC, although we
were unsure of her at home doses of these medications.
.
# Pneumonia - as above, pt p/w sxs of increasing secretions,
increased vent alarms per daughter. Cefepime to stop [**2-9**].
PICC line placed prior to discharge.
.
# ESRD on HD - patient was on M,W,F schedule, underwent HD
during her course without complication. Her most recent HD was
[**1-30**]. She was continued on her nephrocaps.
.
# Anemia - after speaking with pt's outpatient nephrologist,
patient received a uPRBCs for her chronic anemia. Her Hct was
stable throughout her stay.
.
# PEG tube dysfxn - Pt's PEG tube not fxning on admission,
surgery was contact[**Name (NI) **] with two foley changes. Papain was used
without much relief. PEG funcioning upon discharge.
.
# Paroxysmal atrial fibrillation - pt remained in NSR throughout
stay. Patient not on anti-coagulation but remained on
anti-arrythmic.
.
# Hyperlipidemia - continued Lipitor.
.
# Dementia - continue Namenda and Aricept.
.
# FEN - TFs per PEG tube continuned.
.
# Prophylaxis: Heparin SQ for DVT prophylaxis
.
# Access: RIJ tunneled dialysis line, PICC placed.
.
# Communications: Daughter phone number - [**Numeric Identifier 76933**]
Medications on Admission:
Midodrine 10mg PO TID
Aspirin 81mg PO daily
Folic Acid 800 micrograms PO daily
Rythmol 150mg PO BID
Namenda 10mg PO BID
Aricept 10mg PO QHS
Lipitor 10mg PO daily
Lansoprazole 30mg PO daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable [**Numeric Identifier **]: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Propafenone 150 mg Tablet [**Numeric Identifier **]: One (1) Tablet PO BID (2 times
a day).
3. Memantine 5 mg Tablet [**Numeric Identifier **]: Two (2) Tablet PO BID (2 times a
day).
4. Donepezil 5 mg Tablet [**Numeric Identifier **]: Two (2) Tablet PO HS (at bedtime).
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Atorvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Last Name (STitle) **]: One (1) Cap
PO DAILY (Daily).
8. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
9. Midodrine 5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3 times a
day).
10. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Powder in
Packet [**Telephone/Fax (3) **]: One (1) Powder in Packet PO DAILY (Daily).
11. Cefepime 1 gram Recon Soln [**Telephone/Fax (3) **]: One (1) Recon Soln Injection
Q24H (every 24 hours): To end [**2-9**].
Disp:*1 Recon Soln(s)* Refills:*2*
12. Guaifenesin 600 mg Tablet Sustained Release [**Month/Year (2) **]: One (1)
Tablet Sustained Release PO BID (2 times a day) for 2 days.
13. Acetylcysteine 20 % (200 mg/mL) Solution [**Month/Year (2) **]: One (1) ML
Miscellaneous Q6H (every 6 hours): Or keep at-home regimen.
Thank you.
14. Combivent 18-103 mcg/Actuation Aerosol [**Month/Year (2) **]: Four (4)
Inhalation every four (4) hours: at home regimen.
15. Saline Flush 0.9 % Syringe [**Month/Year (2) **]: One (1) Injection twice a
day as needed for flush.
Disp:*5 5* Refills:*5*
16. Heparin Flush 10 unit/mL Kit [**Month/Year (2) **]: One (1) Intravenous once
a day as needed for [**Hospital1 **]:prn.
Disp:*2 2* Refills:*5*
Discharge Disposition:
Home With Service
Facility:
Personal touch Home services
Discharge Diagnosis:
Primary:
1. Respiratory failure - ventilator associated pneumonia.
.
Secondary:
2)hx of tracheal stenosis
3)ESRD on HD
4)Diabetes mellitus
5)COPD (per OSH H+P, daughter denies)
6)Hypertension
7)s/p CVA (per OSH H+P, daughter denies)
8)Aortic stenosis s/p aortic valve replacement in [**2181**]
9)Hypothyroidism per OSH records
10)Paroxysmal atrial fibrillation
11)CAD
12)Dementia
13)Hyperlipidemia
14)CHF
15)Osteoarthritis
Discharge Condition:
Vital signs stable, stable vent setting, tube feeds.
Discharge Instructions:
You were admitted for a tracheostomy change, were treated with
antibiotics for a pneumonia, had a PICC line placed, and
received hemodialsysis.
Please call 911 or come to emergency room if you acquire chest
pain, shortness of breath, nausea, vomiting, or any other
concern that is worrisome for you.
Followup Instructions:
Please call your primary care physician and set up an appt
within 3-5 days for blood draws and an appointment.
Please call Dr. [**Last Name (STitle) 76934**] and set up a nephrology appointment at
his discretion.
ICD9 Codes: 5856, 4280, 496, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1037
} | Medical Text: Admission Date: [**2159-8-22**] Discharge Date: [**2159-9-8**]
Date of Birth: [**2075-11-12**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / Erythromycin Base
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Elective admission for resection of left sided meningioma
Major Surgical or Invasive Procedure:
Left craniotomy for resection of meningioma
History of Present Illness:
83 yo F with known left parasaggital meningioma, followed by Dr.
[**Last Name (STitle) **], who has had progressive right leg weakness and
difficulty walking over the past several months to a year. She
lives independently with her husband and it has become
increasingly difficult to walk. She is altering her gait and
using upper body strenght to walk and climb stairs. Her family
notes that she drags her leg when she walks. No pain, numbness
or tingling.
Work-up of right leg weakness included MRI thoracic and cervical
spine that show only mild degenerative changes and chronic T9
compression fx. She was found to have a left sided meningioma
and he is she is currently scheduled for elective craniotomy.
Past Medical History:
HTN, high cholesterol, oral lichen planus, left sided
parasaggital meningioma (as above), hypothyroid, Irritable bowel
syndrome, GERD, sciatica, aortic/mitral valve insufficiency,
recent PNA 3 weeks ago treated as outpatient.
Social History:
lives independently with husband, cooks and cleans
Family History:
NC
Physical Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRLA EOMs Full
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 mm to
3 mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing decreased to finger rub on right.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-31**] throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Coordination: finger-nose-finger and rapid alternating
movements decreased on right
Handedness Right
Pertinent Results:
[**2159-8-22**] CT Head at 15:00:
The patient is status post left frontal craniotomy approach
resection of a
left parafalcine meningioma as demonstrated on the preoperative
examinations. There is extensive pneumocephalus compatible with
post-surgical change. In addition, high attenuation material
compatible with hemorrhage is demonstrated within the resection
bed with small areas of pneumocephalus. There are low
attenuation areas in the resection bed compatible with edema.
The [**Doctor Last Name 352**]-white matter differentiation is preserved. The
ventricles and sulci are stable in size and configuration. The
visualized portions of the paranasal sinuses and mastoid air
cells are well aerated. There is no shift of normally midline
structures.
IMPRESSION: Status post left frontal craniotomy for resection of
a known left parafalcine meningioma. High-attenuation and low
attenuation regions within the resection bed compatible with
post-surgical hemorrhage and edema.
[**2159-8-22**] CT Head at 19:00:
FINDINGS: Again are noted post-craniotomy changes from a left
frontal
approach with skin staples and a small amount of subcutaneous
emphysema. A
significant amount of bifrontal pneumocephalus is noted, similar
to prior
study with displacement of the frontal lobes and extending into
the middle
cranial fossae. Again is seen in the left frontal resection bed
an
approximately 2 x 1.5 cm focus of intraparenchymal hemorrhage
with surrounding vasogenic edema, which is similar to slightly
decreased compared to prior study. There is no shift of midline
structures. There is no intraventricular hemorrhage or evidence
of hydrocephalus. There is no sign of herniation. The visualized
portion of the paranasal sinuses and mastoid air cells are
clear.
IMPRESSION: Status post left frontal craniotomy for left frontal
mass
resection, with stable appearance of left frontal hemorrhage in
the resection bed. Significant amount of pneummocephalus in the
bifrontal regions with displacement of the frontal lobes; while
this is not significantly changed from prior, correlate
clinically for tension pneumocephalus.
[**2159-8-23**] MR [**Name13 (STitle) **]:
S/post resection of the previously noted left frontal
extra-axial enhancing lesion, likely representing dural-based
lesion such as meningioma. Post-surgical changes are noted,
with presence of blood products at the surgical resection site.
There are also post-surgical changes noted in the adjacent bone
and dura. Small-to-moderate amount of pneumocephalus is noted in
the bifrontal regions. There is moderate amount of surrounding
edema. A few enhancing areas are noted in the surgical resection
site and residual tumor cannot be excluded.
In addition, there is a new moderate sized area of altered
signal intensity in the left parietal lobe, with hypointense
appearance on the T1 and hyperintense on the T2-weighted
sequence with some degree of decreased
diffusion concerning for an infarct in this location. Tiny foci
of negative susceptibility can relate to blood
products/mineralization. There is swelling/thickening of the
cortex with some enhancement on the post-contrast sequences.
There is also enhancement in the sulci in this location. The
appearance can relate to ischemia/infarction, venous
stasis/infarction/inflammatory changes.
There is a small amount of subdural fluid collection noted along
the convexity on both sides. MP-RAGE sequences are limited due
to patient motion-related artifacts. There is likely mild
meningeal enhancement.
The ventricles and extra-axial CSF spaces are otherwise
unremarkable, except for mass effect by the blood products in
the surgical resection site in the left lateral ventricle.
IMPRESSION:
1. Post-surgical changes in the left frontal surgical resection
site at the location of the previously noted meningioma, with
presence of blood products; pneumocephalus and small subdural
fluid collection extra-axially on both sides along with mild
meningeal enhancement.
2. Interval development of a moderate-sized area of altered
signal intensity in the left parietal lobe just posterior to the
surgical resection site, with some degree of decreased
diffusion, cortical swelling concerning for infarction, venous
stasis/infarction/inflammatory changes in this location,
acute-subacute. Followup evaluation to assess interval change
and confirmation of the nature of the abnormality is necessary.
[**2159-8-24**] Head CT at 01:00:
IMPRESSION: Increased intracranial hemorrhage on the left, now
involving the frontal and parietal lobes.
[**2159-8-24**] Head CT at 08:00:
IMPRESSION: Stable intraparenchymal hemorrhage in the left
frontal and left parietal lobes, with associated surrounding
edema and mass effect, unchanged from prior study. Given the
location, especially the left parietal intraparenchymal
hemorrhage as well as the appearance on MR, this raises the
possibility of a hemorrhagic venous infarct.
[**2159-8-24**] Head CT at 14:00:
IMPRESSION: No significant interval change from prior study.
Stable
intraparenchymal hemorrhage in the left frontal and parietal
lobes with
associated surrounding edema and mass effect, unchanged from
prior study.
Given the appearance of MR and the location of the parietal
intraparenchymal hemorrhage, this raises the possibility of
hemorrhagic venous infarct, as mentioned on most recent prior
study.
[**2159-8-25**] ECHO:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and preserved global biventricular systolic
function. Mild aortic regurgitation. Borderline pulmonary artery
systolic hypertension.
[**2159-8-25**] Head CT:
IMPRESSION: No significant interval change compared to prior
study, with
extensive left frontoparietal multifocal parenchymal hemorrhage,
large region of surrounding edema and degree of mass effect,
unchanged. There is no evidence of uncal or other central
herniation.
[**2159-8-26**] Head CT:
IMPRESSION: No significant interval change in comparison to
prior study from [**2159-8-25**] with extensive left
frontoparietal multifocal parenchymal hemorrhages with a
possibility venous infarction laterally and significant moderate
amount of surrounding edema and stable mass effect.
[**2159-8-26**] CXR
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Mild bilateral pleural effusions. Borderline size of the
cardiac
silhouette with retrocardiac atelectasis. Minimal enlargement of
the
pulmonary vessels, making minimal overhydration likely.
No newly appeared focal parenchymal opacities. Unchanged size of
the cardiac silhouette.
[**2159-8-27**] CXR
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Mild bilateral pleural effusions. Borderline size of the
cardiac
silhouette with retrocardiac atelectasis. Minimal enlargement of
the
pulmonary vessels, making minimal overhydration likely.
No newly appeared focal parenchymal opacities. Unchanged size of
the cardiac silhouette.
[**2159-8-27**] MRI/V Brain
IMPRESSION:
1. New area of acute infarct in right cerebellar hemisphere.
2. Extensive left frontoparietal multifocal parenchymal
hemorrhage which is unchanged from the prior study. This
possibly represents venous infarction. Stable mass effect and
perilesional edema.
3.No evidence of thrombosis in the superior sagittal, transverse
and sigmoid sinuses.
[**2159-8-29**] CXR
IMPRESSION: Right apical opacity is indeterminate but has
reappeared. This likely represents an area of atelectasis. Right
lower lobe collapse has resolved.
[**2159-8-30**] CXR
IMPRESSION: No interval change of small bilateral pleural
effusion with
atelectasis. No evidence of congestive heart failure or
pneumonia.
[**2159-8-31**] Lower Extremity Venous Doppler US
IMPRESSION: Superficial nonocclusive thrombus within the mid
portion of the right basilic vein. No evidence of deep venous
thrombosis.
[**2159-9-6**] LENI's: CONCLUSION: No evidence of DVT in right or
left lower extremity.
Brief Hospital Course:
Pt was admitted to neurosurgery service for elective admission
and underwent a left sided craniotomy. She tolerated this
procedure well with no complications. Post operatively she was
taken to the CT scanner for a CT of the head to evaluate for any
post-operative hemorrhage. the CT showed that she had bled into
the resection cavity. A repeat scan was obtained 3 hours alter
which was improved from the prior. She was subsequently
extubated. She remained stable overnight into the morning of
[**8-23**] when she was examined and rounds and found to have no
movement of her [**Last Name (un) **], minimal TFR to noxious with her RLE and was
grossly full with her left side. She had some word finding
difficulties and was slightly perseverative as well. She
underwent MRI scan of the brain to assess the resection cavity
post-operatively which showed complete resection. On the evening
of [**8-23**] she was noted to have two seizures which was exhibited
by right sided rigidity and left side shaking and hiccuping. She
was started on a second anti seizure [**Doctor Last Name 360**], Keppra, continuous
EEG monitoring was ordered. Serial CT scans showed
intraparenchymal hemorrhage in the left frontal and left
parietal lobes, with associated surrounding edema and mass
effect. Dr [**Last Name (STitle) **] had a meeting with the family and discussed
the seriousness of this bleed.
On [**8-25**] she was reintubated for respiratory distress.
Post-intubation she was bradycardiac to the 20's and Atropine
was given. On [**8-26**], her exam was worse and her SBP was pressed
120-140; there was difficulty in doing this because of her
bradycardia.
On [**8-27**] her exam was stable and she was not following commands.
On [**8-28**] she continued with the EEG which showed some spikes so
her Keppra was increased. On the morning of [**8-29**] on rounds she
was noted to be following commands with the LUE and opening eyes
to voice which was an improvement in exam over the past few
days. Family meeting was scheduled for [**8-30**] and the family
decided to allow for more time for improvement in the patient's
mental status before committing to tracheostomy and PEG.
Right Upper extremity Doppler was performed on [**8-30**] due to
swelling and demonstrated only a superficial thrombus was
discovered, no evidence of occlusive DVT. It was managed with
warm compresses and elevation.
Patient was started on vancomycin on [**8-31**] for pneumonia. EEG
showed seizure activity
and we increased dilantin to 200 tid. The level was 9.1 on [**9-1**].
She was cultured for elevated WBC count to 16 on 8.7. She was
without seizure activity on EEG and her neuro checks were made
Q2 hrs.
Over the next several days she continued to have intermittent
focal seizures and her Keppra dose and dilantin dose were
uptitrated periodically to control seizure at the recommendation
of neurology.
Her neurological exam plateaued. She no longer opens her eyes
to voice and does not follow commands. She continues to move
her left side spontaneously and reflexively. She remains
hemiplegic on the right side. Additional family meetings were
held between the ICU attending and the family on [**9-3**] and between
the Neurosurgery attending (Dr. [**Last Name (STitle) **] and the family on
[**7-25**] to discuss the options of tracheostomy and PEG in the
setting of poor neurological prognosis. On [**9-7**] the patient self
extubated but was unable to maintain an airway. Attempt to
contact the family was made but there was no answer therefore
she was reintubated.
Family meeting was held and given the grim prognosis, goal of
care of changed to comfort measures only and patient was
extubated. Patient died on [**9-8**] and pronounced on [**9-20**]. Family
including husband, Mr. [**First Name8 (NamePattern2) 1312**] [**Known lastname 5066**] was at bedside and
family declined autopsy.
Medications on Admission:
norvasc, atenolol, lipitor, cozaar, levoxyl, MVI, k-dur,
prednisone
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Meningioma
Cerebral edema
Bradycardia
Cerebral venous infarct
Intercerebral parenchymal hemorrhages
seizure
respiratory failure
Discharge Condition:
Died on [**2159-9-8**]
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2159-9-8**]
ICD9 Codes: 431, 4019, 2724, 2449, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1038
} | Medical Text: Admission Date: [**2164-12-6**] Discharge Date: [**2164-12-24**]
Date of Birth: [**2164-12-6**] Sex: F
Service: NEONATAL
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 37538**], is the former
1.725 kilogram product of a 31-3/7 week gestation pregnancy
born to a 33 year old Gravida 3, Para 1 woman.
PRENATAL LABORATORY STUDIES: Blood type O positive, antibody
negative, rubella immune, RPR nonreactive. Hepatitis B
surface antigen negative. Group Beta Strep status unknown.
Mother's medical history is notable for a pituitary adenoma
which was resected in [**2160**], rendering her with
pan-hypopituitarism syndrome. She was treated with DGAPV, T4
and hydrocortisone. This pregnancy was complicated by
preterm labor and cervical dilatation. She was hospitalized
from 25 through 29 weeks. She was given betamethasone at 25
weeks gestation. She was readmitted on [**2164-12-5**], with
progressive cervical dilatation to 4 cm. She was given a
second course of betamethasone. She was taken to cesarean
section for a known breech presentation of Twin #2.
This twin #1 emerged with good tone and cry. She required
blow-by O2. Apgars were 8 at one minute and 9 at five
minutes. She was admitted to the Neonatal Intensive Care
Unit for treatment of prematurity.
PHYSICAL EXAMINATION: Physical examination upon admission
to the Neonatal Intensive Care Unit: Weight 1.725 kilograms,
length 42 cm, head circumference 30.5 cm. In general,
non-dysmorphic preterm female in mild respiratory distress.
Head, Ears, Eyes, Nose and Throat: Anterior fontanel open
and flat. Sutures approximated. Palate intact. Positive
red reflex bilaterally. Chest: Breath sounds with shallow
aeration, sternal retractions. Cardiovascular: Regular rate
and rhythm without murmur, normal S1, S2. Femoral pulses
plus two. Abdomen with three-vessel cord, no masses, no
hepatosplenomegaly. Genitourinary: Normal preterm female.
Extremities: Slight flexion deformity of the feet. Spine
intact. Hips stable. Neurological: Alert, intact reflexes,
tone consistent with gestational age.
HOSPITAL COURSE: Hospital course by systems including
pertinent laboratory data.
1. RESPIRATORY: [**Known lastname **] was placed on nasopharyngeal
continuous positive airway pressure shortly after admission
to the Neonatal Intensive Care Unit. Her maximum oxygen
requirement was 30%. She remained on C-PAP through day of
life number three when she was changed to nasal cannula O2.
She required nasal cannula O2 for an additional three to four
days. By day of life number six, she was consistently in
room air and remained in room air through the rest of her
Neonatal Intensive Care Unit admission. She has had rare
episodes of spontaneous apnea that have not required
treatment.
2. CARDIOVASCULAR: A soft murmur was noted on day of
life number one and became intermittent through the first
week of life. On day of life number 10, her murmur
reappeared. Her EKG was within normal limits as were four
extremity blood pressures. On day of life number 13, a
cardiac echocardiogram was obtained showing a large patent
ductus arteriosus and some concern over a slightly small
appearing aortic arch. She was treated with three doses of
Indomethacin finishing on [**2164-12-21**]. A repeat
echocardiogram after the third dose showed the PDA closed and
no coarctation of the aorta. At the time of discharge, her
baseline heart rates are in the 130s to 160s with a recent
blood pressure of 61/40 with a mean of 45.
3. FLUIDS, ELECTROLYTES, NUTRITION: [**Known lastname **] was initially
NPO and maintained on intravenous fluids. Enteral feeds were
started on day of life number one and gradually advanced to
full volume. Her calories were supplemented to 26 per ounce
with additional protein supplement of ProMod. She was made
NPO during her Indomethacin course. Feedings were restarted
on [**2164-11-25**]. At the time of discharge, she is taking 150
cc per kilo per day of premature Enfamil fortified to 26
calories per ounce with 2 calories of medium chain
triglyceride oil and [**12-12**] teaspoon of ProMod per 90 cc. Her
most recent set of electrolytes was on [**2163-12-24**], showing a
sodium of 143, a potassium of 6.0, a chloride of 112 and a
total carbon dioxide of 22. Weight on the day of discharge
is 2.055 kilograms with a head circumference of 32 cm and a
length of 44.5 cm.
4. INFECTIOUS DISEASE: Due to the unknown etiology of
her respiratory distress at birth and the unknown Group Beta
Strep status of the mother, a sepsis evaluation was performed
shortly after admission to the Neonatal Intensive Care Unit.
A complete blood count showed a white count of 8,200 with a
differential of 32% polyps, 0% bands. A blood culture was
obtained prior to starting antibiotics. She received 48
hours of intravenous ampicillin and Gentamycin. The blood
culture was no growth at 48 hours and the antibiotics were
discontinued. There were no other Infectious Disease issues
through the remainder of hospitalization.
5. HEMATOLOGICAL: Hematocrit at birth was 51%. [**Known lastname **]
did not receive any transfusions of blood products. She is
blood type A positive and Coombs' negative. Her most recent
hematocrit was on [**2164-12-21**], at 38%. Platelets at that time
checked due to the Indomethacin course, were 387,000. She
has also received supplemental iron.
6. GASTROINTESTINAL: [**Known lastname **] required treatment for
unconjugated hyperbilirubinemia with phototherapy. Her peak
serum bilirubin occurred on day of life number two with a
total of 8.3. She received phototherapy for four days. Her
rebound bilirubin following her course of phototherapy was a
total of 4.6/0.2 direct.
7. NEUROLOGICAL: [**Known lastname **] has maintained a normal
neurological examination during admission and there are no
neurological concerns at the time of discharge. She had a
head ultrasound on [**2164-12-17**], that was within normal limits.
8. SENSORY: Hearing Screening has not yet been
performed.
CONDITION ON DISCHARGE: Good. The primary pediatrician is
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37539**], [**Location (un) 37540**] Pediatric Associates, [**Apartment Address(1) 37541**], [**Hospital1 **], [**Numeric Identifier 37542**].
DISPOSITION: Transfer to [**Hospital **] Hospital for continuing
Level II care.
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feeding: 150 cc per kilo per day of premature Enfamil
formula fortified to 26 calories per ounce by addition of
2 calories of medium chain triglyceride oil and
additional [**12-12**] teaspoon of ProMod per 90 cc.
2. Medication: Fer-In-[**Male First Name (un) **] 0.15 cc p.o. p.g. q. day. That
is the 25 mg per ml dilution; 4 mg of elemental iron.
3. Car Seat Position Screening has not yet been performed.
4. State [**Known lastname **] Screening has been sent twice during the
admission with no notification of abnormal results to
date.
5. No immunizations administered thus far.
6. Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the following
three criteria: 1) Born at less than 32 weeks gestation;
2) born between 32 and 35 weeks with plans for daycare
during RSV season with a smoker in the household or with
preschool siblings, or, 3) with chronic lung disease.
Influenza immunization should be considered annually in
the fall for preterm infants with chronic lung disease
once they reach six months of age. Before this age, the
family and other caregivers should be considered for
immunization against influenza to protect the infant.
DISCHARGE DIAGNOSES:
1. Prematurity at 31-3/7 weeks gestation.
2. Twin #1 of twin gestation.
3. Mild respiratory distress syndrome, resolved.
4. Suspicion for sepsis, ruled out.
5. Patent ductus arteriosus status post treatment with
Indocin.
6. Apnea of prematurity.
7. Unconjugated hyperbilirubinemia.
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Last Name (Titles) 37384**]
MEDQUIST36
D: [**2164-12-24**] 06:40
T: [**2164-12-24**] 10:13
JOB#: [**Job Number 37543**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1039
} | Medical Text: Admission Date: [**2151-5-13**] Discharge Date: [**2151-5-18**]
Date of Birth: [**2086-6-28**] Sex: M
Service: CCU MEDICINE
HISTORY OF THE PRESENT ILLNESS: The patient is a 64-year-old
male with a history of coronary artery disease, status post
LAD stent in [**2145**] complicated by in-stent thrombosis after
one week status post thrombectomy. The patient had a
coronary artery bypass graft in [**2145**] with LIMA to LAD, SVG to
OM1, SVG to PDA, to PLV for a nonintervenable lesion of the
PDA. The patient also has a history of hypertension,
elevated cholesterol. He had a Persantine MIBI in [**9-7**] for
unstable angina which showed only a small fixed inferior
defect which was thought to be artifact and an ejection
fraction of 63%, now presenting with worsening exertional
chest pain and shortness of breath for the last month. The
patient was found to have new T wave inversions in leads II,
aVF, V2 through V4 on the EKG. He was admitted for
catheterization initially to the CMI Service. The patient
reports chest pain with minimal exertion such as walking one
to two blocks or climbing two to three flights of stairs
associated with shortness of breath. Denied any chest pain
at rest. Denied paroxysmal nocturnal dyspnea, lower
extremity edema, orthopnea.
At catheterization, he was noted to have two 80% serial
lesions between the RPDA and RPL anastomoses. When the wire
crossed these lesions, the patient became bradycardiac and
had an asystolic arrest. He had CPR for two minutes and was
started on dopamine transiently for low blood pressure and
regained normal sinus rhythm. He was given epinephrine and
Atropine and an intra-aortic balloon pump was placed
temporarily and transvenous pacing wires were used
temporarily and removed after catheterization.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
97.6, heart rate 67, blood pressure 119/69, respirations 15,
saturating 99% on room air. General: He was in no acute
distress, alert and oriented times three. HEENT: Mucous
membranes moist. No jugular venous distention.
Cardiovascular: Regular rate and rhythm, no murmurs, rubs,
or gallops. Slight parasternal tenderness to palpation.
Pulmonary: Clear to auscultation bilaterally. Abdomen:
Soft, nontender, nondistended, normoactive bowel sounds.
Extremities: Without edema, slight oozing of the left groin
A line site. There was 1+ dorsalis pedis pulses bilaterally,
2+ posterior tibial pulses bilaterally.
LABORATORY/RADIOLOGIC DATA: White count 10.6, hematocrit
36.9, platelets 152,000. Chemistries revealed a sodium of
145, potassium 4.3, chloride 105, bicarbonate 28, BUN 21,
creatinine 1.2, glucose 100, INR 1.0.
The EKG was normal sinus rhythm, rate of 70, normal axis and
intervals, Q waves present in leads III and aVF, ST
elevations of 3 mm in II, III, and aVF and biphasic T present
in V6.
Persantine MIBI in [**9-7**] showed mild fixed inferior defect,
ejection fraction of 63%.
His cardiac catheterization this admission showed a right
atrial pressure of 5, pulmonary artery pressure of 16, right
ventricular pressures of 23/6, pulmonary capillary wedge mean
pressure of 9. Cardiac output of 3.26, cardiac index of
1.71.
Left ventriculogram showed normal ejection fraction with no
mitral regurgitation. Left main was normal. LAD showed mild
in-stent occlusion, distal filling via LIMA. No significant
disease. Left circumflex showed distal subtotal occlusion
with small distal vessel, RCA showed an occluded PDA and mid
PL branch, both filling via saphenous vein graft. Mild
disease SVG to RPDA to RPL. Serial 80% lesions between
anastomoses to RPDA and RPL. LIMA to LAD is normal, SVG to
OM is occluded.
HOSPITAL COURSE: The patient underwent stenting of serial
80% lesions between the RPDA and RPL anastomoses. An
intra-aortic balloon pump was placed for 24 hours.
During the catheterization, after the wire was passed over
the 80% lesions in the RCA, the patient underwent asystolic
arrest, had CPR initiated for two minutes, regained normal
sinus rhythm after being given epinephrine and Atropine. The
patient had transvenous pacing wires placed which were
removed after his catheterization. After his interventions,
the patient was noted to have ST elevations in inferior leads
and complained of chest pain.
1. ACUTE INFERIOR MYOCARDIAL INFARCTION SECONDARY TO DISTAL
EMBOLIZATION DURING PCI: EKG after
catheterization showed residual ST elevation in II, III, and
aVF. Peak CKs were in the 2,000 range with no evidence of RV
infarction by right heart catheterization. His pain was
controlled with a nitroglycerin drip and Dilaudid p.r.n.
initially. After about eight hours post catheterization, his
pain subsided. He was continued on a beta blocker which was
titrated up, aspirin, Plavix, Lipitor, Integrilin for 18
hours post catheterization, and heparin until his sheath was
pulled.
2. HYPOTENSION: The patient was transiently hypotensive
during catheterization and was placed on dopamine temporarily
which was discontinued after the patient left the
catheterization laboratory. He had an intra-aortic balloon
pump placed for 24 hours after catheterization to improve his
coronary perfusion. He was easily taken off the balloon pump
the next day.
3. HEMATURIA: The patient was with gross hematuria after
catheterization, likely secondary to combination of
Bivalirudin, Integrilin, Plavix, and aspirin during his
catheterization. Possible Foley trauma. He was started on
continuous bladder irrigation for 24 hours. The patient had
several episodes of large clots obstructing which were
flushed and suctioned out of his continuous bladder
irrigation. After his Integrilin was discontinued, his
hematuria resolved over the next day and his catheter was
pulled after his urine drained clear.
4. HYPERTENSION: The patient's blood pressure was well
controlled. His Lopressor was titrated up and he will be
discharged on 150 mg of Toprol XL a day. He was not
initiated on an ACE inhibitor but may benefit from treatment
with Ramipril per his outpatient cardiologist.
5. SUPERFICIAL THROMBOPHLEBITIS: On the patient's third
hospital day, he was noted to have swelling and tenderness
over his left dorsum of his hand associated with a peripheral
IV site. The peripheral IV was pulled. There was
erythematous tracking noted up to the antecubital fossa. The
patient was also noted to spike a low-grade fever to 100.9.
Blood cultures were drawn. He was started on vancomycin for
24 hours which was then switched to oxacillin 2 grams IV q.
eight hours for two days and he was discharged home on
dicloxacillin for one week.
On the day of discharge, his fever had improved and his white
count came down.
6. HYPERCHOLESTEROLEMIA: He was started on Lipitor 80 mg
p.o. q.d. for an acute myocardial infarction.
7. GLUCOSE INTOLERANCE: Per the patient's wife, he has a
history of elevated glucose which has previously been
diet-controlled. He was maintained on a sliding scale
insulin in the hospital and the patient's fingersticks were
noted to be consistently in the 120-200 range and he will
likely need additional treatment initiated as an outpatient.
8. GROIN RASH: On the patient's fourth hospital day, he was
noted to have an itchy erythematous groin rash in his
intertriginous areas. It was consistent with [**Female First Name (un) 564**] with
satelite lesions present. He was started on Clotrimazole
b.i.d. and he was discharged on a two week course of
Clotrimazole.
DISCHARGE STATUS: The patient is ambulatory, chest
pain-free, saturating well in room air.
DISCHARGE DISPOSITION: The patient will be discharged home
with home services for medication teaching.
FOLLOW-UP PLANS: The patient is to follow-up with his
primary care provider in two weeks after discharge. He is
also to follow-up with his cardiologist, Dr. [**Last Name (STitle) **], in
two weeks.
DISCHARGE MEDICATIONS:
1. Plavix 75 mg p.o. q.d.
2. Aspirin 325 mg p.o. q.d.
3. Multivitamin one p.o. q.d.
4. Fish oil one capsule p.o. b.i.d.
5. Lipitor 80 mg p.o. q.d.
6. Clotrimazole 1% cream one application b.i.d. to groin.
7. Dicloxacillin 250 mg p.o. q. six hours times one week.
8. Toprol XL 150 mg p.o. q.d.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Last Name (NamePattern1) 5819**]
MEDQUIST36
D: [**2151-5-18**] 12:34
T: [**2151-5-19**] 18:45
JOB#: [**Job Number 102412**]
ICD9 Codes: 9971, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1040
} | Medical Text: Admission Date: [**2200-10-10**] Discharge Date: [**2200-10-15**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
code stroke
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **]yo female with history of hypertension and remote
non-Hodgkin's Lymphoma, recent admission for legionella
pneumonia
found on the floor at 1:40am not moving her R side and
non-verbal; CT head showed a L MCA stroke on CT head, now s/p
tPA.
Patient was last seen walking and talking at 6pm, at 10pm her
son
saw her sleeping on bed quietly. At 1:40am her son heard a loud
noise and found her on the floor in the bathroom not moving the
right side of the body, with a left facial droop and non-verbal.
He called EMS. On arrival her FS 121 BP 151/73 RR20 Sat 97% NC.
She was found to have a L MCA syndrome, she was non-verbal, with
right gaze preference, R facial weakness and right hemiparesis.
CT head showed are of hypodensity in L insular territory and M2
occlusion of L MCA.
Son [**Name (NI) **] was here and consented for tPA. PAtient has had no
recent surgery, was not on AC. Risks and benefits of tPA were
discussed. She was given 0.9mg/kg tPA; 10% as a bolus at 3:36
am;
the remaining in an infusion over one hour.
Initial NIHSS performed soon after patient arrival was scored at
16.
Loc ?????? 1
Questions ?????? 2 (patient does not respond)
Commands ?????? 2
Gaze ?????? 1 (left gaze deviation)
Visual ?????? 0 (blinks to threat bilaterally)
Facial palsy ?????? 2 (R facial weakness in UMN pattern)
Motor ?????? 5 (no effort against gravity RUE and can??????t resist
gravity
RLE)
Ataxia ?????? 0
Sensory ?????? 0 (Winces to noxious stimuli on R and withdraws on L)
Language ?????? 3 (Mute)
Dysarthria ?????? UN (non-vocal, non-verbal)
Extinction ?????? 0
Past Medical History:
1. Hypertension
2. Hypercholesterolemia
3. h/o Non-Hodgkin's Lymphoma more than 20 years ago
- s/p XRT at [**Hospital1 2025**]
- currently in remission
Social History:
Home: currently living with her son
EtOH: Very rare social EtOH use
Tobacco: Former smoker (quit 30 years ago, 30 pack per year
history prior
Drugs: Denies
Family History:
Mother - died of heart disease in her 70s.
Physical Exam:
Exam:
BP 151/73 RR20 Sat 97% NC FS 121
Gen: Lying in bed
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Eyes closed, non-responsive to verbal stimuli,
non-verbal, grimaces on sternal rub
Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Eyes closed, left gaze preference, normal [**Last Name (un) 81915**],
corneal intact, R facial weakness, tongue was midline
Motor: spontaneous movement L side; triple flexion on R side. No
anti-gravity movement.
Sensation: She retracted less on the right side than left on
noxous stimuli
Reflexes: B T Br Pa Pl
Right 2 1 2 2 0
Left 2 1 2 1 0
Upgoing toe on R
Coordination: unable to test
Gait: unable to test
Pertinent Results:
[**2200-10-10**] 02:15AM BLOOD WBC-11.3* RBC-3.63* Hgb-10.0* Hct-30.3*
MCV-83 MCH-27.6 MCHC-33.1 RDW-15.4 Plt Ct-592*#
[**2200-10-14**] 05:15AM BLOOD WBC-20.8* RBC-3.34* Hgb-9.3* Hct-28.1*
MCV-84 MCH-28.0 MCHC-33.2 RDW-16.3* Plt Ct-439
[**2200-10-10**] 02:15AM BLOOD PT-12.5 PTT-22.7 INR(PT)-1.1
[**2200-10-11**] 06:00AM BLOOD Glucose-135* UreaN-30* Creat-1.4* Na-140
K-3.4 Cl-107 HCO3-21* AnGap-15
[**2200-10-14**] 05:15AM BLOOD Glucose-159* UreaN-31* Creat-1.1 Na-147*
K-3.8 Cl-114* HCO3-22 AnGap-15
[**2200-10-14**] 05:15AM BLOOD Calcium-8.2* Phos-2.3* Mg-2.0
[**2200-10-10**] 02:15AM BLOOD cTropnT-<0.01
[**2200-10-10**] 02:15AM BLOOD Triglyc-111 HDL-63 CHOL/HD-4.3
LDLcalc-189*
[**2200-10-10**] 03:30AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.013
[**2200-10-10**] 03:30AM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2200-10-10**] 03:30AM URINE RBC-0 WBC-0-2 Bacteri-MANY Yeast-NONE
Epi-[**2-6**]
Microbiology:
URINE CULTURE (Final [**2200-10-13**]):
STAPHYLOCOCCUS SPECIES. ~9000/ML
Imaging:
CTA head:
IMPRESSION:
1. Multifocal new calcified emboli, the largest lodged within
the left M1
segment of the middle cerebral artery which has resulted in a
completed
infarct of approximately two-thirds of the MCA territory, with a
larger
penumbra risk involving virtually the entire left MCA
distribution.
2. Extensive multifocal atherosclerotic disease, with
approximately 70%
stenosis of the proximal left internal carotid artery, and
approximately 60%
stenosis of the proximal right internal carotid artery.
CXR [**10-13**]:
FINDINGS: As compared to the previous radiograph, the
nasogastric tube has
been advanced. In the lung parenchyma, there is increasing
density at the
left lung base, in the retrocardiac lung areas. In the
appropriate clinical
setting, these could represent pneumonia. No other parenchymal
abnormalities
are occurred in the meantime. Mild cardiomegaly
Brief Hospital Course:
[**Age over 90 **]yo W with HTN and remote history of non-Hodgkin's Lymphoma and
recent admission for legionella pneumonia was found on the floor
at 1:40am not moving her R side and
non-verbal. On examination she was found to have a L MCA
syndrome. Head CT showed loss of [**Doctor Last Name 352**]-white matter
differentiation at L insular territory and M2 occlusion of L MCA
and CTA confirmed these findings with evidence of multifocal new
calcified emboli, resulting in a infarct of two-thirds of the
MCA territory, and penubram involving the rest of MCA territory.
She was noted to have multifocal atherosclerosis with 70%
stenosis [**Doctor First Name 3098**] and 60% stenosis of [**Country **].
Given that patient was still within timeline for tPA
administration, she received tPA in the ED. She was admitted to
Neuro-ICU with activated stroke protocol (IVF, BP autoregulation
w/ < 180, maintenance of normothermia and euglycemia). She was
started on a statin. Her examination did not improve.
Patient was eventually transferred to the floor with persistent
R hemiplegia, global aphasia. She developed hypernatremia and
aspiration PNA. As these medical conditions were treated, a
discussion was held with family regarding goals of care. Given
poor prognosis and understanding of patient's prior wishes,
patient was made CMO. She expired in the evening of [**2200-10-15**].
Medications on Admission:
Amlodipine 5mg
HCTZ 25mg
ASA 81
Discharge Medications:
na
Discharge Disposition:
Expired
Discharge Diagnosis:
Left middle cerebral artery stroke, aspiration pneumonia
Discharge Condition:
deceased
Discharge Instructions:
na
Followup Instructions:
na
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2200-10-20**]
ICD9 Codes: 5070, 5990, 2760, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1041
} | Medical Text: Admission Date: [**2135-6-7**] Discharge Date: [**2135-7-6**]
Date of Birth: [**2050-9-9**] Sex: M
Service: SURGERY
Allergies:
Lasix / Bumex
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Absominal pain, nausea, empty retching - 12 days ago.
Major Surgical or Invasive Procedure:
s/p ex lap/right colectomy [**2135-6-11**]
tunnelled line
picc line
History of Present Illness:
84 year old male veteran of WWII with a complicated history
including CAD s/p CABG, ESRD on HD, bladder CA, and ANCA+
vasculitis who initially presented to OSH for abdomainl pain 12
days ago. He developed acute onset of nausea and dry heaves and
abdomainl pain which woke him up from sleep. He was admitted on
[**5-26**] and initially treated for diverticulitis with Unasyn and
gentamycin (which were on until [**5-31**]). An NG tube was placed on
[**6-4**] OSH stay which was on gravity at the time of transfer. He
was started on TPN on [**6-6**] (through a peripheral?). TPN
discontinued on arrival. NG connected to LCWS.
Had normal colonoscopy with melanosis amd Int hemorrhoids grade
III in [**2131**], ascending /transv colon not visualized suboptimal
prep.
He is anuric and gets HD-MWF via AVG L arm which was placed by
Dr.[**Last Name (STitle) 816**] on [**2133-11-4**] ans had multiple IR procedures recurrent
dysfunctions and suspected stenoses ; the last Fistulogram, 7-mm
balloon angioplasty of intragraft stenoses was done on [**2135-4-28**].
Denies fever, chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denied cough, shortness of breath. Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea.
Denied arthralgias or myalgias.
Patient requested transfer to [**Hospital1 **].
Past Medical History:
-CAD s/p Coronary Artery Bypass Graft x 5 [**2132-8-8**] (Left internal
mammary artery > Left anterior descending, saphenous vein graft
> diagonal, saphenous vein graft > obtuse marginal 1, saphenous
vein graft > obtuse marginal 2, saphenous vein graft > posterior
descending artery)
-Diastolic CHF
-HTN
-Mitral regurg (1+), Aortic regurg (1+), Tricuspid regurg (2+)
-Dyslipidemia
-Hypothyroidism
-Gout
-Bladder CA (12 years ago)
-Pericarditis (remote)
-Stage IV CKD; largely secondary to microvascular disease of the
kidney, but possibly with a component of atheroembolic disease
in light of persistently elevated eosinophil count and mildly
low complement levels.
-Atrial fibrillation
-Hemoptysis ([**4-/2133**]) thought to be related to ANCA-associated
vasculitis
-s/p right knee replacement
Social History:
Pt is a retired CPA, he recently moved into an [**Hospital3 **]
facility. He is able to maintain ADLs, cares for himself. Pt
smoked but quit 45 years ago; does not drink alcohol currently
and used rarely before his CABG, and has never used recreational
drugs. He is a veteran of WWII.
Family History:
NC
Physical Exam:
Admission PE:
Temp 97.6 Pulse 84 BP 95/60 RR 18 SATS 100 2L
General cooperative, not in distress
NEURO Oriented awake alert, no global or local deficits.
HEENT no thyromegaly, no lymphadenopathy, no carotid bruit.
CHEST crackles basal bilaterally
CARDIAC S1 S2 audible no murmurs appreciated.
ABDOMEN firm, non tender, moderately distended, BS+ high pitched
, no masses, ? R abdominal wall hernia +, guaic positive, no
rebound tenderness or guarding.
Ext: Warm, well perfused, 2+ pitting edema distal pulses +1
LUE: AVG Brachiocephalic thrill+ murmer+ radial pulse+
functional
LABS:
7.3 >30.5 < 237
140 101 52 AGap=18
-------------< 95
4.5 26 6.8
Ca: 8.4 Mg: 2.0 P: 5.8
ALT: 9 AP: 91 Tbili: 0.4 Alb: 2.4 AST: 13 LDH: 158
[**Doctor First Name **]: 51 Lip: 31
PT: 12.5 PTT: 39.4 INR: 1.1
MIcro: Per OSH: Blood Cx, Neg and C. diff neg.
IMAGING:
[**5-26**]: CT was done which was read as asymmetric cecal wall
thickening, inflammatory stranding of peri-cecal fat. Appendix
not visualized. Ascending colon epiploic herniation through
right
abdomainal wall defect.
.
[**5-30**] KUB was done for N/V/Ab distention which showed multiple
dilated loops of small bowel suggestive of obstruction. CT:
Distal mechanical small bowel obstruction.
.
[**6-2**] KUB Persistence of small bowel obstruction. CT on same
day:
with mild improvement in previously seen SBO.
.
[**6-4**]: Ab XR - six views: Partial SBO with passage of contrast
material into colon, suggests incomplete SBO.
right pleural effusion.
Pertinent Results:
[**2135-7-5**] 04:57AM BLOOD WBC-4.9 RBC-2.29* Hgb-7.6* Hct-23.9*
MCV-105* MCH-33.2* MCHC-31.7 RDW-19.0* Plt Ct-203
[**2135-6-30**] 05:52AM BLOOD PT-13.1 PTT-43.4* INR(PT)-1.1
[**2135-7-5**] 04:57AM BLOOD Glucose-107* UreaN-121* Creat-4.8* Na-139
K-4.4 Cl-104 HCO3-23 AnGap-16
[**2135-7-5**] 04:57AM BLOOD Calcium-9.5 Phos-4.3 Mg-2.4
[**2135-6-30**] 05:52AM BLOOD Lipase-122*
[**2135-6-30**] 05:52AM BLOOD ALT-5 AST-5 AlkPhos-91 Amylase-151*
TotBili-0.5
Brief Hospital Course:
He was admitted to the West 1 service under Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with
ESRD and
near-obstructing cecal lesion. Initially plan was to obtain a
colonoscopy, but he was unable to tolerate the prep and exam was
poor quality. CEA was elevated. CXR was without lesions,
non-contrast CT did not demonstrated evidence of metastatic
disease. A PICC was placed and TPN started while he was kept
NPO. On [**2135-9-10**], he was taken to the OR by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who
performed exploratory laparotomy with right colectomy for a
contained cecel perforation. Postop course was complicated by
need for intubated SICU stay for hypotension requiring pressor
support. Gradually, BP improved and he was able to tolerated
CVVHD as well as extubation. Subsequently, he was switched to
hemodialysis 3 time per week. He still experienced hypotension
at times. Anti-hypertensives were held. Diet was not started for
many days due to distension and lack of flatus. TPN via a picc
line was inserted. Gradually diet was reintroduced. He
experienced diarrhea requiring a flexiceal. Stool was sent
several times and was negative each time. The abdominal incision
became erythematous with drainage requiring opening. A wound vac
was applied. The wound grew citrobacter freundii and yeast.
Flagyl and Cefazolin were started on [**6-11**] and continued through
[**6-14**]. He remained afebrile.
He was transferred out of the SICU after several days only to
return to the SICU for mental status changes and respiratory
distress for aspiration. He was reintubated. He was started on
iv flagyl and vancomycin on [**6-19**]. Sputum [**6-19**] isolated
citrobacter freundii and yeast. Ceftazidime was added on [**6-23**].
This was switched to meropenum on [**6-24**]. On [**6-20**], a min bronch
with lavage yielded a sputum spec that isolated the following:
RESPIRATORY CULTURE (Final [**2135-6-23**]):
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
CITROBACTER FREUNDII COMPLEX. 10,000-100,000
ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
ENTEROBACTER CLOACAE. 10,000-100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
YEAST. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
| ENTEROBACTER CLOACAE
| |
CEFEPIME-------------- <=1 S 4 S
CEFTAZIDIME----------- <=1 S =>64 R
CEFTRIAXONE----------- <=1 S =>64 R
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ =>16 R <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ 4 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
POTASSIUM HYDROXIDE PREPARATION (Final [**2135-6-21**]):
BUDDING YEAST WITH PSEUDOHYPHAE.
FUNGAL CULTURE (Final [**2135-7-5**]):
YEAST.
He was also noted to be VRE positive on rectal swab on [**6-20**]. IV
flagyl and Meropenum continued through [**6-30**] when these were
discontinued. He remained afebrile.
He received aggressive respiratory care with improvement. He was
transferred out of the SICU to the med-[**Doctor First Name **] unit where PT worked
with him. He was very weak and required max assist. He appeared
too tired to swallow food/medicines and a swallow eval was done
with recommendations for a video swallow. This was not done as
he requested to stop care.
Hemodialysis continued, but the patient repeatedly expressed
statements that he wanted to stop dialysis and stop all care. He
tended to be hypotensive during dialysis. Last hemodialysis was
on [**7-4**]. A family meeting was held with the patient, his family
and hospital care givers. The decision was made establish
comfort care orders. Palliative Care was consulted. The
patient's family requested transfer to a hospice facility closer
to their homes. [**Location (un) 5481**] was contact[**Name (NI) **] and a bed became
available on [**7-6**]. The patient expressed that he was in agreement
with transfer to [**Location (un) 5481**] for hospice care. Picc line, wound
vac and flexiceal was removed.
Telephone consent was obtained on [**7-6**] at 1725 from son [**Name (NI) **]
[**Name (NI) 6174**] to initiate MA comfort care/DNR form consent prior to
discharge as the patient was very lethargic with some delerium.
He complained of intermittent abdominal pain with radiation to
back. Morphine SL was given for abdominal pain. Sublingual pain
medication were written prior to discharge.
Medications on Admission:
Lexapro 20mg daily
Levothyroxine 0.088mg daily
Zocor 40mg daily
Nephrocaps 1 tab daily
Trazadone 200mg daily
Metoprolol 12.5mg daily
Allopurinol 100mg every other day
Prednisone 10mg daily
Azatioprine 25mg daily
Bactrim SS qMWF
Prilosec ?dose daily
aspirin 325 daily
Colace 200mg [**Hospital1 **]
Renagel 800mg TID
Niaspan 500mg ER
Clotrimazole 100mg troche
astelin NS [**Hospital1 **]
preservision eye vitamin [**Hospital1 **]
sensispar 30mg daily
lactulose 10mg prn daily
.
Allergies:
Lasix --> rash
Bumex --> rash
Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO prn: q 4 hours
as needed for anxiety: give sublingually.
2. Morphine Concentrate 20 mg/mL Solution Sig: 2.5-10 mg PO Q2H
(every 2 hours) as needed for pain: sublingually.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 5481**]
Discharge Diagnosis:
ESRD
s/p ex lap/right colectomy [**2135-6-11**] for perforated cecal
diverticulitis
CAD
HTN
Afib
pneumonia
esrd
VRE
wound cellulitis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: awake,lethargic with brief alertness,
delerium
Activity Status: Bedbound.
Discharge Instructions:
You will be transferred to [**Hospital 5481**] Hospice Care today
Followup Instructions:
Hospice care
Completed by:[**2135-7-6**]
ICD9 Codes: 5856, 5070, 2762, 2930, 2449, 4280, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1042
} | Medical Text: Admission Date: [**2123-4-13**] Discharge Date: [**2123-4-16**]
Date of Birth: [**2058-10-22**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
left hip chronic subluxtion and pain
Major Surgical or Invasive Procedure:
[**Last Name (un) **] and left girdle stone athroplasty
History of Present Illness:
64 yo w f born with cerabal palsy and spastic quadraparesis sp
left thr 20 yrs ago revised 3 times since then last one was
[**2113**] at [**Hospital1 **] dr [**First Name (STitle) **] sledge complicated by polymicrobial
infection now instability has become so severe she is now in a
wheel chair and can not ambulate the hip is lax it comes out of
joint and goes back in on it's own refered to dr [**Last Name (STitle) **] for
surgical rx
Past Medical History:
cerebal palsy
depression
Social History:
live independently uses motorized wheel chair
Physical Exam:
heent wnl does have a speech impairment but answers clearly
chest clear
cor rrr
abd sft nt nd
ortho left leg is shortened by 1.5 inches
distal pulses are intact sensation intact
Pertinent Results:
[**2123-4-13**] 06:34PM BLOOD PT-12.7 INR(PT)-1.0
[**2123-4-14**] 04:40AM BLOOD PT-12.2 PTT-25.0 INR(PT)-0.9
[**2123-4-13**] 06:34PM BLOOD WBC-10.2# RBC-3.97* Hgb-12.0 Hct-35.3*
MCV-89 MCH-30.3 MCHC-34.1 RDW-14.8 Plt Ct-217
[**2123-4-14**] 04:40AM BLOOD WBC-6.2 RBC-3.60* Hgb-10.9* Hct-32.1*
MCV-89 MCH-30.1 MCHC-33.8 RDW-15.3 Plt Ct-225
[**2123-4-15**] 09:25AM BLOOD WBC-6.1 RBC-2.80* Hgb-8.5* Hct-24.8*
MCV-89 MCH-30.2 MCHC-34.1 RDW-14.7 Plt Ct-174
[**2123-4-15**] 01:20PM BLOOD WBC-6.3 RBC-2.80* Hgb-8.3* Hct-24.5*
MCV-88 MCH-29.7 MCHC-33.9 RDW-15.2 Plt Ct-199
[**2123-4-16**] 04:46AM BLOOD WBC-5.6 RBC-3.51*# Hgb-10.6*# Hct-30.6*
MCV-87 MCH-30.4 MCHC-34.8 RDW-14.7 Plt Ct-155
[**2123-4-13**] 06:34PM BLOOD Glucose-132* UreaN-23* Creat-0.4 Na-141
K-3.9 Cl-107 HCO3-30* AnGap-8
[**2123-4-14**] 04:40AM BLOOD Glucose-121* UreaN-22* Creat-0.5 Na-140
K-4.7 Cl-106 HCO3-31* AnGap-8
[**2123-4-15**] 09:25AM BLOOD Glucose-88 UreaN-9 Creat-0.4 Na-140 K-4.3
Cl-100 HCO3-37* AnGap-7*
[**2123-4-15**] 01:20PM BLOOD Glucose-104 UreaN-10 Creat-0.5 Na-135
K-4.2 Cl-99 HCO3-34* AnGap-6*
Brief Hospital Course:
on [**2123-4-13**] was taken to or and underwent [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] and left girdle
stone athroplasty was transfed to pacu in stable condition she
was started on coumadin with goal inr of 1.5- 2.0. because of a
1st degree avb anesthesia wanted the patient to go to the micu
after the pacu and called the micu team in micu she was
slightly hypercapnic 2nd to probable narcotics given narcan and
rr increased was doing well on pod 1 was seen by dr [**Last Name (STitle) **] in
micu and she was then transfered to 11 riseman pod 2 hct was
24.4 given 2 units hct pod 3 was 30.6 her last inr was 0.9 on
[**2123-4-14**]
once she is 1.5-2.0 she should have the sub q heparin dcd.
final rec from id was dc abx she had neg cultures from the or
as well as the needle aspirate in [**2123-1-23**] and or tissue
pathology would not be final for 2 weeks she was then ready or
rehab
ptx felt she was doing great with transfers to bed and wheel
chair
Medications on Admission:
depakote
klonopin
flonase
paxil
remeron
folate
percocet
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed for wheezing.
2. Divalproex Sodium 250 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Divalproex Sodium 250 mg Tablet, Delayed Release (E.C.) Sig:
Five (5) Tablet, Delayed Release (E.C.) PO HS (at bedtime).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
6. Paroxetine HCl 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Clonazepam 1 mg Tablet Sig: Four (4) Tablet PO QHS (once a
day (at bedtime)).
11. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): till inr is 1.7-2.0.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
14. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
16. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig:
One (1) Spray Nasal [**Hospital1 **] (2 times a day).
17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
18. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
19. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO ONCE
(once) for 14 days: ho to dose to keep inr 1.5-2.0.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
left hip chronic osteomyelits
Discharge Condition:
good to rehab
Discharge Instructions:
dc to rehab follow up with dr [**Last Name (STitle) **] as below take dc meds as
ordered coumadin goal is 2.0 call dr [**Last Name (STitle) **] if temp above
100.8 or drainage or sob develops keep dsd dry and intact
should be nwb on the the left and fwb on the rt
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD Where: [**Hospital6 29**]
ORTHOPEDICS Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2123-4-26**] 2:20
Provider: [**Name10 (NameIs) **] [**Doctor Last Name **], OD Where: [**Hospital6 29**]
Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2123-7-9**] 11:30
Completed by:[**2123-4-16**]
ICD9 Codes: 2762, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1043
} | Medical Text: Admission Date: [**2149-7-4**] Discharge Date: [**2149-7-15**]
Date of Birth: [**2121-2-11**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / Fluoxetine / Decongestant Sinus / Klonopin
Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
Hyperglycemia post procedure
Major Surgical or Invasive Procedure:
Lithotripsy, ureteral stent
History of Present Illness:
28 female IDDM recently admitted for DKA in [**Hospital Unit Name 153**], now admitted
to [**Hospital Unit Name 153**] post uretheral stent placement for "blood sugar
monitoring"
.
SInce patient was discharged, her blood sugar had been in the
500-600s. She has no ketones in her urine. She treated her sugar
with sc insulin according to insulin sensitivity and would bring
it down to 300s. Her neprhologist thought that the pain from
kidney stone is causing this erractic pattern and therefore
refer her for lithotripsy. Patient return today for right kidney
stone lithotripsy. Pre-op, her FS was 448 at 7.15am and that
came down to 189 w/ 10u novolog. It was then 100 at noon for
which she received [**Location (un) 2452**] juice. She was then started on D5NS in
OR. Post op, her FS was 361 for which she received 5u of IV
insulin. 1 hour later, her FS was 275. SHe also pulled out her
ureteral stent and therefore in pain. She was suppose to go to
regular post-op floor. However, She was admitted to [**Hospital Unit Name 153**] because
urology and anesthesia was not comfortable managing high blood
sugar.
.
Otherwise, patient denies chest pain, SOB, cough, sputum,
diarrhea, nausea, urinary symptoms, headahce, photosensitivity,
neck stiffness. She had vaginal yeast infection recently for
which she took diflucan. She recently travelled to [**State 15946**]. SHe
is currently in pain from passing ureteral stent. She also
complains of crampy lower abdominal pain and back pain after the
surgery. Otherwise, she is fine
Past Medical History:
rheumatoid arthritis since age 12
Type 1 Diabetes since age 10 w/ neuropathy
episodic gastroparesis with severe nausea and vomiting, on
reglan
endometriosis with previous laparoscopies
right nephrolithiasis
migraines
IBS
Social History:
She does not smoke. She occasionally drinks alcohol.
Family History:
Her mother has [**Name2 (NI) 499**] cancer and lupus. Her sister has Celiac
disease.
Physical Exam:
VSS, AF
Gen- NAD, up in bed, tired
HEENT- anciteric, PERRLA, EOMI, mmm, neck supple, no JVD
CV- rrr, no r/m/g
resp- CTAB
Abdomen- soft, slight tenderness diffusely, no rebound, no
guarding, nml bowel sounds
EXT- no edema, good pedal pulses
Neuro- A+O x3, CN II-XII intact, [**3-28**] strenght globally
Pertinent Results:
[**2149-7-4**] 06:53PM GLUCOSE-462* NA+-135 K+-3.6 CL--99* TCO2-28
[**2149-7-4**] 06:53PM HGB-11.6* calcHCT-35
Brief Hospital Course:
1) HYPERGLYCEMIA: Patient continued to have intermittent severe
hyperglycemia during the first part of the hospitalization.
Initially, it was thought to correlate with her pain level, but
subsequently, even with improved pain, she remained
hyperglyemic. Several days prior to discharge, she went into
mild DKA and was transferred to the unit for insulin gtt and
closer monitoring. DKA resolved quickly. Her insulin regimen
was adjust [**First Name8 (NamePattern2) **] [**Last Name (un) **] recs. At discharge, her BG was still only
moderately controlled.
.
2) GU: The patient also had prolonged course of right flank and
suprapubic pain after her GU procedure. She was placed on a PCA
for pain control. A renal US was done to assure there was no
hydronephrosis and there was only a minimal ammount. As her
pain continued, a abd/pelvis CT was done to look for other
etiologies. This was also unremarkable. Her pain improved, and
there was also some question of patient overreporting level of
pain. PCA was stopped and pt was placed on prn PO oxycodone.
.
Her other chronic medical issues were not active and outpatient
meds were continued.
Medications on Admission:
insulin(1:30 carb ratio, 1U for every 50>150), 30u Lantus at
9PM)
prozac 60mg
ativan 3mg
Xanax 0.25mg
Nexium [**Hospital1 **]
nuerontin 100mg in AM, 300mg in PM
quinine sulfate QD
lisinopril QD
vicodin prn
imitrex prn
celebrex 200mg
plaquenil
Zelnorm prn
zofran prn
seroquel 300mg QHS
motilium 20mg QAC
stool softerner
lactulose prn
Colace
Magnesium citrate
Discharge Medications:
1. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO QAM (once
a day (in the morning)).
2. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO QID (4
times a day).
Disp:*240 Capsule(s)* Refills:*0*
3. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Celecoxib 200 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Quetiapine 100 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
7. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
10. Tegaserod Hydrogen Maleate 2 mg Tablet Sig: One (1) Tablet
PO qhs ().
11. Oxycodone 5 mg Tablet Sig: 2-3 Tablets PO every four (4)
hours as needed for pain for 2 weeks.
Disp:*180 Tablet(s)* Refills:*0*
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
13. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours for 2 weeks.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
15. Insulin Glargine 100 unit/mL Solution Sig: Fifty (50) units
Subcutaneous at bedtime.
16. Metoclopramide 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Discharge Disposition:
Home
Discharge Diagnosis:
Hyperglycemia
Nephrocalcinosis
Discharge Condition:
Good--blood sugars moderately controlled, pain improved.
Discharge Instructions:
Please use insulin as prescribed by [**Last Name (un) **]. I have included a
sliding scale that you can use, along with a 1:7 carb ratio for
mealtimes.
Take flagyl for 3 more days for bacterial vaginosis.
Follow up as below.
Call Dr. [**Last Name (STitle) 42281**] for fever, chills, significantly worsening
pain, or any other symptoms that concern you.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 42281**] (or if you need a new PCP here you can
call [**Hospital3 **] at [**Telephone/Fax (1) 250**] to find a new doctor)
and see him in [**11-25**] weeks.
Follow up with Dr. [**Last Name (STitle) 12746**] next week at [**Last Name (un) **].
Please call Dr.[**Name (NI) 6444**] office to set up a follow up appointment.
ICD9 Codes: 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1044
} | Medical Text: Admission Date: [**2132-11-17**] Discharge Date: [**2132-11-28**]
Date of Birth: [**2054-6-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
unstable angina
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting times three(Left internal
mammary artery to left anterior descending, saphenous vein graft
to right circumflex artery)[**2132-11-24**]
left heart catheterization, coronary angiogram [**2132-11-21**]
History of Present Illness:
This 78 year old male presented with new onset of angina with
minimal activity and at rest. An echocardiogram on [**11-18**]
revealed hypokinesis as well as lateral anterior and
inferoposterior wall hypokinesis. The EF was reduced to 30%. He
also was noted to have Q wave. Catheterization revealed oteal
left main, occluded LAD and a right stenosis of hemodynamic
significance. He was referred for operation.
Past Medical History:
noninsulin dependent diabetes mellitus
hyperlipidemia
s/p open reduction/internal fixation of right humerus fracture
s/p cholecystectomy [**2115**].
s/p Incisional hernia repair.
s/p Appendectomy [**2071**].
s/p Right melanoma on right forehead removed in [**2105**], thought to
be early stage.
Social History:
Race:caucasian
Last Dental Exam:[**10-19**]
Lives with: wife
Contact: [**Name (NI) 28517**] Phone #([**Telephone/Fax (1) 28518**]
Occupation:retired pulmonologist
Cigarettes: Smoked no [x] yes [] last cigarette _____ Hx:
Other Tobacco use:cigar a couple times a year for many years
ETOH: < 1 drink/week [] [**3-17**] drinks/week [x] >8 drinks/week []
Denies illicit drug use
Family History:
Family History:non-contributory
Physical Exam:
Physical Exam
Pulse:81 Resp:20 O2 sat: 97%RA
B/P 127/76
Height:5'[**31**]" Weight:98.1 kgs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 1+ Left:1+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2132-11-26**] 04:27AM BLOOD WBC-10.1 RBC-3.06* Hgb-9.6* Hct-27.8*
MCV-91 MCH-31.3 MCHC-34.4 RDW-13.0 Plt Ct-152
[**2132-11-25**] 03:09AM BLOOD WBC-8.8 RBC-3.37* Hgb-10.7* Hct-29.6*
MCV-88 MCH-31.6 MCHC-36.0* RDW-13.2 Plt Ct-136*
[**2132-11-28**] 08:35AM BLOOD PT-15.8* PTT-28.4 INR(PT)-1.4*
[**2132-11-27**] 05:32AM BLOOD PT-14.6* INR(PT)-1.3*
[**2132-11-24**] 01:12PM BLOOD PT-14.5* PTT-43.8* INR(PT)-1.2*
[**2132-11-24**] 11:56AM BLOOD PT-14.5* PTT-34.1 INR(PT)-1.3*
[**2132-11-28**] 08:35AM BLOOD UreaN-28* Creat-1.4* Na-135 K-4.7 Cl-97
[**2132-11-27**] 05:32AM BLOOD Glucose-130* UreaN-24* Creat-1.3* Na-137
K-4.0 Cl-99 HCO3-30 AnGap-12
[**2132-11-26**] 04:27AM BLOOD Glucose-139* UreaN-19 Creat-1.2 Na-135
K-4.3 Cl-100 HCO3-28 AnGap-11
[**2132-11-24**] Intra-op TEE
Conclusions
Pre-CPB:
Mild spontaneous echo contrast is present in the left atrial
appendage.
Overall left ventricular systolic function is severely depressed
(LVEF= 25 - 30 %), with mild spontaneous echo contrast in the
LV.
There is moderate global free wall hypokinesis.
There are complex (>4mm) atheroma in the descending thoracic
aorta.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present.
Trace aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. Mild (1+)
mitral regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is AV-Paced, on low dose epinephrine.
Improved biventricular systolic fxn. EF now 40 - 45%. No more
spontaneous contrast in LV. The apex remains akinetic and the
distal walls are hypokinetic.
Trace MR. [**First Name (Titles) **] [**Last Name (Titles) **]. Aorta intact.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3318**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2132-11-24**] 15:52
Brief Hospital Course:
He remained stable and pain free after admission. Preoperative
workup was carried out and he went to the Operating Room on
[**11-24**] where revascularization was accomplished as noted. He
tolerated the procedure well and weaned from bypass on
Epinephrine, Neo Synephrine and Propofol. He remained stable,
weaned from pressors and the ventilator uneventfully.
Of note, intra-op TEE revealed a "haze" suggestive of potential
Left Atrial Appendage thrombus. The patient will be
anti-coagulated for this.
Beta blockade was begun and he was gently diuresed to his
preoperative weight. Physical Therapy was consulted for
strength and mobility.
Chest tubes and pacing wires were removed uneventfully. He
experienced transient diploplia and floaters postoperatively and
ophthalmology and neurology consults were obtained. He will
follow up as an outpatient as these were transient and likely of
no consequence.
By the time of discharge on POD 4 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged home with VNA services
in good condition with appropriate follow up instructions.
Medications on Admission:
Medications - Prescription
BETAMETHASONE VALERATE - (0.1% CREAM AS DIRECTED ) - Dosage
uncertain
GLUCOMETER - (AS DIRECTED ) - Dosage uncertain
PRECISION STRIP - (QID) - Dosage uncertain
Medications - OTC
ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth daily
BLOOD SUGAR DIAGNOSTIC [FREESTYLE LITE STRIPS] - Strip - test
one or twice a day
GERIATRIC MULTIVIT W/IRON-MIN [SPECTRAVITE SENIOR] -
(Prescribed
by Other Provider) - Tablet - 1 Tablet(s) by mouth once daily
GLUCOSAMINE-CHONDROIT-VIT C-MN [GLUCOSAMINE COMPLEX] - (OTC) -
500 mg-400 mg Capsule - 2 Capsule(s) by mouth daily
LANCETS MISC. - ([**2-10**] XD) - Dosage uncertain
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
3. Outpatient Lab Work
Labs: PT/INR for LAA thromus
Goal 2-2.5
First draw [**2132-11-29**]
Results to phone Dr. [**Last Name (STitle) 2204**] [**Telephone/Fax (1) 2205**]
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 1 weeks.
Disp:*14 Tablet Extended Release(s)* Refills:*0*
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
8. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
9. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
10. warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once): Dr.
[**Last Name (STitle) 2204**] to manage for goal INR 2-2.5.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
unstable angina
coronary artery disease
prior mnyocardial infarction
s/p coronary artery bypass
noninsulin dependent diabetes mellitus
obesity
s/p open reduction/internal fixation of right humeral fracture
s/p cholecystectomy
s/p appendectomyh/o melano resection
s/p herniorrhaphy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
Leg - healing well, no erythema or drainage.
Edema trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr.[**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) on [**2133-1-6**] 1:45
Cardiologist: Dr[**Doctor Last Name **] office will call you with an appt.
Please call to schedule appointments with:
Primary Care; Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 2205**]) in [**5-13**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for LAA thromus
Goal 2-2.5
First draw [**2132-11-29**]
Results to phone Dr. [**Last Name (STitle) 2204**] [**Telephone/Fax (1) 2205**]
Completed by:[**2132-11-28**]
ICD9 Codes: 412, 4111, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1045
} | Medical Text: Admission Date: [**2195-8-29**] Discharge Date: [**2195-9-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4588**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Intubated [**8-28**] extubated [**8-30**]
History of Present Illness:
[**Age over 90 **] year old male with h/o parkinsons disease, orthostatic
hypotension on midodrine, afib on coumadin and aspiration PNA
presenting to ED with respiratory distress and admitted to MICU
with respiratory failure. Patient had chronic cough since d/c
from rehab in [**Month (only) **] of this year. Over the last week the cough
has gotten worse and he has stopped eating. He has not had
fevers or chills, dysuria or frequency, diarrhea or bleeding
from his rectum. His wife said last night she could hear him
"gurgling" and that he sounded like a "child with croup". She
became concerned about him this morning and thus called EMS. EMS
found him tachypneic, initially started on CPAP in the field.
Satting low-90s on NRB and 100% on CPAP but looked "terrible" on
arrival to ED.
.
Past Medical History:
Parkinson;s disease
AF on warfarin
Cervical spine stenosis
Constipation
Orthostatic hypotension on midodrine
hearing loss
aspiration pneumonia
Social History:
The patient was born in [**Last Name (LF) **], [**First Name3 (LF) 12000**]. He went to [**Hospital1 6930**]
and [**Location (un) 103125**]and then went to the armed forces. He
was an accountant and worked for the IRS for
many years. He then lived in [**Location 3493**] for many years, but four
years ago moved to [**Location (un) 3307**], [**State 350**] to live close to his
daughter. They have home health aide who comes in three days a
week for shower and shave. He smoked half a pack a day for 18
years.
Alcohol, he used to drink one drink five nights a week, but has
not done this for many years.
He has lived with his wife for 61 years. He has two daughters.
[**Name (NI) **] is somewhat estranged from his first daughter, [**Name (NI) **],
lives
in the same two family home, as his daughter, [**Name (NI) 83047**].
Family History:
Significant for the fact that his mother had
heart disease.
Physical Exam:
In MICU
Vitals: T: 97.5 BP:145/60 P:70 R: 12 O2:1005 on 550X12 fio250
peep 5
General: Intubated, sedated
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: irregularly irregular. no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: erythematous sacrum
On [**Hospital1 **]
General: Sleepy, confused, little verbalising. Difficulty with
secretions
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, no LAD. Appears dry
Lungs: Markedly decresaed breath sounds R base with few crackles
L base
CV: irregularly irregular. HS I+II+ soft ESM no radiation,
depressed JVP
Abdomen: soft, non-tender, non-distended, bowel sounds present,
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: erythematous sacrum
Neuro: A+O x1. R arm resting tremor. PERRLA. GCS13-14/15 E3-4 V4
M6
Pertinent Results:
Admission Labs:
[**2195-8-29**] 10:50AM BLOOD WBC-13.6*# RBC-4.21* Hgb-12.4* Hct-39.1*
MCV-93 MCH-29.4 MCHC-31.7 RDW-14.3 Plt Ct-501*#
[**2195-8-29**] 10:50AM BLOOD Neuts-89.4* Lymphs-5.1* Monos-4.3 Eos-1.0
Baso-0.3
[**2195-8-29**] 10:50AM BLOOD PT-54.9* PTT-39.9* INR(PT)-6.1*
[**2195-8-29**] 10:50AM BLOOD Glucose-110* UreaN-27* Creat-0.8 Na-137
K-7.6* Cl-100 HCO3-31 AnGap-14
[**2195-8-29**] 10:50AM BLOOD ALT-18 AST-81* AlkPhos-104 TotBili-0.5
[**2195-8-29**] 10:50AM BLOOD proBNP-[**Numeric Identifier 103126**]*
[**2195-8-29**] 10:50AM BLOOD cTropnT-0.04*
During [**Hospital1 **] stay:
[**2195-8-30**] 01:43AM BLOOD WBC-13.2* RBC-3.61* Hgb-10.9* Hct-31.8*
MCV-88 MCH-30.1 MCHC-34.1 RDW-14.2 Plt Ct-404
[**2195-8-30**] 04:54PM BLOOD WBC-12.1* RBC-3.65* Hgb-10.8* Hct-32.5*
MCV-89 MCH-29.7 MCHC-33.3 RDW-14.2 Plt Ct-406
[**2195-9-1**] 06:35AM BLOOD WBC-10.5 RBC-3.83* Hgb-11.4* Hct-34.5*
MCV-90 MCH-29.7 MCHC-33.0 RDW-14.4 Plt Ct-411
[**2195-9-3**] 06:15AM BLOOD WBC-9.2 RBC-3.66* Hgb-10.7* Hct-33.2*
MCV-91 MCH-29.2 MCHC-32.1 RDW-14.3 Plt Ct-428
[**2195-8-29**] 10:50AM BLOOD Neuts-89.4* Lymphs-5.1* Monos-4.3 Eos-1.0
Baso-0.3
[**2195-9-3**] 06:15AM BLOOD Neuts-85.3* Lymphs-7.6* Monos-4.5 Eos-2.2
Baso-0.3
[**2195-8-29**] 10:50AM BLOOD PT-54.9* PTT-39.9* INR(PT)-6.1*
[**2195-8-30**] 01:43AM BLOOD PT-72.8* PTT-45.9* INR(PT)-8.6*
[**2195-8-30**] 04:54PM BLOOD PT-30.4* PTT-40.4* INR(PT)-3.0*
[**2195-8-31**] 04:08AM BLOOD PT-23.6* PTT-35.6* INR(PT)-2.2*
[**2195-9-1**] 06:35AM BLOOD PT-22.6* PTT-31.6 INR(PT)-2.1*
[**2195-9-2**] 06:25AM BLOOD PT-25.4* PTT-31.2 INR(PT)-2.4*
[**2195-9-3**] 06:15AM BLOOD PT-30.9* PTT-32.9 INR(PT)-3.1*
[**2195-8-29**] 10:50AM BLOOD Glucose-110* UreaN-27* Creat-0.8 Na-137
K-7.6* Cl-100 HCO3-31 AnGap-14
[**2195-8-30**] 01:43AM BLOOD Glucose-88 UreaN-24* Creat-0.7 Na-141
K-4.0 Cl-106 HCO3-25 AnGap-14
[**2195-9-1**] 06:35AM BLOOD Glucose-86 UreaN-21* Creat-0.7 Na-141
K-4.3 Cl-105 HCO3-26 AnGap-14
[**2195-9-3**] 06:15AM BLOOD Glucose-93 UreaN-20 Creat-0.7 Na-141
K-4.2 Cl-104 HCO3-32 AnGap-9
[**2195-8-30**] 01:43AM BLOOD LD(LDH)-149 CK(CPK)-47 TotBili-0.5
DirBili-0.2 IndBili-0.3
[**2195-8-29**] 10:50AM BLOOD proBNP-[**Numeric Identifier 103126**]*
[**2195-8-29**] 10:50AM BLOOD cTropnT-0.04*
[**2195-8-29**] 04:14PM BLOOD CK-MB-4 cTropnT-0.03*
[**2195-8-30**] 01:43AM BLOOD CK-MB-3 cTropnT-0.04*
[**2195-8-29**] 10:50AM BLOOD Albumin-3.8 Calcium-9.3 Phos-4.0 Mg-2.3
[**2195-9-3**] 06:15AM BLOOD Calcium-8.5 Phos-2.8 Mg-1.9
[**2195-8-30**] 01:43AM BLOOD Hapto-220*
[**2195-9-1**] 06:35AM BLOOD VitB12-1083* Folate-14.8
[**2195-9-2**] 06:25AM BLOOD calTIBC-200* Ferritn-293 TRF-154*
[**2195-9-1**] 06:35AM BLOOD TSH-1.7
[**2195-8-29**] 12:25PM BLOOD Type-ART Rates-/16 Tidal V-600 PEEP-5
FiO2-100 pO2-403* pCO2-29* pH-7.54* calTCO2-26 Base XS-3
AADO2-306 REQ O2-55 -ASSIST/CON Intubat-INTUBATED
[**2195-8-30**] 04:54AM BLOOD Type-ART Temp-37.2 Rates-[**12-2**] Tidal V-450
PEEP-5 FiO2-50 pO2-141* pCO2-35 pH-7.47* calTCO2-26 Base XS-2
Intubat-INTUBATED
[**2195-8-31**] 05:42AM BLOOD Type-ART pO2-87 pCO2-40 pH-7.39
calTCO2-25 Base XS-0
[**2195-9-2**] 05:18PM BLOOD Type-ART Temp-35.9 pO2-60* pCO2-42
pH-7.44 calTCO2-29 Base XS-3
[**2195-8-29**] 12:18PM BLOOD K-5.4*
[**2195-8-29**] 01:17PM BLOOD Lactate-3.5* K-4.2
[**2195-8-30**] 10:08AM BLOOD Lactate-0.7
[**2195-9-2**] 05:18PM BLOOD Lactate-1.4
Microbiology
[**2195-8-29**] 11:45 am SPUTUM ETT.
**FINAL REPORT [**2195-8-31**]**
GRAM STAIN (Final [**2195-8-29**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
RESPIRATORY CULTURE (Final [**2195-8-31**]):
SPARSE GROWTH Commensal Respiratory Flora.
BCx2 pending from [**8-29**]
MRSA screen negative
Time Taken Not Noted Log-In Date/Time: [**2195-8-30**] 10:02 am
URINE SPECIMEN TAKEN FROM [**Age over 90 **]M.
**FINAL REPORT [**2195-8-31**]**
Legionella Urinary Antigen (Final [**2195-8-31**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
Time Taken Not Noted Log-In Date/Time: [**2195-9-1**] 11:05 am
SEROLOGY/BLOOD CHEM# [**Serial Number 103127**]M.
**FINAL REPORT [**2195-9-2**]**
RAPID PLASMA REAGIN TEST (Final [**2195-9-2**]):
NONREACTIVE.
Reference Range: Non-Reactive.
[**2195-9-1**] 12:10 pm URINE Source: Catheter.
**FINAL REPORT [**2195-9-2**]**
URINE CULTURE (Final [**2195-9-2**]): NO GROWTH.
BCx2 from [**9-1**] pending
Radiology
CXR [**8-29**]
FINDINGS: ET tube tip is 5 to 5.5 cm above the carina. The
endogastric tube
side port is just below the GE junction. The cardiomediastinal
contours are
unremarkable. Patchy right basilar and retrocardiac opacities
may be due to
infection or aspiration. Hazy opacity primarily overlying the
right lower lung
may represent a layering pleural effusion. The full extent of
the right
costophrenic angle is not appreciated on this study. Trace
blunting of the
left costophrenic angle suggests a small pleural effusion. There
is no
pneumothorax.
IMPRESSION:
1. ET tube 5 to 5.5 cm above the carina.
2. Endogastric tube side port just below the GE junction, would
recommend
advancing 4 to 5 more centimeters to ensure that it is well
below the GE
junction.
3. Patchy opacities in the lung bases may be due to infection or
aspiration
with right layering pleural effusion, and trace left pleural
effusion.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: SAT [**2195-8-29**] 3:36 PM
CXR [**8-30**]
FINDINGS: In comparison with the study of [**8-29**], there is little
overall
change. The side hole of the nasogastric tube is probably just
above the
gastroesophageal junction. Layering right pleural effusion has a
somewhat
different configuration on this semi-upright image. Bibasilar
atelectasis and
probable small left effusion also seen. No evidence of acute
pneumothorax.
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
Approved: SUN [**2195-8-30**] 11:36 AM
CXR [**9-1**]
AP UPRIGHT RADIOGRAPH OF THE CHEST: Moderate bilateral pleural
effusions are
slightly worse, right more than left. There is also worsening
bibasilar
atelectasis. There is no edema. Heart size and cardiomediastinal
silhouette
are obscured by the bibasilar opacities. Calcified aortic
contour is present
and unchanged. The NG tube and ET tube have been removed.
IMPRESSION: Bilateral pleural effusions and bibasilar opacities
slightly
worse than prior, could be atelectasis, however, superimposed
infection in the
right clinical setting is not excluded.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 35563**]
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
Approved: TUE [**2195-9-1**] 5:05 PM
Video swallow assessment
CLINICAL INDICATION: [**Age over 90 **]-year-old male with Parkinson's,
recurrent pneumonia,
and concern for aspiration.
COMPARISON: None available.
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was
performed in
conjunction with the speech and swallow division. Multiple
consistencies of
barium were administered.
FINDINGS: Barium passes freely through the oropharynx without
evidence of
obstruction. Trace aspiration was seen with thin liquids. For
details,
please refer to the speech and swallow division note in OMR.
IMPRESSION: Trace aspiration of thin liquids.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) 5432**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Approved: TUE [**2195-9-1**] 11:51 AM
Cardiology
Cardiology Report ECG Study Date of [**2195-8-30**] 10:14:36 AM
Atrial fibrillation with ventricular premature beat. Right
bundle-branch
block. Left axis deviation may be due to left anterior
fascicular block and/or
possible prior anterior myocardial infarction. No previous
tracing available
for comparison.
Brief Hospital Course:
[**Age over 90 **] YO M with Parkinson's Disease, orthostatic hypotension, AF on
warfarin presented on [**8-29**] with acute on chronic cough,
increased secretions with difficulty managing secretions. In ED
found to be tachypneic, placed on a NRB with sats in the high
80s and was trialled on BiPAP and intubated. CXR with RLL and
retrocardiac opacities in addition to a high serum WBC count and
was started on antibiotics to cover CAP with ceftriaxone and
levofloxacin and admitted to critical care. After a brief
period of intubation, he was successfully extubated. He was
noted to have difficulty clearing his own secretions although
his sputum production as well as initial leukocytosis improved -
his WCC normalised on transfer to the medical [**Hospital1 **]. On [**8-31**] a
sputum culture returned with 1+ GPCs although culture revealed
no growth and his ceftriaxone was stopped and levofloxacin was
continued initially IV then changed to oral on [**2195-9-1**]. His
initial INR was 8.6 on admission and he received vitamin K, this
quickly falling into the normal therapeutic range. He was
restarted on warfarin on [**8-31**] and his INR remained therapeutic.
Due to concern for aspiration risk, he was seen by speech and
swallow and they recommeded a video swallow which showed an
impaired oral stage with trace aspiration on thin liquids. They
recommended thin fluids and soft solids with meds crushed in
puree. They acknowledged that he was an aspiration risk with any
diet type. He continued to receive chest physical therapy while
on the [**Hospital1 **] and requierd intermittent suctioning for his
secretions. His WCC remained stable and he was afebrile whilst
on the [**Hospital1 **] although he continued to have bibasal opacities and
effusions on CXR. On transfer to the [**Hospital1 **], he was noted to be
sleepy and agitated - he was initially given olanzapine and
subsequently quetiapine for agitation but latterly this was not
required. He was oriented only to person and was very confused
initially and further screen for infection, UA was unremarkable,
electrolytes were normal and it was felt likely to his recent
ICU stay, infection and constipation. His orientation improved
and on discharge no longer required sedation. His constipation
was treated. His midodrine was hled while in teh ICU but
restarted on the [**Hospital1 **]. His swallow and secretions remained a
problem but he improved in this regard as he became less drowsy
and confused.
.
# Respiratory failure: Etiologies include aspiration or
community acquired PNA given XR and preceding symptoms. Has h/o
smoking but no h/o COPD so felt unlikely COPD flare and unlikely
pulmonary edema as no evidence on CXR. MI was RO with 3 sets of
negative enzymes and ECG showed no change from prior. Legionella
urinary atigen was negative. Patient treated for pneumonia with
CTX/Levofloxacin initially, and after successfully extubated on
HD 2 the antibiotics were narrowed to levofloxacin. This was
changed to oral on [**9-1**] Speech and swallow evaluated the
patient and found him to be high risk of aspiration so the
patient remained NPO while on the unit. He remaine afebrile and
WBCs were stable and not increasing. CXR repeat was oerhaps
slightly worse but this did not match his clinical condition
clinically although there is certainly evidence of a moderate R
effusion. His levofloxacin was continued and whiel he initially
requierd regular suctioning, as he became less drowy this
improved. His respiratory parameters were stable on the [**Hospital1 **]. He
should continue levofloxacin to complete a 7 day course as per
gerontology - last day [**2195-9-5**].
.
# Confusion and agitation: He was noted to be confused and
agitated while on teh [**Hospital1 **], only oriented to person and this was
not his baseline according to his wife who felt he was forgetful
at times but was generally oriented. This was felt to likely be
? 2o to infection or unfamiliar surroundings/recent ICU
admission/constipation. he was investigated (cultures pending)
and UA unremarkable and electrolytes and Ca were normal. He was
initially given neuroleptics (olanzapine and quetiapine each on
1 occasion) and this was no longer necessary by the end of his
hospital stay and was more oriented on discharge. He initially
was not cooperative with oral meds briefly but this improved in
a matter of hours when he became less drowsy.
.
# poor swallow: Difficulty managing secretion on admission and
concern from speech and swallow, initially being NPO. he was
assessed with a video swallow which showed 1x trace aspiration
and an impaired oral phase although they acknowledged that he ws
at risk of aspiration on any diet type. Diet changed on advice
to thin liquids and soft solids. Meds crushed with puree
consistency. He still had trouble with secretions and is an
aspiration risk.
.
# AF on warfarin: Patient's rate was well controlled without
nodal blocking agents. Initially treated with vitamin K 3mg for
INR 8.6 with no active bleeding. He was initially held due to
supratherapeutic INR but restarted on day 3 of hospital stay.
His INRs were therapeutic. On day of discarge INR was 3.1 and
his dose was decreased from 2mg to 1mg qd on tis day [**9-3**].
.
#Anemia: 6 point HCT drop on admission, no source of bleeding
found so felt to be dilutional. Hemolysis labs negative and his
Hb remained stable during his stay.
.
# PD. Note prev intolerant to L-dopa with hallucinations. No
medications started for this.
.
# Orthostatic Hypotension: On midodrine at home but given NPO
status and given initial concern for sepsis, midodrine was held
and BPs remained stable. This was restarted on the [**Hospital1 **] and
posed no problems.
.
#Microscopic Hematuria: In context of catheterisation. 21-50
RBCs. This will need to be watched and repeat in 2 days
.
#FEN: Poor oral intake will need to monitor this. required small
volume IV fluids on [**9-2**].
#PT: [**Name (NI) **] was evaluated by PT and wanted himto be out of bed as
much as possible.
# DVT: Pneumoboots and S/C heparin while on [**Hospital1 **]
#Bowels: Standing laxatives (senna and docusate) started
.
# Code: Full (discussed with patient's HCP)
Medications on Admission:
warfarin 2 mg Tablet - 1 Tablet(s) by mouth Monday through Fri
2.5mg Sat/Sun, midodrine 2.5 mg t.i.d.,
multivitamins,
vitamin D and calcium,
Senokot
Discharge Medications:
1. Midodrine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) for 7 days.
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shorness of breath for 7 days.
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for loose stools.
7. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 2 days: start [**9-4**].
8. Vitamin D Oral
9. Calcium Oral
10. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Discharge Disposition:
Extended Care
Facility:
[**Street Address(1) 19427**] Nursing & Rehab Center - [**Location (un) 3307**]
Discharge Diagnosis:
Primary Diagnosis:
Pneumonia
Delirium
Secondary Diagnosis:
Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital for difficult breathing and
problems clearing your secretions and as this was severe when
you presented to the ED you were intubated (a breathing tube was
placed) and spent a brief stay on the Medical ICU on a breathing
machine. A chest X-ray was performed and this showed evidence of
a pneumonia and you were treated with intravenous antibiotics
for this. Your INR was also found to be very high (8.6) and you
were given a medication to lower this and reduce the risk of
bleeding (called vitamin K which reduces blood tinning by
warfarin). Following removal of the breathing tube, you were
found to have a poor swallow and you were assessed by the speech
and swallow specialists. You had a video swallow which showed
evidence that your swallow was not normal and that during the
trial, some of the liquid went into your lung (called
aspiration). You were then put on a modified diet. You were
initially drowsy and confused with you being disorientated and
you initially received some sedative medications for significant
agitation for your safety. You quickly iproved in this regard
and you became more oriented. You responded well to antibiotics
and your oxygen requirement decreased quickly overtime. You
still have problems with your swallowing and secretions and this
will be a longstanding problem which could predispose you to
chest infections. We will continue the antibiotics for a total 7
day course. You will be seen in teh commmunity by gerontology
who were looking after you during your hospital stay. You were
discharged to rehab on [**2195-9-3**] and you looked much improved.
Changes to medications:
1) Regular sodium docusate and senna for laxatives
2) Levofoxacin to continue for total 7 days (last day [**9-5**])
3) Warfarin 1mg daily - will need to monitor INR
Followup Instructions:
Department: GERONTOLOGY
When: THURSDAY [**2195-11-5**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2847**], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2195-12-24**] at 12:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 486, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1046
} | Medical Text: Admission Date: [**2199-11-30**] Discharge Date: [**2199-12-12**]
Date of Birth: [**2134-7-11**] Sex: F
Service: NEUROSURGERY
Allergies:
Morphine
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
Cerebral angiogram x 2
History of Present Illness:
HPI: Asked to eval this 65 year old white female with SAH. Pt
is
transferred in by ambulance from [**Hospital1 18**] [**Location (un) 620**]. Per reports she
has had neck pain for a few days and then this evening had
sudden
onset headache. She went to the OSH and CT revealed
perimesencephalic bleed.
Past Medical History:
PMHx:
hysterectomy
ectopic pregnancies x 2
Long Bowel syndrome
Social History:
Social HX:
lives with husband and son in a house / 3 levels / exercises
frequently / works as an employee benefits manager
Family History:
unknown
Physical Exam:
ON ARRIVAL
PHYSICAL EXAM:
O: T: af BP:166 /89 HR:57 R 13 100 O2Sats
Gen: WD/WN, uncomfortable.
HEENT: NCAT Pupils: [**4-16**] brisk EOMIs
Neck: slight nuchal rigidity
Neuro:
Mental status: lethargic, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-19**] throughout. No pronator drift
Sensation: Intact to light touch.
No clonus
On discharge - she is awake and alert, oriented x 3 with non
focal neuro exam except for some diplopia. Her groin site is
dry, intact and flat.
Pertinent Results:
Cardiology Report ECG Study Date of [**2199-11-29**] 10:21:00 PM
Sinus bradycardia. Modest anterolateral ST-T wave changes that
are non-specific
No previous tracing available for comparison.
Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 10592**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
54 172 100 446/435 57 27 76
Radiology Report CTA NECK W&W/OC & RECONS Study Date of [**2199-11-29**]
11:20 PM
FINDINGS:
CT HEAD:
As was seen on the previous CT study from [**Hospital3 628**],
there is
hemorrhage in the basal cisterns, predominantly in the
prepontine cistern,
perimesencephalic and quadrigeminal cisterns.
CT ANGIOGRAPHY HEAD: CT angiography of the head demonstrates
slight
prominence of the origin of the left superior cerebellar artery
which could be due to an infundibulum. Otherwise, there is no
evidence of definite aneurysm greater than 3 mm in size in the
anterior and posterior circulation.
The evaluation of source images and sagittal maximum intensity
projection
images demonstrate subtle prominence of vascular structures at
the foramen
magnum on the left side. This could be due to slightly prominent
meningeal
arteries arising from the vertebral artery, but correlation with
subsequent scheduled cerebral angiography is recommended for
further evaluation of this area to exclude any dural
arteriovenous malformation or fistula in this location.
In the partially visualized cervical arteries, no vascular
stenosis or
occlusion is seen.
IMPRESSION:
1. Subarachnoid hemorrhage is seen in the basal cisterns.
2. No definite aneurysm greater than 3 mm in size noted. Subtle
prominence
of the origin of the left superior cerebral artery appears to be
due to an
infundibulum.
3. Subtle prominence of vascular structures at the foramen
magnum could be
due to prominent meningeal arteries arising from the vertebral
artery.
Correlation with scheduled cerebral angiography is recommended
for evaluation
of this area to exclude subtle dural AV fistula.
COMMENT: This report is provided without the availability of 3D
reformatted images. When these images are available and if
additional information is obtained, an addendum will be given to
this report.
Radiology Report MRA BRAIN W/O CONTRAST Study Date of [**2199-12-1**]
11:19 AM
Provisional Findings Impression: AFSN SUN [**2199-12-1**] 5:04 PM
1. Subarachnoid hemorrhage seen.
2. Small acute infarcts are seen in the right occipital lobe and
right
cerebellum.
3. Abnormal flow voids are seen at the foramen magnum on the
axial T2 images
better evaluated on previous CT angiography and cerebral
angiography.
4. Small retrocerebellar subdural hematoma is seen without
significant mass
effect on the cerebellum.
5. Normal MRA head and neck.
Final Report
EXAM: MRI of the brain and MRA of the head and neck.
BRAIN MRI:
The sagittal T1-weighted images demonstrate a small subdural
hematoma in the retrocerebellar region measuring approximately 5
mm in thickness and extending from the C1 level to the level of
torcula. There is no significant mass effect on the adjacent
cerebellum seen. No abnormal flow voids are seen in this region.
There is subarachnoid hemorrhage identified in the basal
cisterns as seen previously. There is a small area of restricted
diffusion seen within the right cerebellum posteriorly which
could be due to a small area of acute infarct.
T2 images demonstrate subtle flow voids at the foramen magnum
region
corresponding to the vascular structures seen on the CTA
examination noted
previously and of the cerebral angiography of [**2199-11-30**].
IMPRESSION:
1. Subarachnoid hemorrhage.
2. Small retrocerebellar posterior fossa subdural hematoma.
3. Small acute infarct in the right cerebellum and in the right
occipital
region.
4. Small abnormal flow voids at the foramen magnum region
corresponding to
abnormal vascular structures seen on the previous CTA and
cerebral
angiography.
MRA HEAD: The head MRA demonstrates normal flow signal in the
arteries of
anterior and posterior circulation without stenosis, occlusion,
or an aneurysm
greater than 3 mm in size.
IMPRESSION: Normal MRA of the head. MRA neck: The
gadolinium-enhanced MRA
of the neck demonstrate no evidence of stenosis or occlusion in
the arteries
of the neck. No abnormal vascular structures are seen.
Radiology Report MR CERVICAL SPINE W/O CONTRAST Study Date of
[**2199-12-1**] 11:20 AM
Provisional Findings Impression: AFSN SUN [**2199-12-1**] 5:04 PM
PFI:
1. No evidence of abnormal flow void within the cervical spinal
canal but
subtle abnormal flow voids are seen at the foramen magnum which
represent the abnormalities seen on the cerebral angiography and
CT angiography and could represent a dural AV fistula.
2. Small retrocerebellar subdural hematoma is seen.
3. Subarachnoid hemorrhage seen in the basal cistern.
4. Degenerative changes in the cervical region.
5. No abnormal signal within the spinal cord.
FINDINGS: There is a small retrocerebellar subdural hematoma
identified with minimal meningeal thickenings better visualized
on the brain MRI of the same day. Subarachnoid hemorrhage is
seen in the basal cistern. There is no evidence of abnormal flow
voids identified in the cervical spinal canal. Subtle flow
voids at the foramen magnum region are noted better evaluated on
the previous cerebral angiography and CT angiography and likely
represent a small AV fistula.
Degenerative changes are seen in the cervical region with disc
bulging at C3-4 and C4-5 levels. At C5-6, disc bulging posterior
ridging minimally indents the spinal cord with mild narrowing of
the right foramen. At C6-7, there is disc bulging seen with
minimal indentation on the thecal sac and mild bilateral
foraminal narrowing.
At C7-T1, minimal anterolisthesis of C1-7 over T1 seen. From
T2-3 to T3-4
mild degenerative disc disease identified. The spinal cord shows
normal
intrinsic signal.
IMPRESSION:
1. No evidence of abnormal flow void within the cervical spinal
canal but
subtle abnormal flow voids are seen at the foramen magnum which
represent the abnormalities seen on the cerebral angiography and
CT angiography and could represent a dural AV fistula.
2. Small retrocerebellar subdural hematoma is seen.
3. Subarachnoid hemorrhage seen in the basal cistern.
4. Degenerative changes in the cervical region.
5. No abnormal signal within the spinal cord.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2199-12-2**]
3:21 AM
Provisional Findings Impression: AJy MON [**2199-12-2**] 5:29 AM
PFI: No new or increasing intracranial hemorrhage. Subarachnoid
blood within the basal cisterns is again noted, right greater
than left, with decreased conspicuity on the left compared to
the [**11-29**], likely reflecting redistribution. Small
amount of blood is again seen in the occipital horns of the
lateral ventricles. There is no parenchymal edema, mass effect,
or hydrocephalus.
NON-CONTRAST HEAD CT:
In comparison to the prior study, there is no new or increased
intracranial hemorrhage identified. Subarachnoid blood seen in
the basal cisterns is minimally changed. In the prepontine
cistern appears stable, as in the right perimesencephalic and
quadrigeminal cistern, though decreased in conspicuity in the
left perimesencephalic and quadrigeminal cistern. This may
reflect redistribution. Small amount of blood is seen layering
within the occipital horns of the lateral ventricles, also as on
prior study. There is no intraparenchymal, and no subdural
hemorrhage identified.
The ventricles and sulci are stable in size. There has been no
development of hydrocephalus. There is no shift of midline
structures, and there is no
evidence of herniation. The [**Doctor Last Name 352**]-white matter differentiation is
preserved, without evidence of acute territorial infarction.
There is no mass effect.
The osseous structures remain unremarkable. The visualized
paranasal sinuses and mastoids are normally aerated.
IMPRESSION: Little change in subarachnoid hemorrhage within the
basal
cisterns. There has been some redistribution, with decreased
conspicuity of hemorrhage on the left. There is no new or
increasing intracranial hemorrhage identified.
Cerebral Angiogram [**2199-12-3**]:
IMPRESSION:
Subtle sub-occipital epidural AVF fed by musculospinal branches
of V3-V4
segments of the left vertebral artery with venous drainage via
two veins, one vein drained intracranially into the left
transverse sigmoid sinus, the other vein drains extracranially
into the suboccipital venous plexus.
Head CT [**2199-12-5**]:
IMPRESSION: No significant change in subarachnoid hemorrhage
within the basal cisterns. No evidence of new or increasing
intracranial hemorrhage.
CTA/CTP [**2199-12-6**]:
IMPRESSION:
1. Persistent subarachnoid hemorrhage within the basilar
cisterns, not
significantly changed. Minimally increased intraventricular
hemorrhage
layering in the occiptal horns of the lateral ventricles. No
change in size of ventricles. No definite new hemorrhage
identified.
2. No abnormality identified on CTA/CTP. Please note that
perfusion of the
posterior fossa is limited due to technique and location. MRI
should be
performed for further evaluation if there is clinical concern of
posterior
fossa infarct.
3. Known dural AV fistula is not well identified on today's
study and better seen on recent cerebral angiogram.
[**2199-12-10**] Cerebral angiogram: Report not available at time of
discharge.
Brief Hospital Course:
Pt was admitted through the emergency room to the ICU after CT
revealed SAH. BP was controlled and she was started on
Nimodipine and Dilantin. She underwent CTA and later formal
angiography which were both negative for aneurysm. She was kept
in the ICU for close observation. Follow CT scan imaging has
been stable. A pain consult was obtained to assist in managing
the pts headaches.
On [**12-5**] it was noted that she had some behavioral changes and a
Head CT was done which was stable. On [**12-6**] she was confused and
a CTP/CTA was peformed which showed no vasospasm. No
hydrocephalus was noted.
She was kept in the ICU for 1 week for close neurological
monitoring. On [**12-7**] she was cleared for transfer to the step
down unit.
A second cerebral angiogram was scheduled and performed on [**12-10**]. She underwent this procedure without incident. She
ambulated afterwards without difficulty. On [**12-11**], patient was
reported to have a fall hitting her head on the mattress. She
reported headache which was different from the her previous
headache. She refused a head CT, she was monitored overnight and
headaches treated adequeately with pain meds. She was seen on
[**12-12**] with no complaints, headache controlled with pain
medication and she was discharged home.
Medications on Admission:
occasional asa
occasional ambien
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours) for 9 days.
Disp:*108 Capsule(s)* Refills:*0*
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. amlodipine 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
5. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**2-16**]
Tablets PO Q4H (every 4 hours) as needed for headache.
Disp:*60 Tablet(s)* Refills:*0*
6. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
7. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
8. oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0*
9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Subarrachnoid hemorrhage
Headache
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram
Medications:
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
Please call the office at [**Telephone/Fax (1) **] for a follow up
appointment with Dr. [**First Name (STitle) **] to be seen in 4 weeks. You will
need a cervical spine MRI/A at that time.
Please see your Ophthomologist for a follow up eye exam to
evaluate your double vision. You may also come to the eye
clinic at [**Hospital1 18**]. The number is ([**Telephone/Fax (1) 5120**]
Completed by:[**2199-12-12**]
ICD9 Codes: 2761, 4019, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1047
} | Medical Text: Admission Date: [**2157-6-23**] Discharge Date: [**2157-6-24**]
Date of Birth: [**2076-6-10**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Intraparenchymal hemorrhage
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
81 year-old woman with an unknown past medical history, who
presents as a transfer from [**Known firstname **] Hospital after being found
down with possible PEA arrest; Neurology has been consulted for
the finding of an intraparenchymal hemorrhage on imaging.
Although few details are known at this time, the patient was
found down for an unknown duration. Emergency medical services
arrived on the scene and the patient was in cardiac arrest
(possibly pulseless electrical activity). The full initial
management has not been detailed in the available documentation,
but the patient arrived at [**Known firstname **] Hospital on a dopamine drip
at
approximately 2:20 pm. Initial vitals included: temperature
95.0
F, pulse 152, blood pressure 138/66, and SaO2 100% on an ambu
bag. There she was intubated and sedated on Propofol; a
neurologic examination is not detailed on available
documentation. She was loaded with 1 gram Cerebyx and
administered a dose of Zosyn. Initial evaluation revealed a
leukocytosis with left shift (68 polys and 17 bands), normal
coagulation studies (INR 1.1), glucose 370, CO2 16 with an anion
gap of 22, BUN 24, creatinine 1.2, and elevated cardiac enzymes
(CK 359 and MB 21.5). Chest x-ray showed infiltrate versus
atelectasis in the left lower lobe. EKG showed SVT, rate 151.
CT of the head revealed a possible right basal ganglia
hemorrhage
without mass effect.
The patient was transferred [**Hospital3 **] and arrived here at
~8:00
pm. The Propofol was held and a dose of Versed was given for
sedation. One gram vancomycin was administered. Neurology was
called for evaluation.
Review of Systems:
Unable to provide.
Past Medical History:
A. Fib, pt unable to provide, records from PCP only indicate [**Name Initial (PRE) **].
fib and hospitalization 1 year prior for cellulitis, hadn't seen
PCP [**Name Initial (PRE) **] 1 year.
Social History:
Lives independently in [**Location (un) 13011**]. Brother [**Name (NI) **] and [**Name2 (NI) 802**] [**Name (NI) **]
are her closest relatives
Family History:
Unknown
Physical Exam:
Vitals: T 98.4 F BP 148/82 P 92 RR 22 SaO2 100 on
ventilator
General: elderly woman, intubated
HEENT: NC/AT, sclerae anicteric, orally intubated
Neck: Hard C-collar in place
Lungs: clear ventilated breath sounds
CV: regular rate and rhythm, no murmurs appreciated
Abdomen: soft, non-tender, no organomegaly appreciated
Ext: warm, no edema, pedal pulses appreciated
Skin: abrasions noted on legs
Neurologic Examination (off Propofol for ~30 minutes):
Mental Status:
Eyes open, not interacting with environment. Not following
commands.
Cranial Nerves:
No papilledema noted; no blink to threat. Pupils 4 to 3 mm on
the left and 5 mm and unreactive on the right. Eyes
midposition.
No response to corneals and nasal tickle. Reportedly coughed
when orogastric tube placed.
Sensorimotor:
Intermittent decerebrate posturing. Posturing to noxious in the
upper extremities. Stereotyped triple flexion to noxious in
lower extremities. There is an intermittent full body jerk that
emerges when decerebrate-type posturing is noted.
Reflexes:
Difficult to elicit in upper extremities due to posturing, brisk
at knees, with clonus at ankles. Toes were upgoing bilaterally.
Coordination and gait: Unable.
Pertinent Results:
[**2157-6-22**] 08:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2157-6-22**] 08:00PM URINE RBC-0-2 WBC-21-50* BACTERIA-RARE
YEAST-NONE EPI-0-2
[**2157-6-22**] 08:05PM PT-14.9* PTT-25.1 INR(PT)-1.3*
[**2157-6-22**] 08:05PM PLT COUNT-212
[**2157-6-22**] 08:05PM NEUTS-91.5* LYMPHS-3.9* MONOS-4.5 EOS-0.1
BASOS-0.1
[**2157-6-22**] 08:05PM WBC-13.0* RBC-4.01* HGB-12.3 HCT-37.2 MCV-93
MCH-30.6 MCHC-33.0 RDW-12.3
[**2157-6-22**] 08:05PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2157-6-22**] 08:05PM PHENYTOIN-10.9
[**2157-6-22**] 08:05PM PHENYTOIN-10.9
[**2157-6-22**] 08:05PM ALBUMIN-3.8 CALCIUM-8.5 PHOSPHATE-2.8
MAGNESIUM-2.1
[**2157-6-22**] 08:05PM CK-MB-121* MB INDX-6.0
[**2157-6-22**] 08:05PM cTropnT-0.23*
[**2157-6-22**] 08:05PM cTropnT-0.23*
[**2157-6-22**] 08:05PM ALT(SGPT)-449* AST(SGOT)-492* CK(CPK)-[**2152**]*
ALK PHOS-39 TOT BILI-0.4
[**2157-6-22**] 08:05PM GLUCOSE-222* UREA N-27* CREAT-1.2* SODIUM-137
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-19* ANION GAP-19
[**2157-6-22**] 08:14PM HGB-13.4 calcHCT-40
EEG [**6-23**]: Markedly abnormal portable EEG due to the burst
suppression
pattern described above. This can be due to sedating medications
such
as Propofol, but it persisted over 20 minutes after the
medication was
stopped. Alternatively, a severe encephalopathy, including one
caused
by anoxia, could explain the findings. There were no
electrographic seizure seen.
[**6-22**]: CT Head: 1. Findings concerning for development of large
left MCA territory infarct.
2. No significant change in appearance of 1 cm right sub-insular
hyperdensity.
While this may represent a small intraparenchymal hemorrhage, an
underlying
vascular malformation (i.e., cavernoma) or neoplasm are
diagnostic
considerations.
CXR: Tubes and lines positioned appropriately. Left retrocardiac
density may
represent atelectasis versus pneumonia.
Brief Hospital Course:
81yF w/ h/o a. fib admitted with large L MCA stroke, pna, UTI
after being found down with PEA arrest. Unclear how long she
had been down or the inciting incident. She was initially
treated with vancomycin and ceftriaxone for infections, neo to
maintain BP over 120 while on propofol for sedation. Her neuro
exam and EEG were consistent with severe anoxic brain injury due
to her PEA arrest. Her Living Will was obtained and a family
meeting with the brother [**Name (NI) **] and [**Name2 (NI) 802**] [**Name (NI) **] was held where
the decision was made to withdraw care as this was most in line
with her expressed wishes. She was extubated and care was
refocused to comfort care only. She passed away on [**2157-6-24**] at
920pm.
Medications on Admission:
Metoprolol is the only known medication
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
LMCA stroke, anoxic injury, pneumonia, urinary tract infection
Discharge Condition:
Expired
Discharge Instructions:
The patient was admitted with a large left MCA infarct, uti, and
pna after being found in PEA arrest. The patient was made CMO,
and passed away.
Followup Instructions:
None
ICD9 Codes: 486, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1048
} | Medical Text: Admission Date: [**2197-8-5**] Discharge Date: [**2197-8-28**]
Date of Birth: [**2131-2-9**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 3290**]
Chief Complaint:
Vicodin overdose
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
Hemodialysis
History of Present Illness:
66F with chronic pain, takes Vicodin, has OD'ed on vicodin in
past, found down at home by son after likely having slept
outside overnight and BIBA to [**Hospital **] Hospital, IO placed in field.
Pt. reportedly ingested 100 tabs of Vicodin. Pt was lethargic
with garbled speech upon presentation to OSH ED. Initial VS were
97.4 112/70 88 20 98% 2L NC. Ativan 1mg given for unclear
reasons. CT brain showed R frontal intraparenchymal hemorrhage,
recommend repeat head CT per neuro. She received 3L NS with 40cc
dark UOP. R IJ CVL placed. NAC bolused 10,500, drip started at
1745 3500/hr x4 hours.
Labs were notable for AST [**Numeric Identifier **], ALT 9822, Bili 3.8, lipase 77,
Ammonia 75, INR 2, BUN 42, Cr 4, APAP level 31, +benzos and
opiates in urine, EtOH 23, VBG 7.28/38, lactate 2.3.
Past Medical History:
h/o EtOH abuse
Hypothyroidism
Chronic Pain
Migraines
s/p R shoulder surgery
s/p R hip replacement
Social History:
- Tobacco: Denies
- Alcohol: h/o abuse in past, +level at OSH
- Illicits: Unknown
Family History:
Non-contributory
Physical Exam:
On Admission:
Vitals: 97.4 112/70 88 20 98% 2L
General: Somnolent, arouses to voice, mumbling, not following
commands
HEENT: PERRL, sclera anicteric, NGT in place
Neck: supple, R IJ TLC in place
Lungs: Clear to auscultation bilaterally ant/lat, no wheezes,
rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mildly distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: Foley in place
Ext: warm, well perfused, palp distal pulses, no clubbing,
cyanosis or edema
On Discharge:
99.1 118/70 88 18 100%
Gen - well-appearing, NAD, A+Ox3
CV - RRR no mrg
Lungs - CTAB
Abd - soft, NT ND, +BS
Ext - wwp, no clubbing cyanosis or edema
Pertinent Results:
On Admission:
[**2197-8-5**] 10:00PM BLOOD WBC-9.1 RBC-3.19* Hgb-10.4* Hct-29.1*
MCV-91 MCH-32.5* MCHC-35.6* RDW-16.5* Plt Ct-247
[**2197-8-5**] 10:00PM BLOOD PT-20.2* PTT-26.1 INR(PT)-1.8*
[**2197-8-9**] 03:10AM BLOOD Fibrino-544*
[**2197-8-13**] 03:05AM BLOOD Ret Aut-7.6*
[**2197-8-5**] 10:00PM BLOOD Glucose-165* UreaN-57* Creat-4.4* Na-143
K-4.1 Cl-105 HCO3-17* AnGap-25*
[**2197-8-5**] 10:00PM BLOOD ALT-8620* AST-[**Numeric Identifier 88700**]* LD(LDH)-[**Numeric Identifier **]*
CK(CPK)-343* AlkPhos-169* TotBili-2.8*
[**2197-8-5**] 10:00PM BLOOD Albumin-3.8 Calcium-8.3* Phos-3.5 Mg-2.8*
[**2197-8-5**] 10:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-16
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
On Discharge:
[**8-27**]:
7.6
7.3 >----< 396
22.4
137 | 99 | 38
---------------< 137
4.0 | 24 | 2.2
Ca: 9.4
Mg: 1.4
Ph: 5.4
Studies:
CT Head 7/10-1. Suboptimal study due to patient motion. Focus of
acute hemorrhage in right frontal lobe. It is difficult to
exclude extra-axial hemorrhage, and six-hour followup CT is
recommended, with patient sedation if necessary. 2.
Acute-on-chronic maxillary sinus disease.
Echo [**8-7**]-The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened. There is no valvular aortic stenosis. The
increased transaortic velocity is likely related to high cardiac
output. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is borderline pulmonary artery systolic hypertension.
There is no pericardial effusion.
RUQ US: 1. Coarse echogenic liver compatible with acute liver
injury from overdose. There is a simple cyst within the
anterior right lobe, though sensitivity for other liver lesions
is limited and other forms of liver disease such as hepatic
fibrosis/cirrhosis cannot be excluded on this study. 2. Dilated
pancreatic duct measuring 6 mm without obstructive mass seen.
Recommend attention on followup.
CT abd/pelv ([**8-12**])-1. Multiple hypoattenuating liver lesions
incompletely characterized on today's study. 2. No
intra-abdominal collection seen.
Blood Culture, Routine (Preliminary):
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # 326-1588M [**2197-8-8**].
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
VIRIDANS STREPTOCOCCI.
Isolated from only one set in the previous five days.
SENSITIVITIES REQUESTED BY DR. [**Last Name (STitle) **] ([**Numeric Identifier 88701**]).
Anaerobic Bottle Gram Stain (Final [**2197-8-11**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS IN SHORT CHAINS.
Aerobic Bottle Gram Stain (Final [**2197-8-11**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS IN SHORT CHAINS.
Anaerobic Bottle Gram Stain (Final [**2197-8-9**]):
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Urine [**8-9**]: ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S <=2 S
AMPICILLIN/SULBACTAM-- <=2 S <=2 S
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
ECHO 17/15: The left ventricular cavity is unusually small.
Left ventricular systolic function is hyperdynamic (EF>75%).
There is a mild resting left ventricular outflow tract
obstruction. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no
pericardial effusion.
IMPRESSION: mild left ventricular outflow tract obstruction
Brief Hospital Course:
Ms. [**Known lastname 12279**] is a 66 year old female with chronic pain and h/o
Vicodin overdose and alcohol abuse who was found down at home
following likely Vicodin overdose.
# Hepatic failure/Acetaminophen overdose: The patient initially
presented to an OSH following a Vicodin overdose. Initial
laboratory results revealed AST [**Numeric Identifier **], ALT 9822, Bili 3.8,
lipase 77, Ammonia 75, INR 2, BUN 42, Cr 4, APAP level 31.
Started on NAC drip and was transferred to [**Hospital1 18**] for transplant
evaluation. While here, the patient's lvier function has
steadily improved. No need for transplant per txpt [**Doctor First Name **]. NAC
drip was continued until [**8-9**]. LFTs on [**8-11**] revealed continued
improvement with normalization at discharge.
# AMS: The patient presented in the setting of vicodin overdose.
On admission, the patient was lethargic but arousable. Over the
subsequent hospital days, her mental status declined and she
became progressively more lethargic. Unknown etiology of AMS
but likely toxic/metabolic. EEG did not show seizure activity.
Her mental status began to improve with hemodialysis. Psych
consult was called and initially considered her delirious with
the need for 1:1 sitter for suicide risk. Her delirium improved
over her admission and by discharge she was A+Ox3 and had a
better understanding of the events leading to her overdose,
though still denying it was intentional.
# Acute Kidney Injury: The patient presented with a Cr of 4.4
(unknwon baseline). Initially believed to be [**3-1**] ATN in the
setting of acute acetaminophen toxicity. She was initially
unable to tolerate HD [**3-1**] libile blood pressures and was given
CVVH. She needed a line holiday for bacteremia, and was then
restarted on HD on a MWF schedule. Her creatinine began to
improve off dialysis. The weekend before her discharge her
creatinine continued to improve while dialysis was held. Her
tunneled line was removed and she was discharged off dialysis.
Creatinine at discharge was 2.2. Recommend check chem-10 at PCP
visit this week. Renal recommended outpatient follow up as there
may be new chronic renal failure but patient preferred to
arrange through primary care physician.
#Anemia: Patient's hematocrit was in the mid to low twenties
throughout the hospitalization. Most likely due to combination
of phlebotomy and renal failure. Her hematocrit at discharge was
22. There was a normal B12, folate, haptoglobin. Ferritin was
elevated at 580 with normal iron of 80.
# Bacteremia: Patient was found to have positive blood cultures
from [**8-8**] growing MSSA and Subsequently grew S. viradans. Had a
line holiday and did not spike any subsequent fevers. TTE did
not show valvular lesions and TEE was attempted but was a
limited by patient's airway. She was treated with vancomycin
for a 2 week course.
# UTI: Patient was found to have a positve UA and urine
cultures growing E Coli from [**8-9**]. Treated with a five day
course of ciprofloxacin.
# Hypothyroidism: Patient had TSH 0.092 Free T4 0.82, was
maintained on 150 ug levothyroxine.
#Headache: Her headaches remained controlled with valium prn.
Her prophylactic tricyclic was held as it was thought to
possibly be contributing to urinary retention, although more
likely oliguric ATN. A referral to a headache specialist was
recommended.
#Overdose: The medicine team communicated with her primary care
physician our recommendation that she no longer be prescribed
vicodin. She was followed by psychiatry during this
hospitalization. She could not recall the event of the overdose
but called it a mistake that was done in the setting of
overwhelming stress at home (divorce, financial situation).
Psychiatry follow up is recommended.
# Hypertriglyceridemia - thought to be initially related to
propofol but remained high (400s). Needs a fasting TG check as
an outpatient. Her gembifrozil was held during the admission.
Medications on Admission:
Valium 10mg PO BID:PRN
Vicodin 5/500 2 tabs PRN
Triamterene/HCTZ 75/50mg daily
Propranolol 120mg
Levothyroxine 150mcg
Gemfibrozil 600mg
Amitryptiline 150mg
Discharge Medications:
1. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. diazepam 5 mg Tablet Sig: 1-2 Tablets PO Q12H (every 12
hours) as needed for headache.
Disp:*10 Tablet(s)* Refills:*0*
3. propranolol 120 mg Capsule,Extended Release 24 hr Sig: One
(1) Capsule,Extended Release 24 hr PO once a day.
Discharge Disposition:
Home
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Vicodin overdose
Acute renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname **], you were admitted to the hospital after an
overdose of vicodin. You were initially admitted to the
Intensive Care Unit and intubated for difficulty breathing. You
were given medicine to protect your liver from the
acetaminophen, and then started on dialysis for kidney failure.
You also received antibiotics for an infection related to one of
the IV lines you had. You were then transferred to the general
medicine floor. Initially it was believed you'd need dialysis as
an outpatient, but your kidney function began to improve and it
was decided that you would no longer need dialysis.
Medication changes:
1) STOP taking vicodin
2) Hold amitriptyline until you see your primary care doctor
3) STOP taking triamterene/HCTZ for blood pressure
4) STOP taking gemfibrozil
Followup Instructions:
Name: NP [**First Name8 (NamePattern2) 402**] [**Last Name (NamePattern1) 9035**]
Location: [**Hospital3 **]
Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 88702**]
Phone: [**Telephone/Fax (1) 67509**]
Appointment: Wednesday [**2197-8-30**] 10:30am
**This is a follow up appointment of your hospitalization. You
will be reconnected with your primary care physician after this
visit.
ICD9 Codes: 431, 5845, 2762, 2760, 7907, 2449, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1049
} | Medical Text: Admission Date: [**2200-7-12**] Discharge Date: [**2200-7-15**]
Date of Birth: [**2151-4-20**] Sex: M
Service: MEDICINE
Allergies:
Haldol
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
acute mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
49yo M currently at HRI [**Location (un) **] (rehab center) in a dual
diagnosis unit for depression/ETOH detox admitted with AMS over
the last 2 days. The patient completed treatment for EtOH
withdrawal with Librium on [**7-11**]. He was noted to have increasing
confusion, visual hallucinations (angels), and was not oriented
to place. He was transferred here for evaluation of AMS. No h/o
fevers, chills, head trauma,
.
VS on presentation to ED: 97.3 83 108/85 15 100. He was confused
on exam in ED. UA and Utox were positive for benzos. Ammonia
level 32. EKG showed NSR, no ischemic changes. CXR was negative.
CT head was negative. Pt has baseline myoclonic jerking from
Familial Myoclonus. He received Valium 5mg, Ativan 2mg, and a
nicotine patch in the ED. Prior to transfer to the floor, vitals
were: 83, 103/70, 15, 100%
.
On the floor, vitals were: 96 110/80 86 14 99RA. The patient was
agitated and kept asking where his cigarettes were. He was
paranoid and accused staff members of throwing his cigarettes
away. He was not oriented to place. He left the floor and a Code
Purple was called. He calmed down after administration of 2mg IV
Ativan. The patient was placed in restraints and is currently
lying in bed.
Past Medical History:
Familial myoclonus
ETOH abuse
Depression
Social History:
Homeless. Currently at dual diagnosis center for ETOH withdrawal
and depression. Recently divorced. Worked as a truck driver.
Family History:
h/o familial myoclonus
Physical Exam:
VITALS: 96 110/80 86 14 99%RA
GEN: agitated man, pacing around the room
HEENT: PERRL, EOMI, vertical nystagmus
NECK: supple
LUNGS: CTA b/l, no wheezing
HEART: RRR, normal S1S2, no m/r/g
ABD: soft, nt, nd, +bs, no masses
EXTREM: no edema
NEURO: AAOx2, not oriented to place, 5/5 strength throughout,
myoclonic jerking
PSYCH: confused, not oriented to place, paranoid, no SI
Pertinent Results:
[**2200-7-15**] 05:20AM BLOOD WBC-4.8 RBC-4.09* Hgb-13.6* Hct-40.8
MCV-100* MCH-33.4* MCHC-33.4 RDW-13.5 Plt Ct-171
[**2200-7-14**] 04:08AM BLOOD WBC-4.2 RBC-4.53* Hgb-14.8 Hct-44.9
MCV-99* MCH-32.7* MCHC-32.9 RDW-13.4 Plt Ct-136*
[**2200-7-13**] 04:40AM BLOOD WBC-5.7 RBC-4.48* Hgb-14.3 Hct-45.4
MCV-101* MCH-32.0 MCHC-31.6 RDW-13.4 Plt Ct-101*
[**2200-7-12**] 12:30PM BLOOD WBC-4.2 RBC-4.44* Hgb-14.5 Hct-44.2
MCV-100* MCH-32.7* MCHC-32.8 RDW-13.5 Plt Ct-102*
[**2200-7-13**] 04:40AM BLOOD Neuts-62.8 Lymphs-24.5 Monos-9.7 Eos-2.2
Baso-0.8
[**2200-7-12**] 12:30PM BLOOD Neuts-50.7 Lymphs-35.5 Monos-9.2 Eos-4.0
Baso-0.7
[**2200-7-14**] 04:08AM BLOOD PT-12.2 PTT-28.5 INR(PT)-1.0
[**2200-7-13**] 04:40AM BLOOD PT-11.3 PTT-24.8 INR(PT)-0.9
[**2200-7-15**] 05:20AM BLOOD Glucose-100 UreaN-18 Creat-0.9 Na-141
K-3.7 Cl-111* HCO3-23 AnGap-11
[**2200-7-14**] 04:08AM BLOOD Glucose-88 UreaN-15 Creat-0.8 Na-141
K-3.8 Cl-111* HCO3-20* AnGap-14
[**2200-7-13**] 04:40AM BLOOD Glucose-85 UreaN-23* Creat-0.9 Na-141
K-3.7 Cl-109* HCO3-20* AnGap-16
[**2200-7-12**] 12:30PM BLOOD Glucose-99 UreaN-24* Creat-1.0 Na-140
K-4.3 Cl-106 HCO3-24 AnGap-14
[**2200-7-14**] 04:08AM BLOOD ALT-74* AST-62* LD(LDH)-198 AlkPhos-70
TotBili-0.7
[**2200-7-13**] 04:40AM BLOOD ALT-79* AST-76* LD(LDH)-336* AlkPhos-73
TotBili-0.7
[**2200-7-12**] 12:30PM BLOOD ALT-79* AST-62* AlkPhos-84
[**2200-7-14**] 04:08AM BLOOD Albumin-3.7 Calcium-8.2* Phos-2.6* Mg-2.3
[**2200-7-13**] 04:40AM BLOOD Albumin-4.2 Calcium-8.4 Phos-2.7 Mg-2.2
[**2200-7-12**] 12:30PM BLOOD Albumin-4.7 Calcium-9.5 Phos-3.5 Mg-2.4
[**2200-7-12**] 12:30PM BLOOD VitB12-563 Folate-GREATER TH
[**2200-7-12**] 12:30PM BLOOD Ammonia-32
[**2200-7-12**] 12:30PM BLOOD TSH-1.1
[**2200-7-13**] 04:40AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
[**2200-7-12**] 12:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2200-7-13**] 04:40AM BLOOD HCV Ab-NEGATIVE
[**2200-7-12**] 04:45PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.022
[**2200-7-12**] 04:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2200-7-12**] 04:45PM URINE RBC-0-2 WBC-0-2 Bacteri-RARE Yeast-NONE
Epi-0-2
[**2200-7-12**] 04:45PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
.
CXR:
HISTORY: 49-year-old male with altered mental status.
No prior studies available for comparison.
CHEST, PA AND LATERAL: The cardiomediastinal and hilar contours
are
unremarkable. The lungs are clear without consolidation or
edema. There is
no pleural effusion or pneumothorax.
IMPRESSION: No acute cardiopulmonary abnormality.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: SAT [**2200-7-12**] 3:06 PM
.
Head CT:
preliminary read shows no acute process
Brief Hospital Course:
49M with h/o familial myoclonus, depression, EtOH abuse
transferred from HRI [**Location (un) **] for due to changes in mental
status.
.
#. acute mental status changes: Initially the pt was quite
agitated and confused, and was transferred to the ICU due to
demanding nursing care. He was placed in restraints and given 1x
5mg zyprexa and 2mg ativan IV for agitation. Broad differential
initially included infectious, ischemic, metabolic, toxic,
withdrawal symptoms, and psych. Likely not infectious - no
elevated WBC, no fever, UA negative, CXR negative. Likely not
ischemic - EKG normal, CT head negative. Ca, glucose, ammonia
normal. Pt was also not hypoxic. Hepatic encephalopathy was
unlikely as patient does not have ascites, no appreciable
asterixis. His TSH, B12, folate were all normal. Most likely
causes are EtOH withdrawal (EtOH on tox screen negative) with
concurrent Benzo intoxication (pos on tox screen and received
450mg librium over 4 days at HRI [**Location (un) **]), or depression with
psychosis. Psych was consulted and felt that benzo intoxication
was likely. There were no hemodynamic signs of withdrawal, pt
was placed on CIWA scale but did not require any benzos. He
improved with rest, IV fluids, and treatment with vitamins (MVI,
folate, thiamine, B vits). Upon discharge the pt was feeling
much better and was AOx3, cooperative, ambulatory, tolerating a
normal diet with stable vitals (never had any evidence of ETOH
withdrawal during his admission). We recommend to not treat the
patient with benzos as he is not withdrawing and to continue
monitoring and supportive care with nutrition, PT (ambulation),
and social work for long term support. Notably, he also has
allergies to haldol (unknown reaction) so this drug should be
avoided.
.
# Psych / familial myoclonus - psych service was consulted and
we held the pt's vistaril, lexapro, inderal and topamax.
Psychiatry recommended to hold his psych meds until further
outpatient evaluation.
.
# Thrombocytopenia - Pt has low platelet count of 102, which is
likely secondary to chronic EtOH use. We continued to monitor
and upon discharge the pt's Plt count was improved to 171.
.
Medications on Admission:
Ativan 1mg PO BID prn agitation
Folic acid 1mg PO daily
Inderal 20mg PO BID
Lexapro 20mg PO daily
Librium taper (finished [**7-11**])
Magnesium oxide 400mg PO BID
Multivitamin 1 tab PO daily
Potassium chloride 20mEq PO BID
Thiamine 100mg PO daily
Topamax 150mg PO qhs
Vistaril 50mg Po TID
Vitamin B Complex 1 tab PO daily
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. B-Complex with Vitamin C Tablet Sig: One (1) Cap PO DAILY
(Daily).
Disp:*30 tablets* Refills:*2*
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
alcohol intoxication compounded by librium intoxication
.
Secondary:
Familial myoclonus
ETOH abuse
Depression
Discharge Condition:
afebrile, stable vitals, tolerating POs, ambulatory
Discharge Instructions:
You were admitted due to changes in your mental status which was
thought to be either due to depression with psychosis or alcohol
intoxication compounded by intoxication with librium given at
your rehab center. You were initially quite agitated and we had
to transfer you to the ICU for monitoring. You were worked up
for other potential causes of your mental status changes but
they were negative. You did not have any signs of alcohol
withdrawal. In the ICU you were given some medicine to lower
your agitation and calm you. Once you were more stable and less
agitated you were transferred to the medical floor where you had
improved mental status. You were cooperative and were able to
ambulate, use the bathroom normally, and tolerate a normal diet.
You were given vitamins and IV fluids during the time that you
improved.
.
You will be discharged with new medicines: thiamine 100mg daily,
multivitamin daily, vitamin B complex 1 tab daily, folic acid
1mg daily. You will not be discharged with any of your
psychiatric medicines, so please do not take your Topamax 150mg
PO qhs, Vistaril 50mg Po TID, Inderal 20mg PO BID, Lexapro 20mg
PO daily. Your outpatient psychiatrist will re-evaluate your
medications and prescribe them for you at that time.
.
Please take all medications as prescribed.
Please attend all appointments as instructed.
Please do not hesitate to return to the hospital if you have
chest pain, changes in mental status, difficulty breathing, or
any other concerning symptoms.
.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 25821**] at
your earliest convenience. Please follow up with Neuro
appointment at [**Hospital1 2025**] which is already planned. Please follow up
with psychiatry. Please attend Alcoholics Anonymous
ICD9 Codes: 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1050
} | Medical Text: Admission Date: [**2140-8-11**] Discharge Date: [**2140-8-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4980**]
Chief Complaint:
Surgical Wound Draining
Major Surgical or Invasive Procedure:
Debridement of Laminectomy Wound
History of Present Illness:
Ms. [**Known lastname 4643**] is a [**Age over 90 **] year woman with a h/o CAD, HTN, CHF with EF
of 25% s/p L4-L5 laminectomy with Dr. [**Last Name (STitle) 1352**] in [**5-/2140**],
presented from rehab facility with nonhealing lumbar surgical
wound. Wound began producing serous drainage a week prior to
presentation, and started on Keflex [**8-6**]. Drainage was cultured
on [**8-6**] which grew heavy growth of MSSA and moderate alpha
strep, as a result was switched to Levaquin on [**8-8**], then
transferred to [**Hospital1 18**] [**8-11**].
Past Medical History:
s/p L4-5 laminectomy/fusion
CAD
HTN
Hyperlipidemia
Osteoporosis
Osteoarthritis
Skin Cancer
Restless leg syndrome
Social History:
She lives alone in [**Location (un) 3320**]. No tobacco or alcohol use. Has four
sons, two of whom live close by.
Family History:
No premature CAD, SCD
Physical Exam:
O: Tm:98.1 BP:115/64 HR:78 RR:18 SpO2:97% on RA
General: Alert, oriented to Person and Place, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Fine crackles on BL lung bases, no wheezes, ronchi
CV: Regular rate and rhythm
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley draining clear yellow urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2140-8-11**] 06:10PM BLOOD WBC-6.5 RBC-4.30# Hgb-11.1* Hct-35.0*
MCV-82# MCH-25.7*# MCHC-31.5 RDW-17.9* Plt Ct-472*
[**2140-8-19**] 05:42AM BLOOD WBC-7.9 RBC-3.47* Hgb-8.6* Hct-27.0*
MCV-78* MCH-24.9* MCHC-32.0 RDW-18.6* Plt Ct-454*
.
.
.
[**2140-8-11**] 06:10PM BLOOD Glucose-86 UreaN-11 Creat-0.6 Na-136
K-4.7 Cl-101 HCO3-28 AnGap-12
[**2140-8-20**] 04:45AM BLOOD Glucose-89 UreaN-8 Creat-0.6 Na-138 K-3.6
Cl-102 HCO3-29 AnGap-11
[**2140-8-20**] 10:06AM BLOOD Na-142 K-4.2 Cl-103
.
.
[**2140-8-18**] 8:56 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT [**2140-8-18**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2140-8-18**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
.
[**2140-8-12**] 10:45 am SWAB LUMBAR CERVICAL WOUND.
**FINAL REPORT [**2140-8-18**]**
GRAM STAIN (Final [**2140-8-12**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2140-8-16**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ <=0.5 S
ANAEROBIC CULTURE (Final [**2140-8-18**]): NO ANAEROBES ISOLATED.
Brief Hospital Course:
Mrs. [**Known lastname 4643**] is a [**Age over 90 **] year old woman with a h/o CAD, HTN, CHF with
EF of 25% s/p L4-L5 laminectomy with Dr. [**Last Name (STitle) 1352**] in [**5-/2140**], who
presented from a rehab facility with nonhealing lumbar surgical
wound.
#) Wound Infection/Sepsis: She had been started on Keflex [**8-6**] at
the rehab facility and the drainage was cultured on [**8-6**], which
grew heavy growth of MSSA and moderate alpha strep. As a result,
she was switched to Levaquin on [**8-8**] and then transferred to
[**Hospital1 18**] [**8-11**]. She was started on Vancomycin and Unasyn on [**8-12**].
She was taken to the OR on [**8-12**], where copious purulent fluid
was encountered, bathing the hardware. This was thoroughly
irrigated, and samples sent to micro, cultures ultimately grew
CoNS. She was initially placed on vancomycin and cefepime and
then transitioned
to a combination of Unasyn 2 q 12 hours (given her renal
function) and vancomycin 1 q 24 hours. Her OR course was
complicated by the fact that she was required requiring a
fiberoptic intubation, and was noted to have significant
tracheomalacia from midtrachea through carina. She was
successfully extubated in the PACU and required Levophed for
blood pressure support in the ICU for two days post operatively.
She was transferred to the general medicine floor from the ICU
on [**8-15**] where she remained afebrile and had reduced wound
drainage requiring twice daily dry sterile dressing changes. She
received a PICC line for the purpose of administering IV
antibiotics at her rehab facility. Finial infectious disease
recommendations are as follows:
Plan for 8-10 weeks for spinal osteomyelitis with hardware in
place, followed by life-long oral suppression given the presence
of hardware in infected bed.
Opat Antibiotic regimen and projected duration
Unasyn 2 q 12 hours x 8-10 weeks from time of operative
debridement, [**Date range (1) 4981**].
Vancomycin 1 q 24 hours x 8-10 weeks from time of operative
debridement, [**Date range (1) 4981**].
Cultura data (organism and susceptibilities)
MSSA, GAS (OSH)
CoNS ([**Hospital1 18**])
Essential diagnostic date for OPAT rx (TEE< bx, ect) baseline
Pertinent co-morbidities or complications:
Laboratory monitoring required: Weekly CBC with differential,
BUN, Cr, AST, ALT, Alk phos, Tbili, vancomycin trough, ESR, CRP.
All laboratory results should be faxed to Infectious disease
R.Ns. at ([**Telephone/Fax (1) 1353**]. All questions regarding outpatient
antibiotics should be directed to the infectious disease R.Ns.
at
.
#) AMS: She was noted to have fluctuating mental status with
narcotic pain [**Telephone/Fax (1) 4982**], thus these were avoided to the extent
possible with pain control primarily with Tylenol and subsequent
improvement in her mentation to baseline per family. At her
baseline dementia she can answer questions about her care
appropriately.
.
#) Respiratory Failure: She was weaned off the ventilator post
operatively and was subsequently weaned from a non-rebreather to
4L O2 on nasal canula in the ICU and finally to room air with
excellent oxygen saturation on the general medicine floor.
.
#) Systolic CHF: She has a reported LVEF of 25% and requires 20
mg of Lasix daily at home. Because of the intravenous fluids she
as received while admitted this dose should be increased to 40
mg daily and titrated to her daily weight and creatinine.
.
#) Hypokalemia: Secondary to diuresis with Lasix required
monitoring and potassium repletion to reflect Lasix dose as
appropriate.
.
#) Iron Deficiency Anemia: She was started on ferrous sulfate
325mg daily while admitted.
.
#) Incontinence: She was incontinent at baseline and thus
requires absorbent undergarment and miconazole powder QID.
.
#) Depression: She was not restarted on her Citalopram 10mg
daily while admitted, however this may be restarted after
discharge if her mental status is believed to be at baseline
.
#) Loose stools were noted by the nursing staff - however her C.
Diff studies were negative and this may be her baseline.
.
#) DVT Prophylaxis was achieved with 5000 units of SC Heparin
TID.
[**Telephone/Fax (1) **] on Admission:
Trazodone 25mg Q6H PRN Anxiety or Insomnia
Aspirin 325mg daily
Citalopram 10mg daily
Metoprolol ER 25mg daily
Celebrex 200mg daily
Lasix 20mg daily
Tylenol 650mg Q4H PRN pain (not to exceed 4gms daily)
Guaifenein 100mg/5ml 10ml every 4 hrs as needed for cough
Levaquin 500mg daily
Lipitor 80mg daily
Gabapentin 400mg TID
Tramadol 50mg Q6H while awake
Senna 2 tabs PO BID PRN constipation
Debrox gtts 5 gtts in each ear [**Hospital1 **] x 5 days
NTG 0.6mg SL q5min PRN chest pain
Milk of Magnesia 400mg/5ml 30ml daily for constipation
Bisacodyl 10mg supp. rectally
Citrucel powder daily
Oxycodone 5mg every 8 hours as needed for pain
Calcium 500mg tab chewable
Multiday plus minerals
Discharge [**Hospital1 **]:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Acetaminophen 650 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO Q6H (every 6 hours) as needed for
pain.
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day).
8. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Vancomycin 1000 mg IV Q 24H
please hold dose for trough >20
10. Ampicillin-Sulbactam 3 g IV Q12H
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. Nitroglycerin 0.6 mg Tablet, Sublingual Sig: One (1)
Sublingual Q 5 Minutes x 3 as needed for chest pain.
13. Milk of Magnesia 400 mg/5 mL Suspension Sig: 30 ml PO once
a day as needed for constipation.
14. Tramadol 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Discharge Disposition:
Extended Care
Facility:
Liberty Commons Nursing & Rehab Center - [**Location (un) 4979**]
Discharge Diagnosis:
Hardware associated lumbar infection
Systolic Congestive Heart Failure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mrs. [**Known lastname 4643**]
You were admitted to the hospital for an infection of your
spinal surgical wound. Your infection required surgical
treatment in addition to intravenous antibiotics. You will need
to continue these antibiotics for 8 to 10 weeks as recommeded by
your infectious disease doctors. You should take your
[**Known lastname 4982**] as described in this discharge document and keep
your outpatient appointments with your spine docotrs and
infectious disease doctors.
The following changes have been made to your [**Known lastname 4982**]:
1.) Your Furosemide has been INCREASED to 40mg daily
2.) Your Aspirin has been DECREASED to 81mg daily
3.) Your Metoprolol has been INCREASED to 25mg three times daily
4.) Your Citalopram has been HELD and may be resumed as your
mental status continues to improve.
5.) You have been STARTED on Heparin SC 5000 units TID
6.) You have been STARTED on Unasyn and Vancomycin antibiotics
IV please follow instructions from you infectious disease
doctors about these [**Name5 (PTitle) 4982**].
Followup Instructions:
Department: SPINE CENTER
When: TUESDAY [**2140-8-30**] at 11:30 AM
With: [**First Name4 (NamePattern1) 1141**] [**Last Name (NamePattern1) 4983**], NP [**Telephone/Fax (1) 3736**] (works with Dr [**Last Name (STitle) 1352**])
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: INFECTIOUS DISEASE
When: FRIDAY [**2140-9-16**] at 9:00 AM
With: [**Name6 (MD) 1423**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 4019, 412, 311, 4280, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1051
} | Medical Text: Admission Date: [**2156-3-8**] Discharge Date: [**2156-3-12**]
Date of Birth: [**2086-10-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ibuprofen
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest discomfort
Major Surgical or Invasive Procedure:
AVR (tissue) [**2156-3-8**]
History of Present Illness:
69 yo F complained of chest tightness with history of AS. Recent
cath showed severe AS, mild CAD and 2+ MR.
Past Medical History:
HTN, DM-2, AF, hypothyroid, pancreatitis
Social History:
works as cashier
occ/rare etoh
denies tobacco
Family History:
NC
Physical Exam:
Admission:
VS HR 76 RR 12 BP 120/60
NAD
Lungs CTAB
Heart RRR, 4/6 SEM
Abdomen benign
Extrem warm, no edema
Superficial bilateral varicosities
Discharge
VS HR 80 RR 18 BP 156/71
NAD
Lungs CTAB
Heart RRR
Abdomen benign
Extremities warm, no edema
Pertinent Results:
[**2156-3-12**] 05:30AM BLOOD WBC-10.5 RBC-3.46* Hgb-10.4* Hct-29.6*
MCV-86 MCH-29.9 MCHC-35.0 RDW-14.4 Plt Ct-261
[**2156-3-12**] 05:30AM BLOOD Plt Ct-261
[**2156-3-12**] 05:30AM BLOOD Glucose-132* UreaN-17 Creat-0.6 Na-135
K-4.0 Cl-100 HCO3-24 AnGap-15
[**2156-3-11**] 05:30AM BLOOD Mg-2.2
Brief Hospital Course:
She was a direct admission to the operating room on [**3-8**] where
she underwent an AVR. Please see OR report for details. In
summary she had AVR with #19 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Epic porcine valve, her
bypass time was 67 minutes with a crossclamp of 52 minutes. She
tolerated the operation well and was transferred to the ICU in
stable condition. She did well in the immediate post-op period,
her anesthesia was reversed, she was weaned from the ventilator
and was extubated. On POD #1 she remained hemodynamically
stable, her chest tubes were removed and she was transferred to
the floor. Over the next several days she had an uneventful
post-operative course. Her activity was advanced, her
medications where titrated and her epicardial wires removed. On
POD 4 she was ready to discharge home with visiting nurses.
Medications on Admission:
digoxin 0.25', Crestor 20', Hyzaar 100/12.5, Paroxetine 20',
Levothyroxine 50', glipizide 2', ASA
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take while taking percocet for constipation.
Disp:*60 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Glimepiride 2 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Losartan-Hydrochlorothiazide 100-12.5 mg Tablet Sig: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 17718**] Health Care
Discharge Diagnosis:
AS s/p AVR
HTN, DM-2, AF, hypothyroid, pancreatitis, ^chol, Appy, Rt
rotator cuff repair, Tonsillectomy
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr. [**Last Name (STitle) 14522**] 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
Completed by:[**2156-3-12**]
ICD9 Codes: 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1052
} | Medical Text: Admission Date: [**2137-2-5**] Discharge Date: [**2137-2-21**]
Date of Birth: [**2071-9-17**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Amiodarone
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
DOE/worsening fatigue
Major Surgical or Invasive Procedure:
[**2137-2-7**] Aortic Valve Replacement (23 mm CE pericardial)/ Mitral
Valve Replacment ([**Street Address(2) 44058**]. [**Male First Name (un) 923**] porcine)/ Tricuspid Valve
repair
(28 mm [**Doctor Last Name **] MC3 annuloplasty ring)/ Maze with left atrial
appendage ligation
History of Present Illness:
65 yo female with RHD and recurrent AFib. Episode of CHF in
[**1-4**]. Known AI, MS, MR [**First Name (Titles) **] [**Last Name (Titles) **] by echo and cath. Referred for
surgery.
Past Medical History:
rheumatic heart disease
Atrial fibrillation (s/p ablation/PVI [**2134**] and mult. DCCVs)
chronic diastolic heart failure
depression
hypothyroidism
GI bleed secondary to ASA in past
history of amiodarone toxicity ( hypothyroid/neuropathy)
hiatal hernia
TIA [**2135**]
DVT left foot [**2127**]
varicose veins
Social History:
lives alone
retired
social ETOH only
remote tobacco
Family History:
non contributory
Physical Exam:
(from thoracic surgery and cardiac pre-op)
68" 79.3 kg
97% RA sat RR 22 HR 70-100 afib 130-180/70
bowel sounds present in chest
HEENT unremarkable
1+ edema left leg
2/6 systolic murmur at RUSB, 1/6 systolic murmur at left mid-ax.
line, [**Last Name (un) **]
neuro unremarkable
no lymphadenopathy
skin unremarkable
2+ bil. fems/radials
1+ bil. DP/PTs
no carotid bruits appreciated
Pertinent Results:
[**2137-2-21**] 05:52AM BLOOD WBC-12.8* RBC-2.84* Hgb-8.8* Hct-26.3*
MCV-93 MCH-31.0 MCHC-33.4 RDW-15.3 Plt Ct-426
[**2137-2-21**] 05:52AM BLOOD Glucose-92 UreaN-22* Creat-1.4* Na-135
K-4.5 Cl-103 HCO3-23 AnGap-14
[**2137-2-21**] 05:52AM BLOOD Mg-1.6
[**2-7**] Echo: PRE-CPB:1. The left atrium is markedly dilated.
Moderate to severe spontaneous echo contrast is seen in the body
of the left atrium. No mass/thrombus is seen in the left atrium
or left atrial appendage. No atrial septal defect is seen by 2D
or color Doppler. 2. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is mildly depressed (LVEF= 45%).
3. Right ventricular chamber size and free wall motion are
normal. 4. There are simple atheroma in the ascending aorta.
There are simple atheroma in the descending thoracic aorta. 5.
There are three aortic valve leaflets. The aortic valve leaflets
are mildly thickened. There is no aortic valve stenosis.
Moderate (2+) aortic regurgitation is seen. The aortic annulus
is 22 cm. 6. The mitral valve leaflets are severely
thickened/deformed. The mitral valve shows characteristic
rheumatic deformity. There is moderate valvular mitral stenosis
(area 1.0-1.5cm2). Mild (1+) mitral regurgitation is seen. 7.
The tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. The tricuspid annulus is 3.2
cm. Dr. [**Last Name (STitle) 914**] was notified in person of the results. POST-CPB:
On infusion of milrinone, phenylephrine. Apacing for slow sinus
rhythm. Preserved biventricular systolic function. LVEF now 50 %
on inotropic support. 1. Well-seated bioprosthetic valve in the
mitral position. No MR, no paravalvular leak. Transmitral
gradient is 11 mmHg with a mean of 6 at the time the cardiac
output is 7.6 L/min. 2. Well-seated bioprosthetic valve in the
aortic position with no AI, no paravalvular leak. Good flow is
seen in the left main coronary artery. Unable to obtain
transgastric views due to a hiatal hernia, so unable to
calculate gradients across the aortic valve. 3. Well-seated ring
in the tricuspid position with trace TR. 4. Descending aortic
contour appears normal post decannulation.
[**2-6**] CT: 1. Enlarged left atrium. 2. Large hiatal hernia
involving almost all the stomach and part of the colonic splenic
flexure, with the left inferior pulmonary vein sitting just
above it. 3. Grade I anterolisthesis of L4 on L5 and scoliosis.
4. 1-mm left upper lobe nodule, does not warrant further
followup if the patient has no risk factor for malignancy.
5. Bibasilar ground-glass opacity, could be atelectasis or
chronic aspiration given the history of large hiatus hernia.
[**2137-2-15**] 05:47AM BLOOD WBC-10.5 RBC-3.05* Hgb-9.5* Hct-28.4*
MCV-93 MCH-31.1 MCHC-33.4 RDW-15.2 Plt Ct-331
[**2137-2-5**] 10:20PM BLOOD WBC-6.2 RBC-3.64* Hgb-12.0 Hct-33.7*
MCV-93 MCH-33.0* MCHC-35.7* RDW-14.9 Plt Ct-215
[**2137-2-15**] 05:47AM BLOOD PT-14.7* INR(PT)-1.3*
[**2137-2-5**] 10:20PM BLOOD PT-16.7* PTT-133.9* INR(PT)-1.5*
[**2137-2-15**] 05:47AM BLOOD Glucose-93 UreaN-22* Creat-1.0 Na-143
K-3.0* Cl-99 HCO3-35* AnGap-12
[**2137-2-5**] 10:20PM BLOOD Glucose-106* UreaN-22* Creat-0.8 Na-142
K-4.1 Cl-108 HCO3-25 AnGap-13
[**Known lastname **],[**Known firstname **] F. [**Medical Record Number 45942**] F 65 [**2071-9-17**]
Radiology Report CHEST PORT. LINE PLACEMENT Study Date of
[**2137-2-14**] 12:57 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2137-2-14**] 12:57 PM
CHEST PORT. LINE PLACEMENT Clip # [**Clip Number (Radiology) 45943**]
Reason: please check PICC tip 43 cm left basilic please page
with w
[**Hospital 93**] MEDICAL CONDITION:
65 year old woman with
REASON FOR THIS EXAMINATION:
please check PICC tip 43 cm left basilic please page with wet
read thanks
[**Doctor First Name **] [**8-/2571**]
Final Report
INDICATION: PICC placement.
FINDINGS: A new left-sided PICC terminates in the SVC. As
compared to
[**2137-2-12**], there has been marked improvement of now only
mild
pulmonary edema. Large left lower lobe atelectasis and small
pleural effusion
are unchanged. The patient is status post aortic valve, mitral
valve, and
tricuspid valvular repair.
IMPRESSION: PICC in SVC.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 16277**]
DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**]
Approved: [**Doctor First Name **] [**2137-2-14**] 4:19 PM
Imaging Lab
Brief Hospital Course:
Admitted [**2-5**] for IV heparin for Afib and to complete pre-op
workup. CT chest/abd done with thoracic surgery consult to
evaluate large hiatal hernia. On [**2-7**] she underwent Aortic valve
replacement (#23 mm [**Doctor Last Name **] pericardial )/Mitral Valve
Replacement (#29mm St.[**Male First Name (un) 923**] tissue valve)/Tricuspid Valve repair
(#28,,[**Doctor Last Name **] MC3 annuloplasty)/MAZE. Cross clamp time: 137
minutes,Cardiopulmonary bypass time: 179 minutes.Please see
Dr[**Last Name (STitle) 5305**] operative report for further surgical details.
Following surgery she was transferred to the CVICU for invasive
monitoring in stable but critical condition. Within 24 hours she
was weaned from sedation, awoke neurologically intact and was
extubated. She was initially requiring inotropic/pressor support
to optimise her cardiac output. She remained hemodynamically
stable and was successfully weaned off Milrinone and Neo drips.
All lines and drains were discontinued in a timely fashion. She
was transfused with red blood cells for postoperative anemia.
Ms.[**Known lastname 19849**] did complain of severe pain which was treated with a
dilaudid infusion. Aggressive diuresis was initiated. She had
moments of extreme aggitation which was treated with haldol and
ativan. As her daughter had reported she consumed daily alcohol,
thiamine and folic acid were started. Multiple inhalers were
used for worsening atelectasis and a high oxygen requirement.
Postoperatively, Beta-blocker and aspirin were initiated. [**2-10**]
anticoagulation was initiated with Coumadin for her MAZE
procedure. Her INR levels subsequently increased to 7.5.
Ms.[**Known lastname 19849**] was given vitamin K and fresh frozen plasma to correct
this level and Coumadin was held. On [**2-13**] her rhythm went into
atrial fibrillation. Given her continued her confusion, a
swallow evaluation was performed which she failed due to her
altered mental status. Tube feeds were started for nutritional
support. Due to Ms.[**Known lastname 45944**] extreme state of confusion and
agitation, it was not until POD#7 that she was transferred to
the step down unit for further monitoring and progression. Her
mental status improved to full orientation on [**2-15**] with
continued low dose Haldol. Per Dr.[**Last Name (STitle) **], Ms.[**Known lastname 19849**] was started
on heparin drip to bridge her subtherapeutic INR and low dose
Coumadin restarted. She continued to progress, diet was advanced
with improving mental status, and she was ready for discharge to
home on POD 14. She was advised of all follow up appointments.
Medications on Admission:
Coumadin 4 mg daily (LD [**2-2**])
digoxin 0.25 mg daily
verapamil 240 mg [**Hospital1 **]
synthroid 25 mcg daily
neurontin 300 mg TID
nortriptyline 10-40 mg daily
lasix 20 mg daily
protonix 20 mg daily
fluoxetine 40 mg daily
ambien 10 mg QHS
fluticasone spray 50 mcg
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Magnesium Hydroxide 400 mg/5 mL Suspension [**Hospital1 **]: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
3. Sodium Chloride 0.65 % Aerosol, Spray [**Hospital1 **]: Two (2) Spray
Nasal QID (4 times a day) as needed.
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q4H (every 4 hours) as
needed.
5. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Hospital1 **]: Two
(2) Puff Inhalation Q4H (every 4 hours).
6. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
7. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
DAILY (Daily).
8. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
9. Ibuprofen 100 mg/5 mL Suspension [**Hospital1 **]: Three (3) PO Q8H
(every 8 hours) as needed for pain.
10. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
13. Thiamine HCl 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
14. Multivitamin Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
15. Levothyroxine 25 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
16. Warfarin 2 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day for 1
doses: titrate as directed by the office of Dr. [**Last Name (STitle) 45945**]. .
Disp:*30 Tablet(s)* Refills:*2*
17. Outpatient Lab Work
INR to be drawn on [**2137-2-22**] with results faxed to the office of
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 45945**] at ([**Telephone/Fax (1) 45946**]. Phone ([**Telephone/Fax (1) 45947**].
18. Lasix 20 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
19. Fluoxetine 20 mg Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
20. Nortriptyline 10 mg Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO HS (at
bedtime).
Disp:*30 Capsule(s)* Refills:*0*
21. Gabapentin 300 mg Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
22. Metoprolol Tartrate 50 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
23. Ciprofloxacin 500 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO Q12H
(every 12 hours) for 7 days: through Thursday, [**2-28**].
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Rheumatic heart disease s/p Aortic Valve Replacement, Mitral
Valve Replacment, Tricuspid Valve repair
Atrial fibrillation (s/p ablation/PVI [**2134**] and mult. DCCVs) s/p
MAZE procedure with left atrial appendage ligation
Chronic diastolic heart failure
Secondary: Depression, Hypothyroidism, GI bleed secondary to ASA
in past, history of amiodarone toxicity (
hypothyroid/neuropathy)
Discharge Condition:
deconditioned
Discharge Instructions:
no lotions, creams or powders on any incision
shower daily and pat incisions dry
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100.5, redness, drainage or weight
gain of 2 pounds in 2 days
Followup Instructions:
see Dr. [**Last Name (STitle) **] in [**12-28**] weeks
see Dr. [**Last Name (STitle) 23651**] in [**1-29**] weeks
see Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**]
please call for all appts.
Completed by:[**2137-2-21**]
ICD9 Codes: 5180, 2930, 4280, 311, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1053
} | Medical Text: Admission Date: [**2107-9-27**] Discharge Date: [**2107-10-18**]
Date of Birth: [**2047-5-25**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**2107-9-28**]: Placement of bilateral chest tube.
[**2107-10-13**]: PICC line placement
History of Present Illness:
Ms. [**Known lastname 87141**] is a 60 y/o woman no known PMH who is transferred
from an OSH with presumed gallstone pancreatitis, increasing
leukocytosis, and fevers.
On [**9-20**] she presented to [**Hospital3 628**] with a 1-day history
of
epigastric transitioning to RUQ abdominal pain, non-bilious
emesis, and night sweats. Laboratory evaluation was notable for
WBC 13.9, Hct 48.9, lipase 10,000, TBili 1.06, alkaline
phosphatase, 115, ALT 115, AST 94. A RUQ ultrasound was reported
to show gallbladder wall edema with presence of gallstones and
CBD measuring 5mm with no evidence of intraductal dilatation.
She
was admitted to the ICU, given fluid resuscitation, started on
Unasyn. She remained hemodynamically stable and her
amylase/lipase continued to trend down. She then developed
persistent tachycardia which was treated with metoprolol. She
spiked a fever to 101.8 and began wheezing on hospital day 3,
and
a chest x-ray showed bilateral pleural effusions. The effusions
were felt to be secondary to significant fluid rehydration. With
aggressive pulmonary toilet, she improved clinically.
An MRI was obtained on [**9-25**] which reported a hemorrhagic
pancreatitis with a component of necrosis, severe inflammatory
changes, significant retroperitoneal fluid/ascites, and a
distended, fluid-filled gallbladder. MRCP showed no stone in the
CBD. She remained hemodynamically stable but was later found to
have a R subclavian vein thrombus related to her CVL, which was
subsequently replaced.
On [**9-26**] she developed worsening wheezing and became tachypneic
with RR 30-40s. Her WBC count bumped to 21.4, however, her
amylase and lipase continued to decrease (57, 193). A CT abdomen
was performed and reported to show extensive necrosis of the
pancreas with a likely hemorrhagic component, as well as
cholecystitis. There was also reported to be a questionable area
of splenic vein compression due to inflammation. In addition to
her pleural effusions, a LLL opacification was identified,
atelectasis vs. consolidation. Due to concern for fatigue from
her persistent tachypnea, Ms. [**Known lastname 87141**] was intubated [**9-26**] PM.
Due to concern for worsening infection, bilateral pleural
effusions, and an uncertain source of leukocytosis, the patient
was transferred to [**Hospital1 18**] for further evaluation and management.
Past Medical History:
Questionable history of asthma associated with URIs.
Hx of fibroid removal, appendectomy.
Social History:
Denied alcohol, tobacco, or illicit drug use.
Family History:
Significant for mesothelioma in her father.
Physical Exam:
Physical Exam on Admission:
Temp: 99.9 HR: 95 BP: 106/60 RR: 31 O2 Sat: 100%
Vent: CMV 100%, 422 x 14, PEEP 5
GEN: Intubated, sedated. Obeys commands. NG tube.
HEENT: PERRL. Scleral icterus. Moist mucous membranes.
NECK: No JVD appreciated.
RES: Mildly coarse breath sounds in setting of ventilator.
Decreased at bases.
CV: RRR. No m/r/g appreciated.
GI: Soft. Obese. Some distension likely. No arousal when abdomen
palpated to indicate pain.
EXT: Warm, well-perfused. 1+ pitting edema b/l LEs. Cap refill
<2
sec.
On Discharge:
VS: 100, 91, 137/86, 18, 96% RA
Gen: NAD
CV: RRR, no m/r/g
Lungs: Decreased on bases
Abd: Soft, obese. Slightly distended, minimal tenderness on
palpation in epigastric region
Extr: Warm, 1+ pitted b/l edema.
Pertinent Results:
[**2107-9-27**] 10:46PM TYPE-ART PO2-220* PCO2-31* PH-7.50* TOTAL
CO2-25 BASE XS-2
[**2107-9-27**] 10:46PM LACTATE-1.7
[**2107-9-27**] 10:46PM freeCa-1.07*
[**2107-9-27**] 09:41PM GLUCOSE-178* UREA N-23* CREAT-1.0 SODIUM-141
POTASSIUM-3.4 CHLORIDE-107 TOTAL CO2-23 ANION GAP-14
[**2107-9-27**] 09:41PM estGFR-Using this
[**2107-9-27**] 09:41PM ALT(SGPT)-25 AST(SGOT)-33 LD(LDH)-615* ALK
PHOS-111* AMYLASE-97 TOT BILI-0.9
[**2107-9-27**] 09:41PM LIPASE-42
[**2107-9-27**] 09:41PM ALBUMIN-2.5* CALCIUM-7.9* PHOSPHATE-3.9
MAGNESIUM-2.1
[**2107-9-27**] 09:41PM WBC-21.9* RBC-2.89* HGB-8.5* HCT-24.8* MCV-86
MCH-29.2 MCHC-34.1 RDW-15.2
[**2107-9-27**] 09:41PM PLT COUNT-365
[**2107-9-27**] 09:41PM PT-15.4* PTT-32.7 INR(PT)-1.3*
[**2107-10-11**] 07:15AM BLOOD WBC-9.7# RBC-3.63*# Hgb-10.7*# Hct-32.1*#
MCV-88 MCH-29.4 MCHC-33.2 RDW-17.2* Plt Ct-659*
[**2107-10-18**] 04:52AM BLOOD Glucose-113* UreaN-12 Creat-0.8 Na-139
K-3.9 Cl-107 HCO3-24 AnGap-12
[**2107-10-17**] 06:40AM BLOOD Amylase-395*
[**2107-10-17**] 06:40AM BLOOD Lipase-138*
[**2107-9-27**] 11:53 pm BLOOD CULTURE Source: Line-new aline.
**FINAL REPORT [**2107-10-4**]**
Blood Culture, Routine (Final [**2107-10-4**]): NO GROWTH.
[**2107-9-28**] 12:28 am URINE Source: Catheter.
**FINAL REPORT [**2107-9-29**]**
URINE CULTURE (Final [**2107-9-29**]): NO GROWTH.
[**2107-9-28**] 4:25 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2107-10-7**]**
GRAM STAIN (Final [**2107-9-28**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2107-10-7**]):
RARE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. RARE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
[**2107-9-29**] 1:46 am PLEURAL FLUID RIGHT CHEST TUBE.
**FINAL REPORT [**2107-10-5**]**
GRAM STAIN (Final [**2107-9-29**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2107-10-2**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2107-10-5**]): NO GROWTH.
[**2107-10-7**] 1:30 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2107-10-8**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2107-10-8**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
RADIOLOGY:
[**2107-9-28**] CHEST PORT:
IMPRESSION:
1. Small bilateral pleural effusions.
2. Bibasilar opacities, likely atelectasis, pleural fluid or
infection, if
clinically appropriate.
[**2107-10-3**] CHEST PORT:
FINDINGS:
Bilateral chest tubes are again visualized. No pneumothorax is
identified. The endotracheal tube has been removed. The left IJ
line tip is in the SVC. Feeding tube tip is off the film, at
least in the stomach, volume loss in the right lower lung has
increased slightly and there is persistent plate-like
atelectasis in the left lower lung.
[**2107-10-5**] CHEST PA/LAT:
There are persistent low lung volumes. There is mild-to-moderate
bilateral
pleural effusion, larger on the left side, associated with
adjacent
atelectasis. The upper lungs are clear. There are no new lung
abnormalities.
Left IJ catheter and Dobbhoff tube are in place in standard
position. There is no pneumothorax.
[**2107-10-13**] CHEST PA/LAT:
IMPRESSION: Mild increase in bilateral pleural effusions, left
greater than right. Dobbhoff tube tip now in fundus of stomach.
[**2107-10-13**] CT ABd:
IMPRESSION:
1. Large pancreatic pseudocyst essentially replaces pancreatic
parenchyma
with no identifiable parenchyma remain.
2. Non-visualization of splenic vein concerning for splenic vein
thrombosis.
3. Persistently distended gallbladder; gallstones are better
visualized in
prior study.
4. Reactive bilateral left greater than right pleural effusions
with
associated compressive atelectasis, reaching subsegmental level
on the right and segmental on the left.
5. Dobbhoff tube coiled with tip terminating in stomach.
Brief Hospital Course:
Ms. [**Known lastname 87141**] was initially sedated and intubated in the ICU.
She continued to have fevers in the ICU, spiking to 102.3.
Blood cultures taken remained negative. Sputum culture grew
MSSA. B/l chest tubes were placed for pleural effusions, with
the L>R and increased WBC counts. She was gradually weaned from
ventilation and extubated on [**2107-10-2**], started on post-pyloric
tube feeds and transferred to the floor. She was started on
diuresis with IV Lasix to assist in removing excessive water.
On [**2107-10-3**], with minimal chest tube output, her chest tubes were
removed.
Ms. [**Known lastname 87142**] amylase/lipase trended down to near-normal
limits by her arrival to [**Hospital1 18**] but then started to increase
again a few days post-admission to peak on [**10-12**] (677 amylase
peaked on [**10-13**]; lipase peaked to 294 on [**10-7**]) to trend downwards
on discharge (amylase/lipase 395/138).
CT Abd/Pelvis on [**2107-10-13**] showed large pancreatic pseudocyst
essentially replacing the entire pancreas with minimal normal
pancreatic parenchyma.
GI: On the floor, Ms. [**Known lastname 87141**] was advanced to sips then to
clear liquids for a diet along with tube feeds. She had a few
small episodes of emesis and was changed back to NPO status on
[**2107-10-4**] until [**2107-10-10**] when she was readvanced from NPO to sips to
clears which she tolerated well. She was tolerating clears well
at time of discharge. On [**2107-10-15**] her tube feeds were stopped
and she was transitioned to TPN for the duration of her
hospitalization.
ID: Ms. [**Known lastname 87141**] continued to spike low grade temperatures when
on the floor. She was initially on multiple broad spectrum
antibiotics (vanc/levo/flagyl). This was narrowed to nafcillin
given the sputum culture and was dc'd after completion of the
abx course on [**2107-10-11**]. All cultures except for the sputum
culture (MSSA) were negative. Repeat CXRs late in the course of
her hospitalization showed improvement in the pleural effusions
and no signs of pneumonia.
Pulm: On admission patient was found to have large bilateral
pulmonary effusions. Bilateral chest tubes were placed in ICU,
patient had daily chest x-rays to assess her pulmonary status.
Effusions got better with chest tubes and lasix IV. On [**2107-10-3**]
both chest tubes were removed. Patient was treated with IV Lasix
for fluid overload, and she was weaned from supplemental O2.
Currently, patient on room air, denies DOE, last CT ([**10-13**])
showed small b/l effusions.
Heme: Ms. [**Known lastname 87141**] was thought to have acute on chronic anemia.
Her Hct was stable in the in the mid 20s throughout her
hospitalization. She was transfused on [**10-10**] for a Hct of 24.
It responded appropriately and stayed in the high 20s upon
discharge.
Renal: Ms. [**Known lastname 87142**] renal function was normal throughout her
stay with creatinine at baseline and remaining at 0.8 on
discharge. She was diuresed extensively during her stay,
especially in the week prior to discharge and was at her dry
weight prior to discharge.
She was discharged on [**2107-10-18**], at the time of discharge, the
patient was doing well, afebrile with stable vital signs. The
patient was tolerating clear liquid diet, ambulating with
minimal assist, voiding without assistance, and pain was well
controlled. The patient was evaluated by Physical therapy and
recommended to be discharged in Rehab to continue PT. The
patient was discharged in Rehab in stable condition, she will
continue TPN until her f/u appointment with Dr. [**First Name (STitle) **].
Medications on Admission:
None
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q12H (every 12 hours) as needed for constipation.
5. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
8. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas pains.
9. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed for cough.
10. Dextrose 50% in Water (D50W) Syringe Sig: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
11. Famotidine(PF) in [**Doctor First Name **] (Iso-os) 20 mg/50 mL Piggyback Sig:
One (1) Intravenous Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
1. Gallstone pancreatitis
2. Pancreatic pseudocyst
3. Bilateral pleural effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2107-10-28**]
9:30 [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **].
You will have an abdominal CT scan prior you appointment with
Dr. [**First Name (STitle) **], Dr.[**Name (NI) 5067**] office will inform you about time of the CT
scan.
Completed by:[**2107-10-18**]
ICD9 Codes: 5119, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1054
} | Medical Text: Admission Date: [**2112-9-9**] Discharge Date: [**2112-9-13**]
Date of Birth: [**2060-8-8**] Sex: F
Service: MEDICINE
Allergies:
Reglan / Compazine / Gentamicin / Sulfonamides / Tigan /
Meperidine / Iodine; Iodine Containing / Prednisone / Cefotaxime
/ Vancomycin / Cephalosporins / Infliximab / Mercaptopurine /
Mesalamine / Ciprofloxacin / Heparin Agents / Fluconazole /
Meropenem / Tizanidine
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
SVC syndrome/abdominal pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Patient is a 52 female with h.o Crohn's disease with multiple
complications, SVC syndrome s/p angioplasty,
depression/anxiety/PTSD, HIT + who presents with acute on
chronic abdominal pain and facial swelling. Pt reports DOE for
the last month, and orthopnea for the last week. Facial swelling
x1wk. [**First Name3 (LF) 5283**] pain xseveral days. Pt reports that when flushing her
port she experienced [**First Name3 (LF) 5283**] pain that radiated up to her eye. Pt
also reports mild headache for ~1wk which she reports she
usually gets before she's "septic". Otherwise, pt denies
LH/Dizziness, fevers/chills, dysphagia, CP/palp, joint
pain/rash. Pt reports she's had an increase in her [**First Name3 (LF) 5283**] pain with
slight nausea, 1 episode of vomiting this am, no
hematemesis/non-bilious, no diarrhea/constipation/melena/brbpr,
pt able to tolerate meals. Denies LE edema.
.
On review of symptoms, including cardiac, she denies any prior
history of stroke, TIA, pulmonary embolism, bleeding at the time
of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. However, pt
has had SVC clot in the past.
.
Additionally, pt reports that due to her PTSD, she requires 3mg
IV dilaudid Q3hrs, valium 5mg IV prn, 10mg QHS, benedryl 50mg IV
Q3-4hrs.
Past Medical History:
1) Crohn's disease dx [**2079**], s/p ~13 surgeries, including
transverse/ascending colectomy
- rectovaginal fistula
2) h/o multiple SBOs
3) SVC syndrome s/p angioplasty(had prior episode of facial and
neck swelling 11 years ago, when work-up revealed stenoses of R
subclavian and SVC,which were angioplastied by IR in [**2101**]. In
the intervening time period, pt reports only episode of facial
swelling occurred
during work-up and diagnosis of symptomatic parathyroid
adenoma).
4) h/o line/portocath infections (partic w/ coag neg staph)
5) Depression & Anxiety
6) Fatty liver with mildly elevated LFTs at baseline
7) s/p TAH BSO
8) s/p ccy
9) Gastric dysmotility - on TPN over last yr, though recently
tolerating POs
10) Short bowel syndrome
11) Parathyroid adenoma s/p removal
12) Fibromyalgia
13) hypothyroidism
14) HIT+ Ab: s/p 30 days treatment with Fondaparinux
15) Fe deficiency anemia
16) Mediastinal lymphadenopathy NOS: followed by Dr. [**Last Name (STitle) 575**]
17) Pulmonary nodules -- in process of being evaluated
18) PTSD, particularly active when in hospital setting due to
prior assault in hospital setting many years ago
Social History:
Patient lives with husband. [**Name (NI) **] 5 children (3 biologic 2
step).Currently disabled. Used to work as teacher. Denies hx of
tobacco, etoh, illicit drugs
.
Family History:
Significant for family history of Crohn's disease and
osteoarthritis. No reported family history of CAD or DM.
Physical Exam:
VS: T , BP121/67 , HR107 RR19 , O2 99% on RA
Gen: NAD, able to speak in full sentences, perseverating on
doses of narcotics, benzos, benedryl.
HEENT: NC/AT, perrla, EOMI, anicteric, facial plethora/swelling.
No oropharyngeal lesions/exudates.
Neck: Supple, unable to assess for JVP. +swelling, diffuse,
non-pitting, +multiple well healed scars c/w line insertions.
+well healed line c/w parathyroidectomy.
CV: Port C/D/I, s1s2 tachycardic, RRR, no m/r/g
Chest: B/L AE no w/c/r
Abd: +bs, soft, TTP [**Name (NI) 5283**], no guarding/no rebound/no skin rash, no
dullness to percussion
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
ADMISSION LABS:
[**2112-9-9**] 08:50AM BLOOD WBC-5.6 RBC-4.02* Hgb-11.1* Hct-32.8*
MCV-82 MCH-27.6 MCHC-33.8 RDW-14.9 Plt Ct-176
[**2112-9-9**] 08:50AM BLOOD Neuts-75.2* Lymphs-19.0 Monos-4.4 Eos-1.3
Baso-0.2
[**2112-9-9**] 08:50AM BLOOD PT-12.8 PTT-26.3 INR(PT)-1.1
[**2112-9-9**] 08:50AM BLOOD Glucose-100 UreaN-8 Creat-0.6 Na-140
K-3.3 Cl-108 HCO3-22 AnGap-13
[**2112-9-9**] 08:50AM BLOOD ALT-24 AST-22 LD(LDH)-203 AlkPhos-114
Amylase-19 TotBili-0.5
[**2112-9-9**] 08:50AM BLOOD Lipase-26
[**2112-9-9**] 08:50AM BLOOD Albumin-4.3 Calcium-8.8 Phos-2.7 Mg-1.4*
PERTINENT LABS/STUDIES:
Hct: 32.8 -> 30.8 -> 29.2 -> 28.3 -> 28.6
WBC: 7.1 -> 5.0 -> 3.1
INR: ([**9-9**]) 2.8 -> 2.9 -> 3.5 -> 2.1 -> 3.2 ([**9-13**])
TSH: 7.6
U/A ([**9-10**]): 30 Protein, small leukocytes, 20 RBCs, 12 WBCs, few
bacteria
UCx: Negative x2
EKG [**2112-9-7**]: Sinus tachycardia. Otherwise, within normal limits.
Compared to the previous tracing of [**2112-1-5**] diffuse T wave
flattening, which was previously seen, has largely resolved.
Heart rate is faster. The other findings are similar.
.
CT neck/abdomen [**2112-9-9**]: 1)SVC occlusion w/ possible thrombus
extending to rt atrium. Extensive collaterals and prominent
azygous/hemiazygous. 2) stable appearance of small bowel/colon
without evidence of obstruction. 3) stable mediastinal/hilar
adenopathy 4) bilat axillary lymph nodes w/ haziness of
surrounding fat, uncertain etiology.
.
CXR [**2112-9-9**]: No pneumothorax. No new air space consolidation or
effusion. The patient will be undergoing CTA of the chest.
.
KUB [**2112-9-7**]: No obstructive bowel gas pattern.
ECHO ([**2112-9-10**]): The left atrium and right atrium are normal in
cavity size. No mass or thrombus is seen in the right atrium
(best excluded by TEE). Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). The estimated cardiac index is normal (>=2.5L/min/m2).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is an anterior space which most likely
represents a fat pad. Compared with the prior study (images
reviewed) of [**2112-4-13**], the aortic valve leaflets now appear
mildly thickened (non-specific).
DISCHARGE LABS:
[**2112-9-13**] 06:23AM BLOOD WBC-3.1* RBC-3.46* Hgb-9.6* Hct-28.6*
MCV-83 MCH-27.8 MCHC-33.7 RDW-15.6* Plt Ct-211
[**2112-9-10**] 04:22AM BLOOD Neuts-62.0 Lymphs-29.6 Monos-5.6 Eos-2.3
Baso-0.6
[**2112-9-13**] 06:23AM BLOOD PT-31.4* PTT-37.5* INR(PT)-3.2*
[**2112-9-13**] 06:23AM BLOOD Glucose-98 UreaN-5* Creat-0.6 Na-138
K-4.5 Cl-106 HCO3-22 AnGap-15
[**2112-9-10**] 04:22AM BLOOD ALT-22 AST-22 LD(LDH)-219 AlkPhos-112
Amylase-15 TotBili-0.6
[**2112-9-13**] 06:23AM BLOOD Calcium-8.2* Phos-3.8 Mg-2.4
Brief Hospital Course:
Pt is a 52 y.o female with h/o Crohn's dx s/p multiple
complications, and h/o SVC syndrome who presents with facial
swelling and acute on chronic abdominal pain.
.
#. SVC syndrome: Pt has a h/o SVC syndrome in [**2101**] and presented
with facial swelling for one day and pain upon flushing her
port. Chest CT on [**2112-9-9**] revealed SVC clot to R.atrium with
extensive collaterals to the azygous vein. Patient was
evaluated by vascular surgery and Cardiothoracic surgery in the
ED, and both felt that she was not a surgical candidate at this
time, as her collaterals suggested a non-acute nature. The
patient has a history of [**Last Name (LF) **], [**First Name3 (LF) **] she was started on Argatroban
in the ED. This was discontinued on [**9-11**]. Patient was started
on Coumadin on [**9-11**], and her INR was 3.1 at discharge (on 5 mg
daily). Patient has a follow-up appointment with the [**Hospital 197**]
clinic on [**2112-9-15**], and her port may now be used again, per Dr.
[**Last Name (STitle) **].
.
#. Crohn's Disease: Pt has a h/o Crohn's, diagnosed in [**2079**], s/p
multiple complications including fistula, SBO. Pt has had
multiple episodes of abdominal pain requiring high doses of
narcotics. She had an acute exacerbation of her abdominal pain
on [**9-7**]. CT at the time and today showing unchanged stable mild
bowel thickening and distention in the area of anastamosis in
the [**Month/Day (4) 5283**]. GI was consulted and recommended starting her on Cipro
for an acute Crohn's flare. Patient's pain was controlled
during this hospital stay with Dilaudid, Benadryl, and
Anti-emetics. She will complete a two-week course of Cipro, and
she will follow up in clinic with Dr. [**Last Name (STitle) 79**].
.
# Psychiatric: Pt has a history of PTSD, depression, and
anxiety. Pt has extreme distress in the hospital setting. During
this hospital stay, she was given Citalopram, Dilaudid,
Oxazepam, and Benadryl to alleviate her anxiety. She did not
have any acute events during this hospital stay.
#. Code: full
.
# Communication: with patient.
.
Medications on Admission:
ALLERGIES:
Reglan / Compazine / Gentamicin / Sulfonamides / Tigan /
Meperidine / Iodine; Iodine Containing / Prednisone / Cefotaxime
/ Vancomycin / Cephalosporins / Infliximab / Mercaptopurine /
Mesalamine / Ciprofloxacin / Heparin Agents / Fluconazole /
Meropenem / Tizanidine
MEDS ON ADMISSION:
Celexa 40mg daily
nascobal 500mcg/0.1mg 1 spray 1 nare 1xwk
ergocalciferol 50,000 units 1 cap 2x wk
ethanol 10% port
dilaudid 2mg 1-2tab TID prn
IVF
levoxyl 50mcg daily
oxazepam 15mg [**Hospital1 **]
phenergan 1mg IV QID
ultram 50mg [**2-3**] tapbs TID up to 300mg
saccharomyces 250mg daily
slomag 250mg [**Hospital1 **]
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO TWICE WEEKLY ().
6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Oxazepam 15 mg Capsule Sig: One (1) Capsule PO BID (2 times a
day) as needed.
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
9. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 11 days: To complete course [**9-23**] or as
instructed by your [**Month/Year (2) **]. Thank you.
[**Month/Year (2) **]:*44 Tablet(s)* Refills:*0*
10. Promethazine 25 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6
hours) as needed for nausea.
11. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day:
Dose to be changed by [**Company 191**] coumadin clinic.
[**Company **]:*90 Tablet(s)* Refills:*2*
12. ethanol flush Sig: 10% ethanol 2.5cc in each chamber of the
port for a one hour once a day: etoh should then be flushed
through and port locked
with normal saline. The dwell coudl be done daily if port used
daily or if port not used once weekly when port flushed and
locked in usual care.
.
[**Company **]:*qs qs* Refills:*2*
13. Nascobal 500 mcg Spray, Non-Aerosol Sig: One (1) spray Nasal
once a week: One spray in one nare weekly.
14. Promethazine 25 mg/mL Solution Sig: One (1) Injection every
eight (8) hours as needed for nausea.
[**Company **]:*qs qs* Refills:*0*
15. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
for 5 days.
[**Company **]:*20 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
SVC clot
Crohn's flare
Secondary:
Depression
Anxiety
Discharge Condition:
Good. Patient's vital signs are stable, and she is able to
ambulate without difficulty.
Discharge Instructions:
You were admitted to the hospital because you experienced
swelling in your face, and you had pain in your abdomen. While
you were here, you were found to have a blood clot in your
superior vena cava. We started you on a blood thinner,
coumadin, to prevent any complications from this clot. While
you were here, we also started you on Cipro for your abdominal
pain. It was thought that this pain may represent a Crohn's
flare. You should continue this medication for a total duration
of two weeks.
While you were here, we made the following changes to your
medications:
1.
Please take all medications as prescribed.
Please keep all previously scheduled appointments.
Please return to the ED or your healthcare provider if you
experience recurrence of your face swelling, fevers, chills,
bloody diarrhea, confusion, chest pain, shortness of breath, or
any other concerning symptoms.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 1238**] [**Last Name (NamePattern1) 1239**] [**Name8 (MD) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2112-9-20**] 11:00
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Date/Time:[**2112-10-10**] 11:20
Please call Dr.[**Name (NI) 18707**] gastroenterology clinic for a follow-up
appointment within the next 1 week.
You have an appointment with [**Company 191**] coumadin clinic on [**9-15**] -
please call [**Telephone/Fax (1) 2756**].
Completed by:[**2112-9-14**]
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1055
} | Medical Text: Admission Date: [**2186-12-10**] Discharge Date: [**2186-12-14**]
Date of Birth: [**2100-3-26**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4358**]
Chief Complaint:
Bleeding from mouth
Major Surgical or Invasive Procedure:
EGD, IR embolization
History of Present Illness:
Mrs[**Doctor Last Name **] is a pleasant 86 yo woman with dementia, hx CABG,
HTN, hyperthyroidism, DM, TIAs, who presented to [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]
after having been found by her daughter covered in blood, with
blood in her mouth, characterized as approximately 1 L of blood
lost. Daughter states that she left to do an errand and returned
to find her mother confused and bleeding from her mouth. She has
no known history of liver disease or GIB. She was transferred by
EMS to an outside hospital where crit was 24.7 she was started
on vasopressin for SBP of 94, protonix and given 1 unit of
PRBCs, 2 L of fluid, transferred to [**Hospital1 18**] for urgent EGD.
In our ED, on arrival her maps were in the 50s-60s, however
improved to 65-75 and pressors were weaned. She was febrile to
100.7 rectal, exam was notable for petichae in sublingual
region, blood crusting around mouth. ECHO showed appropriate
resp variation in IVC, fast was negative. A left subclavian was
placed and cvp was measured at 5-6. Crit was 23.5, INR was 1.4,
lactate 3.6 pt had a leukocytosis to 16.3. She was 2 U PRBCs
were ordered, 1 was given in the ED. CXR unremarkable, inf q
waves on EKG. She was producing urine, having an output of 50
ccs in last hr prior to ICU transfer. She was given Zosyn and
vanco for fever and continued on a PPI gtt. A left subclavian
was placed and she was transferred with 2 PIVs. CXR showed no
acute process.
.
On the floor, pt is conversant but confused. Denies shortness of
breath, CP, discomfort.
Past Medical History:
diabetes
CAD, s/p 4 v CABG
MI
a fib
arthritis
colitis
dementia
goiter, hyperthyroid, pt refused surgery in the past
HTN
TIA
pernicious anemia
appendectomy, cholecystectomy
Social History:
Lives with daughter, is functional with some supervision. No
EtOH, tob, illicits.
Family History:
Sister with brain cancer
Physical Exam:
On admission:
Vitals: T:96 BP:120/99 P:105 R: 20 O2: 100% RA
General: Interactive, responsive, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD, large neck mass
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: irregular rhythym, tachycardic, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: unable to assess, sedated
Pertinent Results:
On admission:
.
[**2186-12-10**] 07:15PM BLOOD WBC-16.3* RBC-2.70* Hgb-7.6* Hct-23.5*
MCV-87 MCH-28.0 MCHC-32.2 RDW-12.8 Plt Ct-295
[**2186-12-10**] 07:15PM BLOOD PT-15.5* PTT-27.7 INR(PT)-1.4*
[**2186-12-11**] 02:14AM BLOOD Albumin-2.7* Calcium-6.7* Phos-5.2*
Mg-1.8
[**2186-12-11**] 07:02AM BLOOD Type-ART Rates-14/ Tidal V-450 PEEP-5
FiO2-40 pO2-191* pCO2-31* pH-7.44 calTCO2-22 Base XS--1
-ASSIST/CON Intubat-INTUBATED
.
[**2186-12-10**]
Urine Cx and Blood Cx: no growth
.
[**2186-12-10**] CXR
No acute cardiopulmonary abnormality.
.
[**2186-12-11**] CXR
Endotracheal tube ends in standard placement at the thoracic
inlet and the
trachea is shifted substantially to the right and prior to
intubation, one can see is severely narrowed, by a presumed huge
left-sided goiter or a mammoth arterial aneurysm.
.
Tip of the Left subclavian line ends at the origin of the SVC.
Moderate
cardiomegaly is stable. Lungs grossly clear. No pneumothorax or
pleural
effusion. Descending thoracic aorta is tortuous and may be
mildly dilated. Stomach is moderately distended with gas.
.
[**2186-12-11**]: Transcatheter embolization
FINDINGS:
1. Active extravasation from the branch of the GDA into the
proximal
duodenum.
2. Gelfoam slurry embolization and 2 cm x 3 mm coil embolization
of the
branch of SMA with no residual active extravasation.
3. Atherosclerotic aorta and mesenteric arteries.
IMPRESSION:
Successful embolization of the active bleeding focus from GDA
with no residual active extravasation post-procedure.
.
[**2186-12-12**]
R LE u/s of catheterization site
IMPRESSION: No evidence of a hematoma and no pseudoaneurysm
identified.
.
[**2186-12-14**]:
LUE u/s
.
IMPRESSION:
1. Thrombus seen in one of the superficial veins, the left
cephalic vein. No
evidence of deep vein thrombosis in the left arm.
2. Incidental left thyroid nodule.
.
Discharge
[**2186-12-14**] 06:13AM BLOOD WBC-7.1 RBC-2.79* Hgb-8.3* Hct-24.1*
MCV-86 MCH-29.7 MCHC-34.4 RDW-14.2 Plt Ct-149*
[**2186-12-14**] 06:13AM BLOOD Glucose-112* UreaN-10 Creat-0.6 Na-137
K-3.0* Cl-104 HCO3-26 AnGap-10
[**2186-12-14**] 06:13AM BLOOD Calcium-8.1* Phos-2.0* Mg-1.8
Brief Hospital Course:
Pleasant 86 yo female presenting from OSH with hypotension,
bleeding from mouth concerning for UGIB, found to have rapid
arterial bleed in the duodenal bulb, now s/p IR embolization.
.
# UGIB/dieulafoy's lesion: scoped on arrival to the unit, found
to have bleeding ulcer in the duodenal bulb which was bleeding
rapidly and unable to be intervened upon. Unclear cause of
ulcer, pt had been on naproxen/aspirin but had not been taking
recently, no hx of h. pylori. Unstable with pressures in the 90s
and tachycardia to the 120s, repeat crit of 16.4 after
transfusion of 2 units, therefore massive transfusion protocol
was initiated pt went for IR embolization, which was successful
and crits stabilized thereafter. In total, she was transfused 7
units. DNR/DNI status was reversed for the procedure. Procedure
was complicated by groin hematoma. US showed no evidence of
hematoma or aneurysm. On the floor pt remained hemodynamically
stable and hematocrit was stable at 24-25. She was started on
famotidine for GI prophylaxis, as PPIs increase risk of PNA,
specifically aspiration PNA. Her ASA was restarted as the
literature indicates those pt's with true cad, had lower all
cause mortality and fewer MI's when aspirin was continued and a
nonsignificant increased amount of bleeding from PUD. Her dose
was decreased from 325 to 81mg because women do not confer any
survival benefit from high dose asa.
.
# Fever: pt had one fever in the ED, with no clear source. Per
family, pt was asymptomatic prior to arrival. Abx were held and
she had no further fevers throughout the admission. Cxs did not
speciate.
.
# Hx CAD: s/p CABG, no recent CP or evidence of active coronary
disease. Her home aspirin, atenolol, amlodipine, and lisinopril
were held in the setting of active GI bleed. She was restarted
on home medications with the exception of amlodine because she
remained normotensive without it. As mentioned above, her asa
was decreased to 81mg.
.
# Elevated PTH in setting of Hypocalcemia: In ICU attributed to
citrate toxicity from blood transfusions, PTH was sent and found
to be elevated at 125. Of note, pt's was hyperphosphatemic at
the time which can cause elevated PTH secretion. Furthermore, a
free calcium was measured within normal limits and albumin was
low indicating that total Ca decreased due to hypoalbuminemia.
.
# Dementia: home namenda and aricept were held given pt unable
to take POs, restarted when regular diet resumed.
.
# Hyperthyroidism: methimazole was held given pt unable to take
POs, restarted when regular diet resumed. Of note, report from
LUE U/S notes a thyroid nodule, and it is unclear if this was
present earlier.
.
# Superficial Vein Clot: last day, had swelling in Left arm,
nontender. US revealed cephalic vein clot, but no DVT.
.
# DM: maintained on ISS
.
.
DNR/DNI
.
Transitional:
- follow up incidental solid thyroid nodule in L thyroid.
- follow up Ca+ and high PTH as outpt for furtherwork up if
indicated
Medications on Admission:
aspirin 325
Namenda 10 [**Hospital1 **]
aricept 10 q am
atenolol 50 mg
amlodipine 5 mg
lisinopril 10 mg q am
janumet 50/500 1 q AM
methimazole 10 mg daily
Discharge Medications:
1. Outpatient Lab Work
CBC
please fax to Dr. [**Last Name (STitle) 90016**] Office at ([**Telephone/Fax (1) 91019**]
please have labs drawn on [**2186-12-18**]
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. memantine 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. methimazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Janumet 50-500 mg Tablet Sig: One (1) Tablet PO qAM.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Bleeding Dieulafoy's Lesion
Hypovolemic Shock
Atrial fibrillation
alzheimer's dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mrs.[**Doctor Last Name **],
It was a pleasure taking care of you. You were admitted to the
hospital for a gastrointestinal bleed. We performed an exam
called an upper endoscopy and the bleeding source was identified
in your small intestine. A special procedure was performed
called an arterial embolization and the bleeding stopped. When
you were bleeding, your blood pressure dropped and your blood
counts were very low. Because of this, you were admitted to the
intensive care unit and you required multiple blood transfusions
and intravenous fluids. The bleeding has now stopped and we
believe that you are safe to go home.
.
We have made the following changes to your home medications:
1. START Famotidine 20mg tablet by mouth twice daily
2. CHANGE: Aspirin from 325 mg daily to 81mg daily
3. STOP: Amlodipine 5 mg daily
4. STOP: Naproxen 500 mg tablet twice daily. Please avoid all
NSAID medications (includes ibuprofen)
.
We have arranged a follow up appointment for you with your PCP,
[**Name10 (NameIs) **] information for this appointment is below. Prior to
following up with your primary care doctor, we would like you to
get lab work to make sure your blood counts are stable. Please
have this lab work done 2 days prior to your appointment.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Address: [**Street Address(2) 4472**],[**Apartment Address(1) 24519**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 18325**]
Appointment: Friday [**2186-12-22**] 10:00am
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1056
} | Medical Text: Admission Date: [**2144-1-27**] Discharge Date: [**2144-2-10**]
Date of Birth: [**2068-8-3**] Sex: F
Service: TRAUMA [**Last Name (un) **]
CHIEF COMPLAINT: Right groin pain.
HISTORY OF PRESENT ILLNESS: The patient is a 75 year old
female who was recently discharged from [**Hospital6 15083**]
after being treated for injuries sustained in a motor vehicle
crash back on [**2144-1-2**]. Discharge from [**Hospital1 498**]
included the following diagnoses: (1) traumatic diaphragmatic
rupture status post exploratory laparotomy; (2) 15 cm scalp
laceration; (3) right open tib/fib fractures status post
plating; (4) ORIF of left radius and ulna fractures; (5) L-1
through L-4 transverse processes fractures; (6) left ribs 10
through 12 fractures; (7) left SFA DVT. Patient was
discharged on [**1-13**] to rehab. On [**1-26**] patient
complained of right groin pain and had several hours of
"purple emesis." Patient was transferred to [**Hospital 16843**]
Hospital and had a cardiac arrest in the emergency room. She
was intubated, given chest compression and started on
dopamine. Hematocrit was found to be 19 and she was
transfused 2 units of packed red cells. She was Med-Flighted
to [**Hospital1 18**].
PAST MEDICAL HISTORY: Significant for hypertension, breast
cancer.
PAST SURGICAL HISTORY: Right mastectomy. Status post ex-lap
and reduction of gastric hernia and repair of diaphragmatic
rupture. Status post ORIF of left wrist. Status post ORIF
of right tib/fib fractures.
MEDICATIONS: Lovenox 100 mg subcu b.i.d., Coumadin 2 mg p.o.
q.d., Protonix 40 mg p.o. q.d., Colace 100 mg p.o. b.i.d.,
Lopressor 25 mg p.o. b.i.d., Lasix 40 mg p.o. q.d.,
levofloxacin 250 mg p.o. q.d. day two of seven.
ALLERGIES: Penicillin and Keflex.
PHYSICAL EXAMINATION: Patient's vitals on admission to E.R.
were heart rate of 113, blood pressure 80/palp. Patient was
intubated, following commands. Coarse breath sounds
bilaterally. She was tachycardiac, but regular. Abdomen was
obese, nontender, soft. She had a right groin hematoma to
the mid-thigh. She was heme negative on rectal. She had no
distal edema. Right upper extremity was in a brace, was
warm, was neurovascularly intact. Left lower extremity was
without edema and warm.
LABORATORY DATA: On admission white count was 18.1,
hematocrit 9.2, platelets 662. PT 25.3, PTT 45.8, INR 4.2.
Sodium 138, potassium 4.3, chloride 97, bicarb 28, BUN 19,
creatinine 1.0, glucose 170. Arterial blood gas on admission
was 6.95, 117, 54, 28, -10. Fibrinogen was 374, amylase 128,
lactate 15.2. Radiographic studies included chest x-ray
which showed left pleural effusion. Chest CT corroborated
the x-ray. Abdominal CT showed no free fluid, normal aorta,
right retroperitoneal hematoma from the iliacus to right
groin.
HOSPITAL COURSE: In the emergency room patient was
aggressively resuscitated, receiving 8 units of packed red
cells, 8 units of FFP and multiple liters of crystalloid.
Repeat hematocrit in the trauma SICU was 41.7. Gas improved
to 7.26, 38, 127, 18, -9. In the trauma bay she had a left
chest tube placed for the left pleural effusion. She had
multiple lines placed including a right groin line which was
subsequently removed. It is unclear whether patient had
sustained a spontaneous bleed in the right retroperitoneum
versus an iatrogenic hematoma secondary to the right line.
After the line placement, it was found the line had been
placed in the femoral artery. She was transferred to the
trauma SICU where resuscitation continued. There was a
question of a GI bleed as the source of the dramatic fall in
hematocrit an upper endoscopy was performed by the
gastroenterology service which was normal.
Vascular surgery was consulted regarding the right thigh
hematoma and they opted for aggressive correction of her
coagulopathy and close examination. Over the next ensuing
days patient's coagulopathy was corrected and hematocrit
remained stable. She was weaned off ventilatory support
while undergoing diuresis secondary to the large fluid
resuscitation which occurred earlier in her hospital course.
By hospital day five she was extubated. Her chest tube was
discontinued. She had completed a course of IV steroids and
remained stable. She had an IVC filter placed on hospital
day eight due to her history of DVT and an antibody positive
test result.
On hospital day nine she was transferred to the floor in
stable condition. She had been receiving tube feeds and a
swallow study was performed. Video swallow study
demonstrated patient tolerating a pureed and ground diet with
thin liquids. Her diet was advanced and the Dobbhoff was
removed. On the floor she also was found to have a rising
white count to a high of 19.3. She remained afebrile. Blood
cultures were sent which demonstrated gram positive cocci in
one out of four bottles and gram positive rods in two out of
four bottles. She had a central venous line which had been
discontinued. All peripheral access was discontinued.
Subsequent white count was 9.3.
The patient was evaluated by physical therapy. Based on the
notes from [**State 1558**], patient is nonweight
bearing on the right lower extremity and nonweight bearing on
the right upper extremity. She is able to ambulate with a
Cam walker. Patient is otherwise stable and ready for
discharge to rehab.
DISCHARGE DIAGNOSES:
1. Right groin hematoma.
2. Cardiac arrest at outside hospital.
3. HIT antibody positive.
4. Status post IVC filter placement.
5. Status post ORIF of right tib/fib fractures.
6. Status post ORIF of left radius and ulna fractures.
7. Left T11-T12 rib fractures.
8. L-2 through L-4 transverse processes fractures.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o. q.d.
2. Tylenol 650 mg p.o. q.four hours p.r.n.
3. Sertraline 25 mg p.o. q.d.
4. Albuterol MDI two puffs q.i.d. p.r.n.
5. Atrovent MDI two puffs q.i.d. p.r.n.
6. Tylenol #3 one to two p.o. q.four hours p.r.n.
CONDITION ON DISCHARGE: Stable.
FOLLOWUP: The patient should follow up with [**Hospital 28978**] Medical Center orthopaedic office, Dr.
[**First Name (STitle) 4223**], phone number [**Telephone/Fax (1) 47234**], in one week from
discharge. Patient should also follow up with [**State 28978**] trauma clinic, phone number [**Telephone/Fax (1) 47235**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2144-2-10**] 09:56
T: [**2144-2-10**] 11:09
JOB#: [**Job Number 47236**]
ICD9 Codes: 2875, 5119, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1057
} | Medical Text: Admission Date: [**2110-12-5**] Discharge Date: [**2110-12-20**]
Date of Birth: [**2041-1-14**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: The patient is a postoperative
admission, admitted directly to the operating room for an
aortic valve and aortic root replacement. This is a 69 year
old woman with a known dilated aortic root to 4.9 centimeters
and critical aortic stenosis. She had a recent admission
with planned surgery which was delayed secondary to a white
blood cell count of 3.0. She had a hematology evaluation and
she was cleared for surgery. Readmitted on [**2110-11-21**], for
scheduled surgery again and was found to have a left
cellulitis secondary to a Pneumovax vaccine that she had
several days prior to admission. The case was again
postponed and she was admitted on the day of surgery for a
scheduled aortic valve replacement along with a root
replacement. She had a cardiac catheterization done
[**2110-10-9**], that showed normal coronaries and aortic root of
4.9 centimeters, one plus mitral regurgitation and one plus
tricuspid regurgitation, ejection fraction of 65 percent with
critical aortic stenosis and the aortic valve area 0.5
centimeter square and a gradient of 113 with one plus aortic
regurgitation.
PAST MEDICAL HISTORY: Aortic stenosis.
Hypertension.
PAST SURGICAL HISTORY: Partial oophorectomy.
Bilateral vein stripping.
ALLERGIES: She states an allergy to Penicillin which causes
a rash.
MEDICATIONS ON ADMISSION:
1. Lisinopril 40 mg daily.
2. Hydrochlorothiazide 25 mg daily.
3. Multivitamin.
4. Benadryl.
5. P.r.n. Albuterol.
SOCIAL HISTORY: She lives with husband in [**Name (NI) 11333**],
[**State 350**]. She works part-time as a bank teller. She
denies tobacco use. Alcohol use two glasses of wine per day.
FAMILY HISTORY: Significant only for an aunt who had
coronary artery disease.
PHYSICAL EXAMINATION: Height five feet seven inches, weight
160 pounds. General sitting comfortably in chair in no acute
distress. Neurologically, alert and oriented times three,
moves all extremities, follows commands, nonfocal
examination. Respiratory clear to auscultation bilaterally.
Cardiovascular regular rate and rhythm, S1 and S2, with a
III/VI holosystolic murmur. The abdomen is soft, nontender,
nondistended with normoactive bowel sounds. Extremities are
warm and well perfused with no edema. Pulses - radial two
plus on the right and one plus on the left. Dorsalis pedis
two plus bilaterally. Posterior tibial two plus bilaterally.
HOSPITAL COURSE: As stated, the patient was admitted
directly to the operating room for a planned aortic valve
replacement, aortic root repair. Please see the operating
room report for full details. In summary, she had an aortic
valve replacement with a number 27 millimeter [**Last Name (un) 3843**]-
[**Doctor Last Name **] pericardial valve and replacement of the ascending
and hemi-arch aorta with 28 millimeter Gelweave graft. Her
bypass time was 120 minutes with a cross clamp time of 76
minutes and a circulatory arrest of 9 minutes. She tolerated
the operation well and was transferred from the operating
room to the Cardiothoracic Intensive Care Unit. At the time
of transfer, the patient was AV paced at 80 beats per minute
with a mean arterial pressure of 65 and a CVP of 6. She had
Neo-Synephrine at 1.0 mcg/kg/minute, Propofol at 10
mcg/kg/minute and Amiodarone at 1 mg per minute. The patient
did well in the immediate postoperative period. Her
anesthesia was reversed. She was weaned from the ventilator
and successfully extubated. On postoperative day number one,
the patient continued to be hemodynamically stable requiring
only Neo-Synephrine to maintain an adequate blood pressure.
She also continued on her Amiodarone drip which was initially
started for ventricular tachycardia in the operating room of
which she had no further episodes during her immediate
postoperative period, a postoperative day number one. The
patient remained in the Cardiothoracic Intensive Care Unit
for close hemodynamic monitoring. On postoperative day
number two, the patient again was doing well. Her Neo-
Synephrine infusion was weaned. Her Swan-Ganz catheter was
removed and she was begun on diuretics. Additionally, the
patient's Amiodarone drip was converted to oral dosing. She
remained in the Intensive Care Unit for continued requirement
of Neo-Synephrine to maintain an adequate blood pressure. By
postoperative day number three, the patient had weaned off
her Neo-Synephrine drip and was transferred from the
Cardiothoracic Intensive Care Unit to [**Hospital Ward Name 121**] Two for continued
postoperative care and cardiac rehabilitation. Over the next
several days, the patient's activity level was increased with
the assistance of the nursing staff and the physical therapy
staff. It was noted on postoperative day number five that
the patient did have an intermittent sternal click
accompanied by a complaint of pain, however, the wound looked
clean with no erythema and no drainage. However, by the
following day, the patient did begin to drain serosanguineous
fluid from the base of her sternal incision site. Over the
next several days, the patient continued to have sternal
drainage. She remained hemodynamically stable without a
white blood count during this entire period, however, because
of the continued drainage on [**2110-12-15**], the patient returned
to the operating room where she underwent sternal debridement
and rewiring. Cultures from that debridement came back
negative. She tolerated the operation well and was
transferred again from the operating room to the
Cardiothoracic Intensive Care Unit. She remained
hemodynamically stable and extubated immediately after
surgery. She remained in the Intensive Care Unit only on the
day of surgery and then was transferred back to the floor the
following morning for continued postoperative care. On
postoperative day number two from her sternal rewiring, her
chest tubes were put to water seal following which the
patient was noted to have a 20 percent right-sided
pneumothorax. The tubes were again returned to suction with
the lung fully reexpanding. On the following morning, the
patient's chest tubes were again placed to water seal and a
follow-up chest x-ray showed minimal apical pneumothorax.
The tubes were left on water seal for 24 hours. A repeat
chest x-ray showed no change in the apical pneumothorax and
on postoperative day number four from the rewiring, her chest
tubes were removed. On postoperative day number five from
the rewiring, it was deemed that the patient was stable and
ready to be transferred to rehabilitation for continuing
care.
At the time of this dictation, the patient's physical
examination is as follows: Temperature 97.3, heart rate 87,
sinus rhythm, blood pressure 114/69, respiratory rate 20,
oxygen saturation 95 percent in room air. Laboratory data
reveals white blood cell count 8.3, hematocrit 32.8. Sodium
137, potassium 3.9, chloride 99, CO2 29, blood urea nitrogen
9, creatinine 0.8. Glucose 98. On physical examination, the
patient is alert and oriented times three, moves all
extremities, follows commands. Pulmonary clear to
auscultation bilaterally. Cardiac regular rate and rhythm,
S1 and S2 with no murmurs. The sternum is stable and incision
with staples. No erythema or drainage. The abdomen is soft,
nontender, nondistended, with normoactive bowel sounds.
Extremities are warm and well perfused with no edema. Follow-
up chest x-ray after chest tubes were removed shows a small
residual right apical pneumothorax unchanged from the two
prior days, both before and after chest tubes were removed.
CONDITION ON DISCHARGE: Good.
MEDICATIONS ON DISCHARGE:
1. Percocet 5/325 one to two tablets q4-6hours p.r.n.
2. Acetaminophen 325/650 q4hours p.r.n.
3. Aspirin 81 mg p.o. daily.
4. Colace 100 mg p.o. twice a day.
5. Metoprolol 100 mg twice a day.
6. Multivitamin one tablet daily.
7. Zinc Sulfate 220 mg daily.
8. Ascorbic Acid 500 mg twice a day.
9. Niferex 150 mg daily.
10. Thiamine 100 mg daily.
11. Potassium Chloride 40 mEq daily for two weeks.
12. Lasix 40 mg daily for two weeks and then 20 mg daily
times one week.
DISCHARGE STATUS: The patient is to be discharged to [**Location (un) 37268**].
FO[**Last Name (STitle) 996**]P: She is to have follow-up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 5263**] in two to three weeks and follow-up with Dr. [**Last Name (Prefixes) 411**] in four weeks.
DISCHARGE DIAGNOSES: Aortic stenosis, status post aortic
valve replacement with a number 27 [**Last Name (un) 3843**]-[**Doctor Last Name **]
pericardial valve.
Aortic root enlargement, status post replacement of the
ascending and hemi-arch aorta with a number 28 Gelweave
graft.
Status post sternal rewiring.
Hypertension.
Status post oophorectomy.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2110-12-20**] 11:44:43
T: [**2110-12-20**] 12:33:46
Job#: [**Job Number 57167**]
ICD9 Codes: 4241, 4271, 2762, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1058
} | Medical Text: Admission Date: [**2201-5-26**] Discharge Date: [**2201-6-1**]
Date of Birth: [**2142-8-30**] Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 2234**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: 58F Spanish speaking with cirrhosis
and renal failure, gets usual care at [**Hospital1 112**], presented to [**Hospital1 18**] ER
after taking some drugs off the street and lethargy. T 100.9,
BP88/50 HR 69 O2 99%2L, she was initially given Narcan 0.4mg
with some improvement in mental status and dose was repeated X
2. She had a low grade fever T 100.9 and LP was done. Prior to
LP, she was given ceftriaxone 2 grams. She continued to be
lethargic so received 2mg IV narcan X 2 and planned for narcan
gtt, however, she was arousable to voice so this was not
started. Last dose of Narcan was 10 AM [**5-26**]. CT head and CXR in
the ER were unremarkable. She also had a several BS in the 64-75
range and received Dextrose. Per ER notes additional history was
obtained from family (2 daughters) who stated that patient
abuses oxycodone, vicodin, T3 (no tyelnol in tox). Family denied
that patient was on sulfonylureas for diabetes.
.
At time of transfer to the ICU, she was easily arousable. She
complained of lower back pain, which she's had for years.
Otherwise denies any chest pain, shortness of breath. Denies any
abdominal pain, fevers or chills at home. Daugther thinks she
took altogether 34 pills (vicodin and tylenol #3) over past [**2-15**]
days. She does not think her mom is depressed.
Past Medical History:
Chronic lung disease - BOOP
Depression
Hypercholesterolemia
Multiple overdose (states has been admitted ~6 times, last time
6 months ago)
Cirrhosis
Diabetes
Arthritis
Kidney Failure
Social History:
Lives with her son, no smoking (prev 5ppd), denies etoH. No IVDA
per daughter
Family History:
non contributory
Physical Exam:
VS: Tmax: Temp: BP: / HR: RR: O2sat
.
General Appearance: pleasant, comfortable, NAD, non toxic
Eyes: : PERLLA, EOMI, no conjuctival injection, anicteric
ENT: no sinus tenderness, MMM, op without exudate or lesions, no
supraclavicular or cervical lymphadenopathy, JVP to cm, no
carotid bruits, no thyromegaly or thyroid nodules
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops
appreciated
Gastrointestinal: nd, +b/s, soft, nt, no masses or
hepatosplenomegaly
Musculoskeletal/extremities: no cyanosis, clubbing or edema
Skin/nails: warm, no rashes/no jaundice/no splinters
Neurological: AAOx3. Cn II-XII intact. 5/5 strength
throughout. No sensory deficits to light touch appreciated. No
pass-pointing on finger to nose. 2+DTR's-patellar and biceps.
No asterixis, no pronator drift, fluent speech.
Psychiatric:pleasant, appropriate affect
Heme/Lymph: no cervical or supraclavicular lymphadenopathy
GU: no catheter in place
Rectal: guiaic negative
Pertinent Results:
Admit labs:
[**2201-5-26**] 01:32AM WBC-11.1* RBC-3.38* HGB-10.3* HCT-32.7*
MCV-97 MCH-30.4 MCHC-31.5 RDW-15.7*
[**2201-5-26**] 01:32AM NEUTS-76.2* LYMPHS-19.6 MONOS-3.7 EOS-0.4
BASOS-0.3
[**2201-5-26**] 01:32AM PLT COUNT-182
[**2201-5-26**] 01:32AM GLUCOSE-92 UREA N-32* CREAT-3.1* SODIUM-136
POTASSIUM-5.1 CHLORIDE-105 TOTAL CO2-19* ANION GAP-17
[**2201-5-26**] 01:32AM ALT(SGPT)-25 AST(SGOT)-50* ALK PHOS-380* TOT
BILI-0.4
[**2201-5-26**] 01:32AM LIPASE-13
===================================================
[**2201-5-26**] 10:38PM TSH-0.35
[**2201-5-26**] 10:38PM calTIBC-351 VIT B12-950* FOLATE-8.6
FERRITIN-31 TRF-270
[**2201-5-26**] 10:38PM ALBUMIN-3.1* CALCIUM-8.2* PHOSPHATE-3.9
MAGNESIUM-1.8 IRON-78
[**2201-5-26**] 10:31AM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-560*
POLYS-44 LYMPHS-50 MONOS-0 MACROPHAG-6
[**2201-5-26**] 10:30AM CEREBROSPINAL FLUID (CSF) PROTEIN-52*
GLUCOSE-51
[**2201-5-26**] 10:30AM CEREBROSPINAL FLUID (CSF) WBC-5 RBC-[**Numeric Identifier **]*
POLYS-68 LYMPHS-25 MONOS-0 EOS-1 ATYPS-3 MACROPHAG-3
==================================================
Micro:
CSF, Blood cultures no growth, finalized.
RPR non reactive.
Stool cultures including c. diff x1 negative.
=======================================
ECG: Normal ECG.
================================================
CT HEAD W/O CONTRAST [**2201-5-26**] 6:03 AM
CT HEAD W/O CONTRAST
Reason: r/o ICH
[**Hospital 93**] MEDICAL CONDITION:
58 year old woman with lethargy, AMS
REASON FOR THIS EXAMINATION:
r/o ICH
CONTRAINDICATIONS for IV CONTRAST: kidney disease, not needed
INDICATION: 58-year-old female with lethargy and altered mental
status. Rule out intracranial hemorrhage.
No comparison studies.
TECHNIQUE: Non-contrast CT of the head.
FINDINGS: There is linear hyperdensity within the nondependent
portions of the choroid plexus likely calcified choroid.
Posterior to the mid brain and anterior to the cerebellum, there
is linear hyperdensity which is not in a characteristic location
for hemorrhage, likely a benign structure, correlation with MRI
of the head is recommended if clinically warranted. There is no
mass effect, shift of normally midline structures, or acute
major vascular territorial infarction. The ventricles are normal
in size and symmetric.
The visualized paranasal sinuses and mastoid air cells are
clear.
IMPRESSION: No definite intracranial hemorrhage.
=================================================
CHEST (PORTABLE AP) [**2201-5-26**] 5:43 AM
CHEST (PORTABLE AP)
Reason: r/o acute process
[**Hospital 93**] MEDICAL CONDITION:
58 year old woman with somnolence
REASON FOR THIS EXAMINATION:
r/o acute process
INDICATION: 58-year-old female with somnolence. Rule out acute
process.
No comparison study.
PORTABLE UPRIGHT CHEST RADIOGRAPH: Lung volumes are low. The
cardiomediastinal silhouette is within normal limits. There is
increased interstitial opacity diffusely with prominent hila
bilaterally. There are no appreciable effusions.
IMPRESSION: Low lung volumes. Likely mild pulmonary edema. If
there is further concern, repeat evaluation with better
inspiration is suggested.
=====================================================
ABDOMEN U.S. (COMPLETE STUDY) [**2201-5-27**] 2:14 PM
ABDOMEN U.S. (COMPLETE STUDY)
Reason: CIRRHOSIS. EVAL FOR ASCITES. FEVER
[**Hospital 93**] MEDICAL CONDITION:
58 year old woman with h/o DM, cirrhosis a/w fever, lethargy.
Please evaluate for cirrhosis, ascites.
REASON FOR THIS EXAMINATION:
Please evalute for ascites, cirrhosis.
INDICATION: Assess for ascites and cirrhosis.
COMPARISON: None available.
ABDOMINAL ULTRASOUND: [**Doctor Last Name **]-scale and color Doppler son[**Name (NI) 493**]
images were obtained and demonstrate the liver to be of
coarsened echotexture without ascites. No focal hepatic lesions
are demonstrated in this study limited by patient factors. The
gallbladder is nondistended. There is no pericholecystic fluid,
no evidence for cholelithiasis and the common bile duct is
nondistended measuring 5 mm. Portal venous flow is normal in
terms of direction. The left kidney measures 10.4 cm
pole-to-pole and the right kidney 10.1 and there is no evidence
for hydronephrosis, nephrolithiasis, or renal mass. The spleen
is homogenous in terms of echotexture and measures 4.3 cm.
IMPRESSION:
1. Coarsened echotexture of liver consistent with fatty liver.
2. No ascites.
The study and the report were reviewed by the staff radiologist.
=
=
=
================================================================
Discharge labs:
[**2201-5-31**] 07:05AM BLOOD WBC-9.9 RBC-3.26* Hgb-9.8* Hct-30.0*
MCV-92 MCH-30.1 MCHC-32.7 RDW-15.6* Plt Ct-178
[**2201-5-26**] 09:05AM BLOOD Neuts-70.7* Lymphs-23.6 Monos-5.3 Eos-0.3
Baso-0.2
[**2201-5-31**] 07:05AM BLOOD Plt Ct-178
[**2201-5-31**] 07:05AM BLOOD PT-15.1* PTT-37.1* INR(PT)-1.3*
[**2201-5-31**] 07:05AM BLOOD Glucose-110* UreaN-20 Creat-0.8 Na-140
K-3.6 Cl-106 HCO3-25 AnGap-13
Brief Hospital Course:
58 yof with history of CKD, Cirrhosis and history of multiple
drug overdoses with opiates presented to ER with altered mental
status.
.
Please note, discharge summary not updated by [**Hospital Ward Name 332**] ICU team,
thus discharge summary limited. Patient transferred to floor on
HD#3
1. Altered Mental Status/ Lethargy/Opiate overdose - Secondary
to opiate overdose.
- CXR, UA negative for infection, urine and blood cultures, LP
negative for infectious etiology. Given narcan x 1 with
improvement in mental status.
- Given empiric lactulose by ICU team with concern for hepatic
encephalopathy
- By HD#3 mental status at baseline, lactulose discontinued
without return of confusion
- Evaluated by psychiatry who did not feel patient was suicidal
- No further opiods prescribed.
.
2. Acute renal failure - Improved with IVF in ER. Combination
of dehydration. Lasix and lisinopril outpatient medications
were held and then re-started once creatinine at baseline.
.
3 DM - held glargine insulin and aspart on admit. ISS. Patient
was taking 80 units of lantus at night and 28 units of aspart
before each meal. Only able to safely titrate insulin to 20
units glargine at night and 20 units aspart before meals as
patient was having morning lows around 100. will need ongoing
titration.
.
4. NASH/ Cirrhosis - LFTs unremarkable but carries a diagnosis
per history. Abdominal ultrasound consistent with NASH.
.
5. Chronic low back pain - Neurontin and lidocaine patch
continued
.
6. Chronic diastolic heart failure/Coronary Artery Disease/HTN:
With altered mental status, acute renal failure, lasix and
lisinopril held. By discharge, back on lasix, lisinopril,
aspirin, statin, beta blocker.
.
7 Chronic lund disease/BOOP - continued prednisone at 5mg
.
8)Depression: evaluated by psychiatry, maintained on celexa.
Not suicidal. Offered follow up
.
Patient with history of severe non compliance with appointments
and medications as per [**Hospital1 756**] Records. Extensive teaching by
nursing, physicians and social work. Support and resources
offered. VNA and PT arranged. Repeatedly emphasized importance
of primary care. Daughter involved and trying to facilitate
ongoing healthcare. Medication usage extensively reviewd.
Discharge Medications:
1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Sennosides 8.6 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for constipation.
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
9. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
12. Insulin Aspart 100 unit/mL Cartridge Sig: Twenty (20) units
Subcutaneous three times a day: 10 minutes before each meal. do
not take if you are not going to eat.
13. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
14. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
four times a day as needed for shortness of breath or wheezing.
16. Atrovent HFA 17 mcg/Actuation Aerosol Sig: 1-2 puffs
Inhalation three times a day as needed for shortness of breath
or wheezing.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. Opiate abuse/overdose
2. Altered Mental Status
3. Depression
4. Type II DM, uncontrolled
5. Chronic diastolic heart failure
6. BOOP
7. NASH
8. Hypokalemia
9. Thrush
10. coagulopathy
11. Anemia
12. Hypertension
13. Acute renal failure
14. hyperlipidemia
Discharge Condition:
stable, mental status at baseline, afebrile
Discharge Instructions:
You must follow up with your primary care doctor and with
psychiatry.
If you develop fevers, chills, confusion or any other new
concerning symptoms contact your doctor.
Do not take any narcotics such as codeine, tylenol #3, percocet,
oxycodone, oxycontin, morphine, dilaudid and do not use and
illegal drugs.
Do not take any medications that are not on the list of your
discharge medications. If you are starting any medications,
you must let your primary care doctor know.
Followup Instructions:
Follow up with your primary care doctor, Dr. [**Last Name (STitle) 106620**] at [**Hospital1 **]. Call [**Telephone/Fax (1) 9251**] to make an appointment for later
this week or early next week.
If you would like to have a new primary care doctor here, call
[**Telephone/Fax (1) 1247**] to set up an appointment. Once you see the new
primary care doctor, they will help you set up a psychiatry and
social work appointment.
ICD9 Codes: 5849, 5715, 5859, 2720, 4280, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1059
} | Medical Text: Admission Date: Discharge Date: [**2188-4-11**]
Date of Birth: [**2188-3-24**] Sex: M
Service:NEONATOLOGY
PRIMARY DIAGNOSIS: Prematurity.
SECONDARY DIAGNOSIS:
1. Hyperbilirubinemia.
2. Resolved feeding immaturity.
3. Sepsis evaluation.
4. RDS resolved.
HISTORY OF PRESENT ILLNESS: [**Known lastname **] is a 1,495 gm male twin #2
born at 30 and 1/7 weeks by cesarean section due to preterm
labor and concerns of maternal infection to a 33-year-old G
1, now P 2 mother. The pregnancy was complicated by preterm
labor and question of urinary tract infection on [**2188-2-29**]
and was initially admitted to [**Hospital3 **]. She was
transferred to [**Hospital6 256**] and
treated with ampicillin, betamethasone and magnesium. She
remained inpatient on and off magnesium for preterm labor.
The day before delivery, she developed a fever to 103 and
shaking chills. Blood culture grew Gram negative rods, as
well as urine grew Gram negative rods. She was treated with
ceftriaxone. Given preterm labor, rupture of membranes and
concern for chorio prompted cesarean section on the day of
delivery.
In the delivery room, the baby emerged with a big cry. He was
given blow-by oxygen in the Delivery Room only. Apgars were
eight and eight. Prenatal screens B positive, antibody
negative, hepatitis survey antigen negative, rubella immune,
normal fetal survey.
PHYSICAL EXAMINATION: On admission to Neonatal Intensive
Care Unit was notable for inspiratory crackles and grunting,
flaring and retracting.
HOSPITAL COURSE BY SYSTEMS:
RESPIRATORY: On admission, the patient was intubated for
continued respiratory distress and received one dose of
Surfactant. He was extubated to CPAP by day of life two. By
day of life three, he was on nasal cannula and was able to
transition to room air by day of life nine. He required some
additional flow by nasal cannula shortly after, but has
remained on room air for the past seventy-two hours.
CARDIOVASCULAR: [**Known lastname **] has remained hemodynamically stable
after one normal saline bolus for perceived poor perfusion.
He has had stable blood pressures. He was started on caffeine
on day of life three. He remains on caffeine for occasional
bradycardiac spells and is currently on a dose of 10 mg
daily. [**Known lastname **] has between one and five bradycardiac spells per
day. He has never had a murmur.
FLUID/ELECTROLYTES/NUTRITION: He was initially started on 80
cc/kg/day of 10% dextrose solution. His daily fluids were
increased to 160 by day of life five for significant weight
loss greater than 10% of birth weight and then reduced to 130
cc/kg/day for concerns of reflux. He remains currently on 130
cc/kg/day. He was initially started on premature Enfamil
formula and now receives 28 calorie premature Enfamil formula
with ProMod. He receives vitamin E and iron. He has been on
reflux precautions for large spits that occur one to three
times per day. The mother plans to breast feed, but has had
to waste her breast milk for the past two weeks as she was on
ciprofloxacin for a continued bacteremia. The last
electrolytes were within normal limits. Glucose levels have
always been stable.
HEMATOLOGY: [**Known lastname **] was started on phototherapy on day of life
two. He had a peak bilirubin level on day of life four of 8.7
with a direct component of 0.5. Phototherapy was discontinued
on day of life six with a rebound the following day of 4.3
and 0.4. Initial hematocrit was 56 with a repeat of 55 on day
of life three. Platelets were 241 on day of life one.
INFECTIOUS DISEASE: [**Known lastname **] was started on ampicillin and
gentamycin on day of life one. Initial white blood count was
8.2 with 23% polys and 0% bands. He had a repeat white blood
count on day of life three for concerns of neutropenia that
showed a white blood count of 7.5 with 38% polys. He has
shown no concerns for infection.
NEUROLOGICAL: Head ultrasound on day of life nine was
normal. He still requires an eye examination when he is older
than 32 weeks.
ROUTINE HEALTH CARE MANAGEMENT: [**Known lastname **] has not received his
hepatitis B vaccine. He has not yet had his hearing test.
Newborn screen was last sent on [**2188-3-31**] and was all within
normal limits.
DISCHARGE DIAGNOSIS:
1. Prematurity.
2. Feeding immaturity.
3. Hyperbilirubinemia resolved.
4. RDS resolved.
DISCHARGE MEDICATIONS:
1. Caffeine citrate 10 mg p.o. PG daily.
2. Iron sulfate 0.1 cc p.o. PG daily.
3. Vitamin E five units p.o. PG daily.
DISCHARGE WEIGHT: On day of life sixteen, weight is 1,560
gm.
PHYSICAL EXAMINATION ON DISCHARGE: Anterior fontanel soft,
open and flat, normocephalic, atraumatic. Equal air entry
bilaterally with no grunting, flaring or retracting. Clear
breath sounds bilaterally. Regular rhythm and normal rate. No
murmur. Abdomen is soft, nontender, nondistended with
normoactive bowel sounds. 2+ femoral pulses. Normal male
genitalia with testes high in the canal. Warm and pink with
normal tone.
Reviewed By: [**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36250**]
Dictated By:[**First Name3 (LF) 55155**]
MEDQUIST36
D: [**2188-4-9**] 14:16
T: [**2188-4-9**] 14:31
JOB#: [**Job Number 55156**]
ICD9 Codes: 769, 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1060
} | Medical Text: Admission Date: [**2115-3-29**] Discharge Date: [**2115-3-29**]
Service: MEDICINE
Allergies:
Demerol
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Transfer from OSH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 87 y/o F with h/o CAD s/p CABG [**01**] who is transfered
from OSH after having PEA arrest s/p Right knee replacement.
.
Patient underwent Right knee replacement [**2115-3-28**] without aparent
complications. This morning at around noon patient went into
afib with RVR, diltiazem drip was started but after a bolus she
started droping her HR and BP, code blue was called, patient
received epinephrine, atropine x1 and was intubated.
There were no strips sent during the code. EKG were received and
it seems that patient had an inferior MI and also escape
junctional rhytm after the events. Echocardiogram was done that
showed dilated RV and given high suspicion for PE patient was
started heparin. Patient remained hypotensive levophed and
dopamine were started.
.
Patient transfered to [**Hospital1 18**] for further management.
Past Medical History:
1. CAD - s/p CABG two vessels [**2101-11-21**] LIMA--LAD, SVG -- OM1
2. HTN
3. Paget's disease
4. Hyperthyroidism
5. History of seizures
6. Paroxysmal SVT
7. Osteoarthritis
8. s/p Total abdominal histerectomy
9. s/p Right Knee replacement [**2115-3-28**]
Social History:
Lives at home. Daughter lives upstairs. Per prior records no
tobacco use. No alcohol abuse.
Family History:
No family history of CAD.
Physical Exam:
VS: SBP 60's. HR 80 externally paced, Sats 93%
AC 450/18/100/10
General: Patient intubated, sedated, pale
HEENT: pupiles dilated non reactive to light. Fixed. doll's
eyes. No JVD appreciated, no lymphadenopathy.
Oropharinx: ETT tube in placed. echymosis upper lip.
Lungs: clear to ausculation bilaterally.
Cardiovascular: distant heart sounds, regular rate rhytm, no
murmurs appreciated.
Abdomen: BS decreased, mildly distended. obese. No hepatomegaly.
Extremities: cold, clamy, cyanotic.
Pertinent Results:
[**2115-3-29**] 09:19PM LACTATE-12.3*
[**2115-3-29**] 09:19PM TYPE-ART O2-100 PO2-61* PCO2-30* PH-7.19*
TOTAL CO2-12* BASE XS--15 AADO2-641 REQ O2-100 -ASSIST/CON
INTUBATED-INTUBATED
[**2115-3-29**] 09:23PM PT-22.7* PTT-150* INR(PT)-2.2*
[**2115-3-29**] 09:23PM PLT COUNT-108*
[**2115-3-29**] 09:23PM WBC-21.4* RBC-4.26 HGB-12.6 HCT-38.2 MCV-90
MCH-29.6 MCHC-33.0 RDW-14.5
[**2115-3-29**] 09:23PM CALCIUM-7.0* PHOSPHATE-5.9* MAGNESIUM-2.7*
[**2115-3-29**] 09:23PM ALT(SGPT)-11 AST(SGOT)-81* LD(LDH)-699*
CK(CPK)-402* ALK PHOS-75 TOT BILI-0.8
[**2115-3-29**] 09:23PM estGFR-Using this
[**2115-3-29**] 09:23PM GLUCOSE-425* UREA N-10 CREAT-1.1 SODIUM-134
POTASSIUM-5.6* CHLORIDE-100 TOTAL CO2-16* ANION GAP-24*
.
EKG: Hr 53, junctional scape rhytm. St elevation III.
2D-ECHOCARDIOGRAM bed side echo: largely dilated RV. EF ~ 10-15%
Brief Hospital Course:
This is a 87 y/o with h/o HTN, CAD s/p CABG, s/p recent R knee
replacement c/b PEA arrest likely secondary to PE transfered for
further management.
# Hypoxemic Respiratory Failure: Patient with an elevatede A-a
gradient, FIo2 100% and PaO2 60, x ray with no clear evidence of
infiltrates, this is more likely secondary to pulmonary embolism
- continue vent support
- heparin drip
- midazolam - fentanyl drip
- recheck x ray after transfer for ETT tube
.
# Hypotension: Patient with severe hypotension on dopamin and
levophed drip on arrival. Likely secondary to poor cardiac
output secondary acute PE.
- continue IV fluids
- continue dopamin, levophed, and add vasopresin
- Bedside Echo
- holding all BP meds
- Stat labs - lactate
.
# Cardiac:
CAD: EKG from OSH showed st elevations in the inferior leads.
Last troponin 3.36
More likely demand ischemia in the setting of acute hypotension.
.
Rhytm: after external pacer was discontinued, patient with a
junctional escape rhytm.
- continue to monitor
.
Pump: cardiogenic shock
- Bed side echo
- continue dopamin, levophed
.
# Neuro: patient with fix dilated pupiles and dull eyes which
represent severe brain injury. Very poor likelyhood of recovery.
.
# Communication: daughter [**Name (NI) **] HCP - [**Telephone/Fax (1) 6621**] cell
[**Telephone/Fax (1) 6622**] (H), [**Telephone/Fax (1) 6623**] (w)
Addendum:
After patient evaluation, patient clinical status was discussed
with daughter [**Name (NI) **] at length. Given the poor prognosis of
recovery, worsening acidosis, poor neurological status
patient's code status is changed to DNR. No further scalation of
care. The patient died within 4 hours of admission to the
hospital.
Medications on Admission:
Medications on transfer:
Heparin drip
Fentanyl
Midazolam
Dopamin drip
Norepinephrine
Home Meds:
Fosamax 10 mg daily
aspirin 81 mg p.o/ day
phenobarbital 6.2 mg t.i.d.
quinapril 20 mg p.o/ day
metoprolol 37.5 mg p.o. b.i.d.
methimazole 5 mg q.a.m. alternating with 2.5 mg
Dilantin 100 mg p.o. t.i.d.
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
ICD9 Codes: 9971, 4275, 5185, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1061
} | Medical Text: Admission Date: [**2198-2-15**] Discharge Date: [**2198-2-23**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5827**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
R IJ central line placement
PICC line placement
History of Present Illness:
This is a [**Age over 90 **] yo M with COPD, PAF, dementia, with a recently
diagnosed bilateral PNA at nursing home who presents with
hypoxia. He was started on levofloxacin at the NH, changed to
CTX today. The pt was initially hypoxic to 80's on RA, placed on
4L NC, desated again to 80's, and then was placed on NRB satting
91% at NH.
.
In the ED the pts vitals were: T98 HR 110 BP 108/72 RR 20-26 Sat
95-100% on NRB. The pt was noted to have rhonchi on exam, rales
left base, otherwise speaking in short sentences, somewhat
labored breathing, sinus tachy. CXR showed dense confluent
airspace opacities, air bronchograms, butterfly distribution, no
significant cardiac enlargement, no vascular congestion. He
received 1 L NS, Ceftaz, Clindamycin, and Vanc in the ED. In
addition, he was noted to have an NSTEMI with CK 471, MBI 7.9,
and Tpn T 1.88. BNP was 25,131. His EKG however had no clear
changes. He was given ASA but no BB.
Past Medical History:
1. h/o Paroxysmal atrial fibrillation
2. HTN
3. h/o falls
4. BPH
5. L ear deafness
6. R eye cataracts s/p lens replacement
7. Arthritis bilateral knees and L hip
8. Mild dementia, unspecified type
Social History:
Mr. [**Known lastname 40370**] lives in the [**Hospital3 15333**]
facility. Daughter [**Name (NI) **] (work: [**Telephone/Fax (1) 40371**]) is his HCP.
Smoked for 30 years, [**1-21**] pack/day. Denied EtOH use. No recent
smoking or alcohol.
Family History:
Noncontributory.
Physical Exam:
T: 97 BP 100/63 P 94 RR 31 Sat 94% on 100% NRB
General: This is a elderly male, sitting up in bed, tachyneic,
oriented x3
HEENT: anisocoria w/ right pupil 3->2 mm and left 2->1 mm. EOMI
without nystagmus, anicteric; MMM, no erythema/exudate
Neck: supple, no JVD
Pulmonary: diffuse rales with end expiratory wheezing
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: trace BL ankle edema, 2+ radial, 1+DP and PT pulses
b/l
Neurologic: AAOx3. CNII-XII grossly intact. MAFE
Pertinent Results:
[**2198-2-15**] 10:15AM GLUCOSE-192* UREA N-31* CREAT-0.9 SODIUM-132*
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-24 ANION GAP-13
[**2198-2-15**] 10:15AM CK-MB-37* MB INDX-7.9* cTropnT-1.88*
proBNP-[**Numeric Identifier 32490**]*
[**2198-2-15**] 10:15AM CK(CPK)-471*
[**2198-2-15**] 11:22AM WBC-15.5*# RBC-4.38* HGB-13.1* HCT-40.4
MCV-92 MCH-29.8 MCHC-32.3 RDW-14.0
[**2198-2-15**] 11:22AM NEUTS-86.2* LYMPHS-9.9* MONOS-3.9 EOS-0
BASOS-0.1
[**2198-2-15**] 06:54PM CK-MB-18* MB INDX-6.2* cTropnT-2.94*
[**2198-2-15**] 06:54PM WBC-12.7* RBC-3.98* HGB-12.4* HCT-36.9*
MCV-93 MCH-31.1 MCHC-33.5 RDW-14.1
[**2198-2-15**] 11:22AM NEUTS-86.2* LYMPHS-9.9* MONOS-3.9 EOS-0
BASOS-0.1
.
ECHO:
Left Atrium - Long Axis Dimension: 3.5 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 5.1 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.4 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.3 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.7 cm
Left Ventricle - Fractional Shortening: 0.37 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 50% (nl >=55%)
Aorta - Valve Level: *3.9 cm (nl <= 3.6 cm)
Aortic Valve - Peak Velocity: 1.0 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A Ratio: 1.33
Mitral Valve - E Wave Deceleration Time: 250 msec
TR Gradient (+ RA = PASP): *26 mm Hg (nl <= 25 mm Hg)
Pulmonic Valve - Peak Velocity: 1.0 m/sec (nl <= 1.0 m/s)
INTERPRETATION:
Findings:
This study was compared to the report of the prior study (images
not
available) of [**2196-1-25**].
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. No
resting LVOT
gradient. No VSD.
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
Paradoxic septal motion consistent with conduction
abnormality/ventricular
pacing.
AORTA: Mildly dilated aortic sinus.
AORTIC VALVE: ?# aortic valve leaflets. Mildly thickened aortic
valve
leaflets. No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Mild (1+) MR. [Due to acoustic shadowing, the
severity of MR
may be significantly UNDERestimated.]
TRICUSPID VALVE: Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: No PS.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions:
Sub-optimal image quality. The left atrium is normal in size.
There is mild
symmetric left ventricular hypertrophy with normal cavity size.
The [**Year (4 digits) **]
wall appears hypokinetic in some views (limited by poor image
quality).
Overall LVEF is probably preserved/mildly reduced. There is no
ventricular
septal defect. The right ventricular cavity is mildly dilated.
Right
ventricular systolic function is normal. The aortic root is
mildly dilated at
the sinus level. The number of aortic valve leaflets cannot be
determined. The
aortic valve leaflets are mildly thickened. There is no aortic
valve stenosis.
No aortic regurgitation is seen. The mitral valve leaflets are
mildly
thickened. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.]
There is mild pulmonary artery systolic hypertension. There is
no pericardial
effusion.
Compared with the report of the prior study (images unavailable
for review) of
[**2196-1-25**], the [**Year (4 digits) **] wall now appears hypokinetic. If
clinically indicated, a
repeat study with echo contrast (Definity) may better
characterize
regional/global LV systolic function.
.
CXR:
There are dense, confluent air space
opacities, with prominent air bronchograms, involving both
parahilar regions
and the medial aspect of the right lung base, in a somewhat
"butterfly"
distribution. However, there is no significant cardiac
enlargement and no
pleural effusion or gross pulmonary vascular congestion is
identified. There
are atherosclerotic changes involving the thoracic aorta.
IMPRESSION: Multifocal air space process with overall
appearance more
suggestive of extensive pneumonic consolidation than pulmonary
edema.
Brief Hospital Course:
Mr. [**Known lastname 40370**] is a [**Age over 90 **] year old male with COPD, PAF, dementia,
with a recently diagnosed bilateral PNA at nursing home who
presents with hypoxia and pneumonia vs. pulmonary edema and
found to have an NSTEMI.
.
1. Hypoxia: The patient's chest film findings were more
consistent with pneumonia than pulmonary edema. However, both
infection and heart failure were considered as etiologies for
his hypoxia. He initially required an non-rebreather for
adequate oxygenation. He was given ceftriaxone and vancomycin
the emergency room and once in the MICU he was converted to
vancomycin and zosyn for broader coverage given his continued
hypoxia and hypotension. He slowly improved and was weened down
to 4L NC. Given his initially hypotension, he was given many
boluses of IVF and eventually developed pulmonary edema. This
was treated with furosemide with good resolution. He was
discharged with a continued oxygen requirement of 3L nasal
cannula with oxygen saturation in the mid-90s%. Subsequent doses
of furosemide were not found to improve his oxygenation and
indeed may run the risk of dehydrating him. His hypoxia is
likely to resolve only as the pneumonia resolves. The patient
also was started on standing ipratropium nebulizer to improve
his respiratory status.
.
2. Pneumonia: As stated above, the patient was treated with
broad spectrum antibiotics on admission and in the ICU. His
blood cultures were negative, however, his sputum culture
contianed E.Coli that was broadly resistant (ESBL). See results
section for details. Although the culture was sensitive to
pipercillin/tazobactam, it was resistant to piperacillin alone,
and therefore there was a concern that it would develop
resistance to piperacillin alone. The patient was therefore
switch to meropenem, which he will require IV for at least a two
week course. Determination of the full length of course will be
determined by his primary physician, [**Name10 (NameIs) **] on his clinical
improvement. Because he had a highly resistant form of E.Coli,
he was switch to contact precautions while on the floor.
.
3. NSTEMI: Pt has elevated cardiac enzymes with CK 471-->291,
Tpn 1.88-->2.94. No clear EKG changes. Cardiology was consulted
and recommended starting a heparin gtt and giving a plavix load.
He was given aspirin and atorvastatin. It was thought that he
more likely had the NSTEMI in the setting of infection and
tachycardia causing a demand ischemia. The heparin gtt was
stopped and he was not continued on plavix. He was initially
not given a beta blocker or an ACEI given his hypotension. Once
this resolved, his rate allowed for metoprolol 12.5mg TID, but
his blood pressures were still on the low side and for this
reason, an ACEI was not started. He had an ECHO done which was
a poor study but showed 1+MR [**First Name (Titles) 151**] [**Last Name (Titles) **] wall hypokinesis and a
relatively preserved EF. He was continued on metoprolol,
aspirin, and statin.
.
4. PAF: patient had transient episodes of PAF. The risks for
starting coumadin seem to outweigh the benefits of
anticoagulation in this demented elderly patient at high risk
for falls.
.
5. ARF: His creatinine rose after using furosemide to help with
his pulmonary edema. Given this time course, his ARF was likely
secondary to this diuresis. His Cr was continued to be
monitored. On discharge, his creatinine had returned to his
baseline level of 0.8.
.
6. GU: On the morning of discharge, the patient's urine was
noted to be quite concentrated. He had a foley in throughout his
stay. A U/A and urine culture was sent and results were pending
at time of discharge. The patient is being discharged on
meropenem, which is broadly active against urinary tract
pathogens. However, if a resistant bacteria is found on urine
culture, the [**Hospital 228**] nursing home will be contact[**Name (NI) **]. The
patient's foley was changed out. He failed to void after three
hours and in the interest of smooth transition of care, a foley
was replaced. However, a voiding trial should be considered as
soon as feasible at the [**Hospital 228**] nursing home. For the
patient's BPH he was continued on finasteride.
.
7. Lines: The patient has a right arm PICC line which was placed
on [**2198-2-23**]. The patient self-dc'd this PICC line earlier in his
stay. Thus, every attempt should be made to protect this PICC by
heavy wrapping with gauze. The patient's Foley was replaced on
[**2198-2-23**].
.
#Dementia/Psych: He was continued on his home doses of aricept,
celexa
.
#Speech and swallow: The patient had a speech and swallow eval
which found that he could tolerate thin liquids and ground
consistency solids. No straws. Dentures should not be worn
during meals given loose fit and risk of choking. Pills can be
given whole with puree. Finally, "if fixodent adhesive could be
brought for patient, he could be advanced to regular solids once
his pneumonia has cleared."
The patient was noted to have some trouble at times with whole
pills in puree and pills should be ground up if he demonstrates
ongoing aspiration risk.
.
#Contact: Daughter, [**Name (NI) **], [**Telephone/Fax (1) 40372**]
.
#DNR/DNI
.
Medications on Admission:
-Aricept 10mg qHS
-ASA 325mg daily
-Citalopram 10 mg daily
-Vitamin B12 q month
-Finasteride 5 mg daily
-Metamucil
-Tylenol 1g tid
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day): Hold for SBP<100, HR<60.
10. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by
2 ml of 100 Units/ml heparin (200 units heparin) each lumen
Daily and PRN. Inspect site every shift.
11. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q8H (every 8 hours) for 2 weeks: Full course to be
determined by covering physician.
12. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Primary:
Pneumonia
Non-ST elevation myocardial infarction
.
Secondary:
Dementia
BPH
Discharge Condition:
Stable
Requires assistance ambulating
Require supplemental O2
Requires assistance taking pills.
Discharge Instructions:
The patient was hospitalized with pneumonia and coronary
ischemia. He improved with antibiotics, however he still
requires supplemental oxygen to maintain normal saturation. He
also will require an extended course of at least two weeks of
meropenem. Full extent of the course of antibiotics depends on
patient's clinical improvement, as determined by his clinician.
Followup Instructions:
Follow-up care will be managed by your primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **], or by other doctors in the [**Hospital3 4262**] Group.
Completed by:[**2198-2-23**]
ICD9 Codes: 5849, 4280, 5070, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1062
} | Medical Text: Unit No: [**Unit Number 59010**]
Admission Date: [**2139-1-31**]
Discharge Date: [**2139-2-14**]
Date of Birth: [**2060-11-11**]
Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 78 year old
gentleman with a past medical history significant for
cerebrovascular accident, mechanical valve replacement and
coronary artery bypass graft who was admitted to [**Hospital1 346**] status post a subarachnoid
hemorrhage. The patient developed headache two days prior to
admission with worsening confusion, presented to an outside
hospital where a head CT showed a subarachnoid hemorrhage
centered around the left sylvian fissure. There was a
question of a ruptured aneurysm. The patient was transferred
to [**Hospital3 **] for further management. Patient had a
cerebrovascular accident in [**2138**] with aphasia and word
finding difficulties as his only baseline residual.
PAST MEDICAL HISTORY: Also includes rheumatic heart disease,
coronary artery bypass graft.
ALLERGIES: No known allergies.
PHYSICAL EXAMINATION: His blood pressure was 101/39, heart
rate was 58, respiratory rate 15, saturations 98 percent. In
general he was in no acute distress, calm. Head, eyes, ears,
nose and throat: His pupils are equal, round and reactive to
light. Neck was supple. Cardiovascular: Regular rate and
rhythm. Lungs clear to auscultation. Abdomen soft,
nontender, nondistended, positive bowel sounds. Extremities:
No clubbing, cyanosis or edema. Neurologic: Awake, alert
and oriented times three with word finding difficulties,
fluent aphasia. Cranial nerves grossly intact. Strength
was 5 out 5 in all muscle groups.
He was admitted to the Intensive Care Unit for close
neurologic observation. He was on Coumadin for his
mechanical valve on admission and his INR was 2.8 on
admission. Anticoagulation was stopped and reversed on
admission. Cardiology was consulted to assess the risk of
leaving off anticoagulation versus mechanical valve
thrombosis. It was felt the patient could be off
anticoagulation for a week safely. The patient was taken to
angio to rule out aneurysm which was negative. Post angio he
was awake, alert and oriented. His groin site was clean, dry
and intact with no hematoma. He continued to be monitored in
the Intensive Care Unit. He did have a new onset of atrial
fibrillation on [**1-30**] with left bundle branch block.
Neurology was also consulted regarding when it was safe to
restart Coumadin. They felt the patient could be safely off
for one to two weeks. The patient continued to be monitored
in the Intensive Care Unit and remained neurologically
stable. Patient had repeat head CT on [**2139-2-1**]. This
showed increase in the left temporal lobe hemorrhage.
Therefore, all anticoagulation was held and the patient's INR
was corrected to normal. The patient had a transesophageal
echocardiography. Transesophageal echocardiography was
negative for any clots around his valves. Neurology
continued to follow the patient. On [**2139-2-5**] the patient was
taken back for repeat angio to assess for possible aneurysm
or vasospasm. The patient did have some left middle cerebral
artery vasospasm which was treated with papaverine intra-
arterially. There was no evidence of aneurysm. The patient
continued to be intubated but opening his eyes, attending to
examiner, squeezing well on the left, moving all extremities.
He continued to have plegia in the right upper extremity,
moving the left upper extremity spontaneously. His left side
moved spontaneously. His right side at times moves to
command and at other times does not. The patient had bedside
swallowing evaluation which he failed and a PEG was placed on
[**2139-2-13**]. He has remained neurologically stable. He will
follow up with Dr. [**Last Name (STitle) 739**] in two weeks with a repeat
head CT.
His medications at the time of discharge include Dilantin 200
mg per PEG B.I.D., famotidine 20 mg per PEG B.I.D.,
metoprolol 50 per PEG t.i.d., Lasix 20 mg per PEG daily,
hydralazine 10 mg per PEG q 6 hours, amlodipine 60 mg P.O. q
4 hours, Pravastatin 20 mg per PEG daily, levofloxacin 500 mg
per PEG q 24 hours, digoxin 0.125 mg daily, may be switched
to P.O. daily.
CONDITION ON DISCHARGE: Stable at the time of discharge.
FOLLOW UP: With Dr. [**Last Name (STitle) 739**] in two weeks with a repeat
head CT.
[**Name6 (MD) **] [**Name8 (MD) 739**], MD [**MD Number(2) 2930**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2139-2-13**] 16:24:37
T: [**2139-2-13**] 17:18:10
Job#: [**Job Number 59011**]
ICD9 Codes: 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1063
} | Medical Text: Admission Date: [**2101-8-31**] Discharge Date: [**2101-9-14**]
Date of Birth: [**2034-12-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
jaw pain
Major Surgical or Invasive Procedure:
[**2101-8-31**] Cardiac catheterization
[**2101-9-5**] Unsuccessful PCI of RCA total occlusion
[**2101-9-8**] 1. Coronary artery bypass grafting x3 with a free left
internal mammary artery from the [**Doctor Last Name **] of the diagonal
vein graft to the left anterior descending coronary
artery; reverse saphenous vein single graft from the
aorta to thefirst diagonal coronary artery; as well as
reverse saphenous vein single graft from the aorta to
the distal right coronary artery.
2. Endoscopic right greater saphenous vein harvesting.
3. Epi-aortic duplex scanning.
History of Present Illness:
This 66 year old white male has had
two episodes of jaw and arm pain, one with exertion and one with
rest. He had an ETT today which showed ST depressions at rest
and significant ST and T changes during recovery. He had a
troponin which was 0.2 and he was transferred from the [**Location (un) 620**]
ED
to [**Hospital1 18**] for cardiac cath.
Past Medical History:
Hypertension
Peripheral [**Hospital1 1106**] disease
bilateral carotid stenosis
glaucoma
psoriasis
Social History:
He is married. He is a retired contractor electrician
Lives with spouse
-[**Name (NI) 1139**] history: quit 2 years ago, 35 pack year history.
-ETOH: None
-Illicit drugs: None
Family History:
non-contributory
Physical Exam:
VS: Temperature not recorded. 140/88, 95, 18, 97% onRA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, no JVD. Bilateral carotid bruits R>L.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No thrills, lifts. No S3 or S4. [**3-18**]
systolic murmur best heard at RUSB.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 1+ PT 1+
Left: Carotid 2+ DP 1+ PT 1+
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 105200**] (Complete)
Done [**2101-9-8**] at 1:05:37 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2034-12-9**]
Age (years): 66 M Hgt (in): 72
BP (mm Hg): / Wgt (lb): 188
HR (bpm): BSA (m2): 2.08 m2
Indication: Chest pain. Coronary artery disease. Mitral valve
disease. Shortness of breath.
ICD-9 Codes: 786.05, 440.0, 424.0
Test Information
Date/Time: [**2101-9-8**] at 13:05 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 32862**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW02-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *6.0 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.5 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 45% to 55% >= 55%
Aorta - Ascending: *3.9 cm <= 3.4 cm
Findings
LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo
contrast or thrombus in the LA/LAA or the RA/RAA. No
mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Low normal LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Mildly dilated ascending aorta.
Normal aortic arch diameter. Simple atheroma in aortic arch.
Normal descending aorta diameter. Simple atheroma in descending
aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. Mild to moderate ([**1-14**]+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications. The patient appears to be in sinus rhythm.
patient. See Conclusions for post-bypass data
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-BYPASS:
The left atrium is moderately dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium/left
atrial appendage or the body of the right atrium/right atrial
appendage. No mass/thrombus is seen in the left atrium or left
atrial appendage.
No atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thicknesses are normal.
Overall left ventricular systolic function is low normal (LVEF
45-55%). The mid latera is hypokinetic.
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. There are simple atheroma
in the aortic arch. There are simple atheroma in the descending
thoracic aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. There is no aortic valve stenosis. No
aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**1-14**]+) mitral regurgitation is seen.
There is no pericardial effusion.
Dr. [**Last Name (STitle) 914**] was notified in person of the results on [**Known firstname 122**]
[**Known lastname **] before incision..
POST-BYPASS:
The patient is not receiving any inotropic support post-bypass.
Preserved biventricular systolic function. LVEF 55%. The Circ
distribution remains mildly hypokinetic. The aorta is intact
post-decannulation. All findings communicated to surgeon
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2101-9-8**] 21:05
Brief Hospital Course:
Transferred from outside hospital for cardiac catherization,
which revealed coronary artery disease. He was referred for
surgical evaluation. After review of films by surgery and
cardiology the decision was to attempt PCI. The PCI however was
unsuccessful and he underwent preoperative workup and plavix
washout. However he developed chest pain and was transferred to
the CCU [**2101-9-8**] which resolved with treatment. He was taken to
the operating urgently [**9-8**] due to chest pain for coronary
artery bypass graft surgery. See operative report for further
details. He received vancomycin for perioperative antibiotics
because he was in the hospital preoperatively. In the first
twenty four hours he was weaned from sedation, awoke
neurologically intact and was extubated without complications.
He remained in the intensive care unit due to hypotension
requiring neosynephrine. He developed atrial fibrillation that
was treated with amiodarone and betablockers. He did convert
back into normal sinus rhythm on amiodarone. Physical therapy
worked with him on strength and mobility. He was transferred to
the floor on post operative day three for the remainder of his
care. Mr. [**Known lastname **] was gently diuresed toward his pre-operative
weight. He was ready for discharge home with services on post
operative day six.
Medications on Admission:
MEDICATIONS ON TRANSFER:
Amlodipine 5mg daily
Lisinopril 10mg daily
Simvastatin 20mg daily
Aspirin 325mg daily
Xalatan 0.005% drop gtt OU qhs
timolol 0.5% drop gtt [**Hospital1 **]
Plavix 600mg x 1 @ 13:15
heparin gtt
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
Disp:*qs qs* Refills:*0*
6. Xalatan 0.005 % Drops Sig: One (1) drop each eye Ophthalmic
at bedtime: 1 drop each eye .
Disp:*qs qs* Refills:*0*
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*2*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO ONCE (Once) for 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day:
take one pill (200mg) two times daily for seven days, then take
one pill daily.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
Coronary artery disease s/p cabg
Non ST elevation myocardial infarction
Post operative atrial fibrillation
Severe peripheral [**Hospital1 1106**] disease.
Severe cerebrovascular disease.
Left-sided subclavian steal syndrome.
Claudication
Hypertension
Peripheral [**Hospital1 1106**] disease
bilateral carotid stenosis
glaucoma
psoriasis
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Dr [**Last Name (STitle) 914**] (cardiac surgeon) in 4 weeks [**Telephone/Fax (1) 170**]
Dr [**Last Name (STitle) **] (PCP) in [**1-14**] weeks [**Telephone/Fax (1) 6163**]
Dr [**Last Name (STitle) **] (cardiologist) in [**1-14**] weeks
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD ([**Last Name (NamePattern4) 1106**]) Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2102-1-16**] 10:30
Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2102-1-16**]
10:00
Completed by:[**2101-9-14**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1064
} | Medical Text: Admission Date: [**2103-5-17**] Discharge Date: [**2103-5-28**]
Service:
ADDENDUM - DISCHARGE DIAGNOSES:
1. Myocardial infarction.
2. Coronary artery disease.
3. Hypertension.
4. Anemia.
5. Depression.
DISCHARGE MEDICATIONS:
1. Coated aspirin 325 mg po qd.
2. Plavix 75 mg po qd.
3. Atorvastatin 80 mg po qd.
4. Metoprolol XL 25 mg po qd.
5. Valsartan 160 mg po qd.
6. Amlodipine 5 mg po qd.
7. Sublingual Nitroglycerin 0.3 mg po q 5 min, up to 3
tablets, prn angina.
8. Sertraline.
9. Vitamin B12 50 mcg po qd.
10.Calcium acetate 667 mg po tid with meals.
11.Calcium carbonate 600 mg po bid in between meals.
12.Vitamin 400 U po qd.
13.Colace 100 mg po bid prn constipation.
14.Bisacodyl 10 mg po qd prn constipation.
15.Coumadin 2.5 mg po q hs.
FOLLOW-UP PLANS:
1. Have spoken with Dr. [**Last Name (STitle) 51717**], patient's primary
care physician, [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 3658**], to follow-up with patient
regarding INR levels in next few days. The patient will call
for an appointment.
2. She will also follow-up with Dr. [**Last Name (STitle) 1295**] in [**Location (un) 47**] in
the next 3-4 weeks for cardiology.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 1606**]
MEDQUIST36
D: [**2103-5-28**] 09:24
T: [**2103-5-28**] 09:32
JOB#: [**Job Number 55011**]
ICD9 Codes: 4280, 4271, 2875, 5849, 5990, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1065
} | Medical Text: Admission Date: [**2174-8-9**] Discharge Date: [**2174-8-12**]
Date of Birth: [**2110-9-30**] Sex: M
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is a 53-year-old
gentleman with history of hypertension and diabetes who
presents with one week of progressive headache. He did have
workup with a neurologist at an outside hospital that showed
an MRI showing a large right subdural hematoma. He reports
that this headache started approximately one week ago,
described as "an ice-cream freeze." He has no loss of
consciousness. The patient began taking Tylenol and
indomethacin, which did not provide much relief. He does
report hitting his head on the porch while underneath it,
approximately three weeks ago. He does report some blurry
vision out of his left eye for the last few weeks.
PAST MEDICAL HISTORY: Angina.
Diabetes.
Depression.
Gout.
Hypertension.
MEDICATIONS: Medications at the time of admission were,
1. Diazepam.
2. Folic acid.
3. Atenolol.
4. Glipizide.
5. Lipitor.
6. Paxil.
7. Indomethacin.
8. Aspirin.
ALLERGIES: He has no known drug allergies.
REVIEW OF SYSTEMS: No shortness of breath. Some headache
and chest discomfort.
PHYSICAL EXAMINATION: Blood pressure was 190/94, heart rate
was 64, respiratory rate 16, and O2 saturation was 98
percent. He was alert and oriented. Head was normocephalic,
atraumatic. Heart showed regular rate and rhythm. Lungs
were clear to auscultation bilaterally. Abdomen was soft.
Neurologic exam: Cranial nerves II through XII were grossly
intact. Strength was [**3-23**] throughout the upper and lower
extremities. He had no pronator drift. Finger-to-nose was
done well. He had no clonus. He had good sensation to light
touch in the upper and lower extremities. Deep tendon
reflexes were 2 plus bilaterally at triceps, knees; and
plantars were flexor.
RADIOGRAPHIC DATA: He did have a CAT scan, which showed a
large right subdural hematoma with a midline shift. The
hematoma appeared chronic in nature, not acute.
LABORATORY DATA: His admission labs showed white count of
6.9, hematocrit of 40.4, and platelets of 236. Sodium 138,
potassium 4.9, chloride 105, bicarbonate 22, BUN 22,
creatinine 1.2, and glucose 111. PT was 12.3, PTT was 24,
and INR was 1.
HOSPITAL COURSE: The patient was admitted to the
Neurosurgical Service. His blood pressure was kept less than
140, starting with a Nipride drip. He was loaded with
Dilantin for seizure prophylaxis. He was admitted to the
Intensive Care Unit for every one-hour neurologic checks for
close monitoring. He did have EKG, which was within normal
limits; and he had cardiac enzymes, which were negative. He
did have a frontal subdural drain placed, which did drain a
chronic-appearing hematoma. He tolerated the procedure well.
The drain was kept in place until [**2174-8-11**], when it was
removed without difficulty. The patient had continued to be
neurologically intact throughout all this time. After the
drain was removed, he had a repeat CAT scan, which continued
to show good resolution of the subdural hematoma. He was
transferred to the floor. He continued to do well, was on
physical therapy, and was discharged to home on [**2174-8-12**]. He
is scheduled to follow up with Dr. [**Last Name (STitle) 1327**] in approximately
two weeks for staple removal and repeat CAT scan of the head.
DISCHARGE MEDICATIONS:
1. Tylenol p.r.n.
2. Atenolol 50 mg q.d.
3. Folic acid 1 mg 2 tablets q.d.
4. Dilantin 100 mg t.i.d. for 5 more days.
5. Glipizide 5 mg 1 p.o. q.d.
6. Paxil 20 mg p.o. q.d.
DISCHARGE DIAGNOSIS: Subdural hematoma, neurologically
stable.
OTHER DIAGNOSES: Hypertension.
Depression.
Diabetes.
Gout.
Angina.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 12001**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2174-8-12**] 11:08:11
T: [**2174-8-12**] 12:49:02
Job#: [**Job Number 56867**]
ICD9 Codes: 2749, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1066
} | Medical Text: Admission Date: [**2176-7-5**] Discharge Date: [**2176-7-7**]
Service: SURGERY
Allergies:
Amoxicillin / Penicillins / Coumadin / Oxycodone / Megestrol
Acetate / Remeron / Ritalin
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
Free air on CXR
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 87 y/o male with extensive past medical history who
was recently discharged after admission for possible
meningitis/altered mental status. During that admission the
patient was found to be a significant aspiration risk and a
G-tube was placed by interventional radiology. He was discharged
to [**Hospital **] rehab in good condition off all antibiotics on [**7-4**].
He
presents today after a routine CXR was performed at [**Hospital **] rehab
which demonstrated free intra-abdominal air beneath the right
hemidiaphragm. The patient was subsequently transfered to [**Hospital1 18**]
for evaluation. At the time of presentation he was in no acute
distress, without complaints of pain, nausea/vomiting,
fever/chills. He had a suprapubic catheter which was
functioning
appropriately as well as a flexi-seal rectal tube which was
collecting appropriate volumes of stool.
Past Medical History:
-DM II, on insulin
-prostate CA s/p XRT [**2156**]
-chronic urinary incontinence, s/p TURP [**10-6**]
-history of UTIs, including prior MRSA, klebsiella, proteus,
pseuduomonas
-s/p bladder rupture and repair x2, [**2-8**], [**6-8**]
-atrial fibrillation, not anticoagulated due to h/o bleeding
-hyperthyroidism
-depression
-hypertension
-moderate aortic stenosis on TTE [**5-/2176**]
-peripheral vascular disease
-h/o CVA [**2172**]
-severe chronic axonal neuropathy, radiculopathy and plexopathy
(due to XRT) per Dr. [**Last Name (STitle) **], with right foot drop for many
years
-L3 compression fracture
-cataract s/p bilateral laser surgery, also with "macular edema"
s/p dexamethasone injection
-hard of hearing
-left thyroid nodule, benign
Social History:
Smoked 2 ppd tobacco x24 years. Quit in [**2137**]. Denies EtOH.
Former WWII vet. Former Fire Fighter. Wife is HCP. Daughter is
RN, son is engineer.
Family History:
No illnesses, strokes, DM or early heart attacks run in the
family.
Physical Exam:
On Admission
GEN: NAD
HEENT: AT/NC, EOMI, neck supple, trachea midline
CV: Irregular, no m/g/r
RESP: CTAB
ABD: soft, non-tender, non-distended, no rebound, no guarding,
no
external evidence of injury, no gross masses, midline
infra-umbilical incision well healed. L midline; G-tube secured,
no surrounding erythema or discharge. Suprapubic catheter,
secured, no discharge/erythema. Rectal tube in place
EXT: no C/C/E
TLD: R PICC
Pertinent Results:
[**2176-7-4**] 05:55AM BLOOD WBC-5.8 RBC-2.50* Hgb-7.5* Hct-23.8*
MCV-95 MCH-29.8 MCHC-31.3 RDW-17.1* Plt Ct-396
[**2176-7-4**] 05:55AM BLOOD Plt Ct-396
[**2176-7-4**] 05:55AM BLOOD Glucose-116* UreaN-31* Creat-1.7* Na-147*
K-4.3 Cl-118* HCO3-23 AnGap-10
[**2176-7-4**] 05:55AM BLOOD Calcium-8.0* Phos-2.5* Mg-2.2
Radiology Report CHEST (PA & LAT) Study Date of [**2176-7-5**] 2:22 PM
FINDINGS: Comparison made to 5/28/200, and to fluoroscopy from
GJ tube
placement [**2176-7-3**].
Free intraperitoneal air under both hemidiaphragms is not
unexpected following recent G-tube placement. Cardiomediastinal
contours are unchanged. The lungs are grossly clear and well
expanded. Right PICC terminates in the mid SVC. There is no
pleural effusion or pneumothorax.
Radiology Report CHEST (PA & LAT) Study Date of [**2176-7-6**] 2:22 PM
FINDINGS: There is a moderate amount of free air seen under the
right
hemidiaphragm extending across the midline. The amount on the
right is
similar compared to prior. The amount on the left is slightly
less. _____
tube is again seen over the left upper quadrant. There is patchy
atelectasis in the left lower lung. The right subclavian PICC
line is unchanged.
Brief Hospital Course:
Pt admitted to observation due to free air seen on CXR s/p PEG
placement. Abdominal exam benign during hospital course. Free
air stable on serial CXR. Tube feeds via g-tube resumed and
advanced and tolerated well. Pt discharged back to rehab
facility [**2172-7-5**].
Medications on Admission:
1. Phenytoin 125 mg/5 mL Suspension Sig: One (1) PO TID (3
times a day).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
7. Insulin Glargine 100 unit/mL Cartridge Sig: Six (6) Units
Subcutaneous at bedtime.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. Phenytoin 125 mg/5 mL Suspension Sig: One [**Age over 90 **]y Five
(125) mg PO TID (3 times a day).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
4. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) as needed for fungus.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
6. Colace 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO twice a
day as needed for constipation.
7. Lantus 100 unit/mL Solution Sig: Six (6) Units Subcutaneous
at bedtime.
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units SC Injection TID (3 times a day).
10. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Free air on CXR s/p G-tube placement
Discharge Condition:
Good
Discharge Instructions:
Please call your surgeon if you develop chest pain, shortness of
breath, fever greater than 101.5, severe abdominal pain or
distention, persistent nausea or vomiting, inability to eat or
drink, or any other symptoms which are concerning to you.
Activity: No heavy lifting of items [**11-14**] pounds until the
follow up appointment with your doctor.
Medications: Resume your home medications. You should take a
stool softener, Colace 100 mg twice daily as needed for
constipation. Pain medication may make you drowsy. No driving
while taking pain medicine.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7025**], MD Phone:[**Telephone/Fax (1) 5285**]
Date/Time:[**2176-8-8**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**]
Date/Time:[**2176-8-9**] 11:00
Please call the office of Dr.[**Last Name (STitle) **] at ([**Telephone/Fax (1) 9000**] to schedule
a follow-up appointment.
ICD9 Codes: 2762, 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1067
} | Medical Text: Admission Date: [**2136-5-14**] Discharge Date: [**2136-5-20**]
Date of Birth: [**2091-10-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 25876**]
Chief Complaint:
Fever and left abdominal pain, transfer to [**Hospital Unit Name 153**] for hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
44 yo M with metastatic melanoma s/p recent biochemotherapy
initiation (cisplatin/vincristine, IL-2, DTIC, IFN) on [**5-8**] who
presented last night with complaints of fevers, chills, and
abdominal pain. He was d/c'd on [**5-9**] and had fever and vomiting
but symptoms at that time were felt to be secondary to his
chemotherapy. He was on cephalexin 500 mg po tid during that
admission. (He also had an admission from [**Date range (1) 21389**] for
initiation of cycle 1 of biochemotherapy
cisplatin/vincristine/Dacarbazine/IL-2/IFN. During that
admission, his goal SBP was 80's and baseline likely 90-100). He
was admitted last night from clinic last night with fevers to
104 and also described having abdominal pain since his
discharge. This pain had been in control with his morphine. He
denies any nausea, vomiting, but does have a lot of diarrhea.
.
Overnight, his BP fell from 107/55 to 86/58 at 4:30 AM. He was
started on IVF and was given over 4L IVF and his BP remained
69/51. He was mentating throughout this whole episode and no
urine output was recorded and the patient doesn't remember how
much he urinated. He was transferred to the [**Hospital Unit Name 153**] for further
care. Prior to transfer to the [**Hospital Unit Name 153**], he had a lot of green
colored diarrhea and this was noted to be guiac negative.
Past Medical History:
Metastatic melanoma to lungs, liver, spleen, dx'd 4 wks ago as
stage IV. Presented with mole on back in [**2130**]
Social History:
SOCIAL HISTORY: He lives in [**Location **] in Great [**Country 65588**]. He is
married, with two children. He has two brothers. [**Name (NI) **] denies
smoking and drinks alcohol only socially
Family History:
FAMILY HISTORY: His mother is healthy and his father- is
unknown whether he had cancer or not.
Physical Exam:
Tm 104.6 Tc 98.1 HR 97 BP 89/59 (MAP 60) RR 20 O2 99% RA
Gen: AAOX3. lying in bed in NAD
Skin: no rashes noted everywhere
HEENT: PEERLA, dry MM, perrla, neck supple, no oral erythema
Lungs: Clear to auscultation bilaterally
Heart: RR, s1-s2 normal,
Abd: soft, tenderness to palpation diffusely in more in LLQ but
no rebound or guarding. Palpable liver and spleen.
Ext: No edema, distal pulses strong bilaterally.
Neuro: AOx3 CN II-XII intact
Pertinent Results:
Abdominal CT -
1. Multiple low attenuation lesions within the liver and spleen
with
splenomegaly, unchanged compared to prior study, with no
evidence of splenic bleed or free fluid.
2. Multiple pulmonary nodules consistent with metastatic
disease, unchanged.
3. Multiple peritoneal implants, unchanged, consistent with
metastatic disease.
4. slightly enhancing wall seen within the sigmoid colon as well
as descending colon that appeared present on prior study.
.
Abdominal U/s
1. Significant amounts echogenic material in the gallbladder
that likely represents sludge.
2. A 7-mm gallbladder wall lesion that could be a gallbladder
wall metastasis Vs. a polyp. There is no evidence for
cholecystitis.
AP single view of the chest has been obtained with the patient
in upright position and comparison is made with a similar
preceding study obtained on [**2136-5-13**]. Identified is a
right-sided PICC line seen to terminate in the lower SVC some 2
cm below the level of the carina. There is evidence of bilateral
pleural effusions blunting the lateral pleural sinuses
apparently slightly more on the right than the left. The
accessible lung fields do not demonstrate any pulmonary vascular
congestion and there is no evidence for any new parenchymal
abnormality. Bilateral there is no evidence of any apical
pneumothorax.
.
Abdomen X ray
FINDINGS: Supine and upright portable abdominal radiographs
demonstrate normal caliber large and small bowel. A small amount
of air is noted within the rectum. There is no evidence of
obstruction and no free intra-abdominal air is seen. Osseous and
surrounding soft tissue structures are unremarkable.
IMPRESSION: Normal caliber bowel without evidence of
obstruction.
[**2136-5-14**] 11:05AM BLOOD WBC-13.5* RBC-4.59* Hgb-12.4* Hct-38.1*
MCV-83 MCH-27.0 MCHC-32.5 RDW-14.7 Plt Ct-261
[**2136-5-16**] 04:30AM BLOOD WBC-19.8* RBC-3.47* Hgb-9.8* Hct-29.2*
MCV-84 MCH-28.3 MCHC-33.6 RDW-15.3 Plt Ct-267
[**2136-5-14**] 11:05AM BLOOD Neuts-77* Bands-2 Lymphs-14* Monos-6
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Other-1*
[**2136-5-15**] 09:18AM BLOOD Fibrino-395 D-Dimer-3045*
[**2136-5-15**] 09:18AM BLOOD FDP-10-40
[**2136-5-14**] 11:05AM BLOOD Glucose-121* UreaN-15 Creat-0.9 Na-137
K-4.4 Cl-98 HCO3-30 AnGap-13
[**2136-5-16**] 04:30AM BLOOD Glucose-92 UreaN-11 Creat-0.7 Na-139
K-3.5 Cl-111* HCO3-23 AnGap-9
[**2136-5-14**] 11:05AM BLOOD ALT-20 AST-26 LD(LDH)-625* AlkPhos-158*
TotBili-0.8 DirBili-0.3 IndBili-0.5
[**2136-5-14**] 05:40PM BLOOD Lipase-52
[**2136-5-14**] 11:05AM BLOOD Albumin-3.7 Calcium-8.9 Phos-3.9 Mg-1.9
[**2136-5-15**] 09:18AM BLOOD Cortsol-26.4*
[**2136-5-15**] 11:03AM BLOOD Cortsol-33.2*
[**2136-5-15**] 11:17AM BLOOD Cortsol-37.5*
[**2136-5-15**] 06:02AM BLOOD WBC-25.2*# RBC-3.60* Hgb-9.8* Hct-29.4*
MCV-82 MCH-27.3 MCHC-33.4 RDW-15.0 Plt Ct-250
[**2136-5-15**] 03:59PM BLOOD WBC-18.3* RBC-3.51* Hgb-9.4* Hct-29.1*
MCV-83 MCH-26.8* MCHC-32.3 RDW-15.1 Plt Ct-233
[**2136-5-16**] 04:30AM BLOOD WBC-19.8* RBC-3.47* Hgb-9.8* Hct-29.2*
MCV-84 MCH-28.3 MCHC-33.6 RDW-15.3 Plt Ct-267
[**2136-5-17**] 03:20AM BLOOD WBC-11.8* RBC-3.40* Hgb-9.8* Hct-28.0*
MCV-82 MCH-28.8 MCHC-35.0 RDW-15.2 Plt Ct-285
[**2136-5-18**] 04:55AM BLOOD WBC-12.3* RBC-3.29* Hgb-9.4* Hct-27.0*
MCV-82 MCH-28.5 MCHC-34.7 RDW-15.2 Plt Ct-265
[**2136-5-19**] 05:18AM BLOOD WBC-17.7* RBC-3.35* Hgb-9.4* Hct-27.4*
MCV-82 MCH-28.0 MCHC-34.3 RDW-15.5 Plt Ct-249
[**2136-5-20**] 06:55AM BLOOD WBC-18.6* RBC-3.62* Hgb-10.4* Hct-29.9*
MCV-83 MCH-28.7 MCHC-34.8 RDW-15.7* Plt Ct-259
[**2136-5-14**] 05:40PM BLOOD Neuts-92.9* Lymphs-3.1* Monos-3.3 Eos-0.6
Baso-0.1
[**2136-5-20**] 06:55AM BLOOD Neuts-74* Bands-2 Lymphs-14* Monos-7
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-1*
[**2136-5-20**] 06:55AM BLOOD PT-13.6* PTT-30.6 INR(PT)-1.2*
[**2136-5-20**] 06:55AM BLOOD Glucose-95 UreaN-10 Creat-0.7 Na-139
K-3.9 Cl-106 HCO3-22 AnGap-15
[**2136-5-15**] 11:03AM BLOOD LD(LDH)-465*
[**2136-5-15**] 07:38AM BLOOD Lactate-2.0
Brief Hospital Course:
A/P: 44y/o M with Metastatic melanoma(liver, lung, spleen) s/p
recent biochemotherapy initiation who presents with fever and
abdominal pain.
.
# Fever/Hypotension: Likely source is abdominal given diarrhea
and abdominal pain. He had an abdominal CT which showed no
increased bleeding into the abdomen and but he did have slightly
enhancing wall seen within the sigmoid colon as well as
descending colon. His CXR showed no evidence of PNA. His Hct
drop was significant compare to day of admission however his
baseline hct is 31 thus the hct yesterday may have been
concentrated. He had no evidence of intraabdominal bleeding from
his last CT scan. Pt had a Abd u/s showing GB sludge w/ ?
metastasis to GB wall.
Patient was broadly covered on admission to [**Hospital Unit Name 153**], IV levo for
gram negative bowel coverage, PO flagyl for possible c diff and
IV vanco given hypotension .
[**Last Name (un) **] stim test was negative. Lactate 2.0. U.A was negative.
Stool cultures came back positive for C diff.
A central line was placed in the [**Hospital Unit Name 153**] and aggresive fluid
resucitation was given. No pressors were required. Surgery was
consulted and decision was made to follw serial physical exams.
Abdominal pain improved and blood Cx remained negative to day of
discharged.
Patient was transferred from the [**Hospital Unit Name 153**] on [**2136-5-18**] to the floor.
No more hypotensive episodes and fevers resolved.
.
# Elevated WBC: Patient with had a high WBC up to 25 during
hospital stayed. After a?B were started, WBC started to come
down. 2 days prior to discharged WBC started to go up despite
clear clinical improvement. On day of discharged WBC of 18 with
diff N 75, Bands 2%, L 14%, M 7%. It was decided to send patient
home with very close follow up. Day after discharged patient
will come to clinic to have blood drawn CBC and diff.
.
# Diarrhea: Patient started having diarrhea about 8 hours after
being admitted. Positive for C diff. Bowel movements decrease
over time and by the time of discharged he was having about [**4-14**]
more formed bowel movements. Patient was advised to keep and
adequate fluid intake to maintain his hydration.
.
#. Dehydration: Pt dehydrated on arrival in the setting of low
po intake and later on with abundant diarrhea. Iv fluids were
given to keep up with his output. Clinically improved.
.
#. Metastatic Melanoma:
Follow by Dr [**Last Name (STitle) 1729**]. Chemotherapy per oncology. His LDH is
improving as a response from chemotherapy (from around [**2130**] to
700). Further management will be discussed as an outpatient.
.
#.Coagulopathy - Initially increased INR and PTT. DIC labs were
sent- and were negative. Vitamin K was given and coagulation
test improved.\
.
Medications on Admission:
Home MEDS:
1. Morphine 30 mg Tablet Sustained Release q 12h
2. Pantoprazole 40 mg po qd
3. Ativan 0.5 mg po q4h prn nausea.
Discharge Medications:
1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for nausea for 4 days.
4. Compazine 10 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
5. Outpatient Lab Work
[**2136-5-21**] CBC + diff
Please send results to Dr [**Last Name (STitle) 1729**] office ([**Telephone/Fax (1) 65589**]
Discharge Disposition:
Home
Discharge Diagnosis:
1. Sepsis - abdominal source
2. Clostridium Difficile diarrhea
3. Metastatic Melanoma
Discharge Condition:
Good, tolerating PO's
Discharge Instructions:
Please continue your medications as prescribed
Please follow your appointments as scheduled.
Please continue drinking lots of fluids to keep your self
hydrated.
If fever, chills, shortnes of breath, abdominal pain, nausea,
vomit, please call Dr [**Last Name (STitle) 1729**] or come to the Emergency Department
Followup Instructions:
Please call Dr [**Last Name (STitle) 1729**] office on Monday for a follow up
appointment. Phone: ([**2136**]
Please come to [**Hospital Ward Name 23**] Building - 9 floor to get labs drawn.
Completed by:[**2136-5-20**]
ICD9 Codes: 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1068
} | Medical Text: Admission Date: [**2101-11-19**] Discharge Date: [**2101-11-23**]
Date of Birth: [**2047-7-25**] Sex: F
Service: CCU
CHIEF COMPLAINT: Chest pain radiating to the left shoulder.
HISTORY OF PRESENT ILLNESS: The patient is non-English
speaking. The history was obtained from the chart as well as
from the patient's son.
The patient reportedly awoke on the morning of admission
around 1 a.m. with the sudden onset of chest pain and
epigastric rated [**7-30**] radiating to the left shoulder. The
pain was associated with nausea, vomiting, and diaphoresis.
She also complained of bilateral arm numbness; and according
to her son she experienced similar symptoms two days prior to
this admission. 911 was called.
Emergency Medical Service responded and performed an
electrocardiogram at home which revealed ST elevations in
leads II, III, and aVF with right-sided leads showing an ST
elevation in V4. The patient was treated with aspirin and
morphine and brought to the [**Hospital1 188**] Emergency Department.
In the Emergency Room, the patient's pain was then [**2-27**].
Electrocardiogram done again revealed a sinus rhythm at 55
beats per minute with a normal axis and intervals with
persistent 1-mm to 2-mm ST elevations in leads II, III, and
aVF along with 1-mm ST depression in aVL. Q waves were seen
in II, III, and aVF as well. Right-sided electrocardiogram
leads showed persistent 1-mm ST elevation in V4.
Further history obtained from the patient's son at that time
revealed decreased exercise tolerance over the past few weeks
to one month, a history of claudication over the last couple
of months as well, and constipation.
The patient was taken directly from the Emergency Department
to the catheterization where right heart catheterization
revealed a cardiac output of 2.73 and with a cardiac index of
1.46 by Fick method, a wedge pressure of 23, right atrial
pressure of 21, pulmonary artery pressure of 39/23, with a
mean of 28, and right ventricular pressure of 39/17.
Coronary angiography revealed a right-dominant system with a
normal left main. The left anterior descending artery had
diffuse disease of less than 50% with an 80% proximal
stenosis prior to the second diagonal sub-branch. The left
circumflex had a 50% proximal lesion as well as diffuse minor
disease. The right coronary artery had a total occlusion of
the medial portion with poor collaterals coming from the left
coronary artery. The right coronary artery occlusion was
treated with Angio-Jet thrombectomy and stenting times two.
There were recurrent episodes of slow flow; however, treated
with multiple doses of intracoronary diltiazem with
improvement. The final result was TIMI-II fast flow with no
residual stenosis.
The hemodynamics reported above were consistent with right
ventricular infarction with the elevated wedge pressure of 23
mm. Temporary pacing required for periods of marked sinus
slowing with decreased blood pressure and loss of atrial
synchrony. For these reasons, an intra-aortic balloon pump
was placed due to the markedly reduced cardiac index and the
above hemodynamics. The patient was then admitted to the
Coronary Care Unit for further management.
PAST MEDICAL HISTORY:
1. Hypercholesterolemia.
2. Osteoporosis.
3. Osteoarthritis.
4. Lichen planus.
5. Cervical spine disk herniation.
6. Chronic low back pain.
MEDICATIONS ON ADMISSION:
1. Lipitor 20 mg p.o. q.d.
2. Ibuprofen.
3. Hormone replacement therapy.
4. Calcium.
5. Zoloft.
6. Valium.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Family history negative for coronary artery
disease.
SOCIAL HISTORY: The patient is married and has four
children. She smokes six to ten cigarettes per day.
CARDIAC RISK FACTORS: Cardiac risk factors included tobacco,
age, and high cholesterol.
PHYSICAL EXAMINATION ON PRESENTATION: Examination on
admission to the Coronary Care Unit revealed the patient was
afebrile, heart rate ranged from 57 to 61, blood pressure
ranged from 136 to 148/76 to 96 (with mean arterial pressure
of 108), oxygen saturation was 99% on 3 liters. In general,
she appeared comfortable. She denied chest pain at the time
of admission to the Coronary Care Unit status post
catheterization. Pertinent physical findings revealed no
jugular venous distention on examination of the neck. Her
lungs were clear to auscultation bilaterally without
crackles. Her heart rate was 60 with a normal first heart
sound and second heart sound. No murmur was audible. Her
abdomen was protuberant and obese but nontender with normal
active bowel sounds. Her extremities revealed trace pedal
edema. She had 2+ pulses bilaterally with the balloon pump
in place.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
on admission revealed white blood cell count was 9.8,
hematocrit was 35.5, and platelets were 253. Coagulations
were normal. Chemistry-7 was unremarkable. First cardiac
enzymes revealed creatine kinase was 1395, with a MB of 278,
and a MB index of 19.9. Troponin was read as greater than
50. Liver function tests revealed elevation of ALT at 43,
AST was 146, and alkaline phosphatase was 77. Amylase and
lipase were normal as was total bilirubin.
HOSPITAL COURSE:
1. CARDIOVASCULAR SYSTEM: Following catheterization, the
patient was continued on Integrilin, heparin drip, and
Plavix.
On the night status post catheterization, the patient did
experience some episodes of neck pain, back pain, and arm
pain without electrocardiogram changes. However, creatine
kinases continued to climb, reaching 6148 on the first
hospital day with improved hemodynamics. The patient's
balloon pump discontinued later on the first hospital day
with a small amount of oozing groin site which was stopped
with pressure. The patient's hematocrit did fall from 32 to
29; although, no transfusion of packed red blood cells was
necessary. As mentioned above, the creatine kinase peaked
and fell quickly thereafter. As heart rate and blood
pressure tolerated, the patient was initiated on Lopressor
and low-dose captopril at 6.25 mg t.i.d. She had no further
complaints of chest pain, neck, or back pain.
An echocardiogram was performed on hospital day two which
revealed a normal left atrium. Left ventricular wall
thickness was normal. Overall left ventricular systolic
function was mildly depressed with an ejection fraction of
40% to 45%. Resting regional wall motion abnormalities
included basal and medial inferolateral, inferoseptal, and
inferior hypokinesis. Ascending aorta was mildly dilated.
There was 1+ mitral regurgitation, and no pericardial
effusion.
On [**2101-11-23**], the patient underwent a Persantine MIBI
stress test to evaluate for any further reversible defect.
She elevated her heart rate to 77 (which was 46% of her
maximum heart rate). She had no chest discomfort or ischemic
changes. The nuclear report revealed moderate partially
reversible perfusion defect of the inferior wall with an
ejection fraction of 38%. There was global hypokinesis which
was most pronounced in the inferior wall.
The patient's medications were changed to once daily
medications, including atenolol and lisinopril. She remained
hemodynamically stable and was called out to the floor.
She was discharged later that day in good condition. The
patient was discharged back home to [**Country 6607**] with a copy of her
cardiac catheterization on CD-ROM to show to her doctors at
[**Name5 (PTitle) **].
2. HEMATOLOGIC ISSUES: On admission, the patient's
hematocrit was noted to be 35.5; reaching a nadir of 29.1 on
[**2101-11-20**] following removal of the balloon pump. As
stated above, she was transfused one unit of packed red blood
cells for this drop in hematocrit to which she responded
appropriately; bringing her hematocrit up to 33.5. On the
day of discharge her hematocrit was 34.3.
3. ANXIETY ISSUES: The patient was continued on her
outpatient doses of Zoloft as well as given Valium on a as
needed basis.
4. GASTROINTESTINAL SYSTEM: For her presenting complaint on
review of systems of constipation, she was given a bowel
regimen of Colace, Senna, and Dulcolax with good effect.
DISCHARGE DIAGNOSES:
1. Inferior and right ventricular myocardial infarctions.
2. Status post thrombectomy and right coronary artery stent
times two.
MEDICATIONS ON DISCHARGE:
1. Atenolol 12.5 mg p.o. q.d.
2. Lisinopril 25 mg p.o. q.d.
3. Atorvastatin 20 mg p.o. q.d.
4. Sertraline 50 mg p.o. q.d.
5. Plavix 75 mg p.o. q.d.
6. Aspirin 325 mg p.o. q.d.
7. Milk of Magnesia.
8. Senna.
9. Lactulose.
10. Ibuprofen as needed.
CONDITION AT DISCHARGE: Condition on discharge was good.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**]
Dictated By:[**Name8 (MD) 3491**]
MEDQUIST36
D: [**2102-1-16**] 13:33
T: [**2102-1-17**] 09:12
JOB#: [**Job Number 42051**]
ICD9 Codes: 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1069
} | Medical Text: Admission Date: [**2109-11-29**] Discharge Date: [**2109-12-2**]
Date of Birth: [**2087-6-19**] Sex: F
Service: MEDICINE
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 6381**] [**Name (STitle) **]
CARDS: Dr. [**Last Name (STitle) **]
.
CC: acute loss of consciousness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
22 yo female w/ bicuspid aortic valve c/b endocarditis x2 p/w
acute LOC in setting of 3d N/V/D and fevers, no new CP or SOB,
mild H/A. Pt was discharged [**2109-10-1**] for endocarditis (thought to
be chronic) after dental procedure. Small, mobile echodensity
was confirmed on aortic valve by TEE but pt remained afebrile
througout hospitalization w/ negative cultures and was
discharged w/o antibiotics. Her ESR/CRP/CBC and repeat blood
cultures prior to admission have all been negative.
.
The pt presented today after transient LOC close to the
hospital. She reports feeling dizzy but does not remember LOC,
no clear head trauma. She has had 3d of nausea, vomiting and
watery diarrhea with abdominal cramping. No melena, no BRBPR,
no hematemesis. She denies sick contacts. She measured a
temperature of 104 this morning. She endorses a headache with
prior dizzyness which has now resolved. In general she has felt
fatigued since her last admission with occasional dizzyness and
h/o syncope of unknown etiology, no chest pain, no palpitations,
no shortness of breath. She denies night sweats but has had
16-lb unintentional weight loss since moving to [**Location (un) **] in
[**Month (only) **]. Her GI symptoms feel improved but she had 4 episodes
of non-bloody vomiting today with multiple episodes over past
few days. She denies sore throat or sinus congestion, +chronic
dry cough w/o SOB, extremity swelling, dysuria or hematuria.
.
In the [**Name (NI) **] Pt's VS were 97.2 108/74 60 16 100% RA. She had
transient episode of SBP to 70s and received 2L NS. Antibiotics
for possible endocarditis were originally held then started in
setting of hypotension. She received gentamicin 50mg x1 and
nafcillin 2g IV x1. ID was consulted and will follow.
Past Medical History:
1. Coarctation of the aorta, s/p repair at age 7
2. Bicuspid aortic valve
3. h/o BE x 2 - once in childhood, most recent episode 4 years
ago
4. Rheumatic fever [**2-6**]
5. Mediastinal lymphadenopathy followed by Heme-Onc, CT Surgery;
radiographic surveillance, ?residual thymus
6. h/o Syncope
Social History:
Graduate student in theater lighting and design and BU. She
denies tobacco/drugs and has occasional glass of wine.
Family History:
H/o Leukemia and lymphoma (grandparents), grandfather w/
congenital [**Last Name **] problem, h/o breast and colon CA, father with
acquired heart and lung problems, thyroid dysfunction, mother
with no particular health problems
Physical Exam:
GEN'L: thin, well-appearing, NAD
VS: 96.6 105/70 50 12 99%RA
HEENT: NC/AT, MMM, OP clear, sclera anicteric, conjunctivae pink
NECK: supple, no carotid bruits
LN: no supraclavic/axillary/[**Last Name (un) **] cervical/submandibular LN
CVS: NR/RR, III/VI crescendo/decrescendo murmur RUSB radiating
to axilla, +s1, prominent s2, no s3/s4
PUL: CTAB w/ soft occas'[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
[**Last Name (un) **]: +BS, flat, soft, NT/ND, no rebound/guarding, no
organomegaly
BACK: muscular tenderness, no CVAT
EXT: warm, no c/c/e
NEURO: altert and oriented
PULSES: 2+ radial and periph pulses bilat
SKIN: no rashes, no osler's nodes or splinter hemorrhages
Pertinent Results:
142 105 10
============< 67
3.9 20 0.6
.
AG: 17
.
CK: 70 MB: Notdone Trop-T: <0.01
.
Ca: 9.6 Mg: 2.4 P: 3.3
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
HCG:<5
.
CRP: Pnd
.
5.8 > 40.7 < 299
N:62.9 L:29.2 M:5.6 E:0.9 Bas:1.3
.
SED-Rate: 6
.
CXR: no acute cardiopul process
.
EKG: NSR 60s, nml intervals, nml axis, no ST seg changes, Jpt
elevation V2-V3
TECHNIQUE: Non-contrast head CT scan.
FINDINGS: There is no evidence of hemorrhage, mass effect, shift
of the normally midline structures, or infarction. The
[**Doctor Last Name 352**]-white matter differentiation is preserved. There is no
hydrocephalus. The osseous structures are unremarkable. The
paranasal sinuses and mastoid air cells are well aerated.
IMPRESSION: No hemorrhage or mass effect.
TTE [**2109-11-30**]
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 70%) There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. There
is a mild coarctation of the distal aortic arch. The aortic
valve is bicuspid. The aortic valve leaflets are mildly
thickened. No masses or vegetations are seen on the aortic
valve. Trace aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. No mass or vegetation is seen
on the mitral valve. The estimated pulmonary artery systolic
pressure is normal. No vegetation/mass is seen on the pulmonic
valve. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2109-9-30**], the findings are similar.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis
Brief Hospital Course:
22yo F s/p childhood repair of coarctation of aorta, bicuspid
aortic valve and h/o endocarditis p/w 3-d h/o fevers, nausea,
vomiting and diarrhea, transient LOC and hypotension to 70s.
.
# Viral gastroenteritis
Initial transient hypotension was concerning given h/o fevers
and h/o endocarditis but pt does not appear septic and has been
afebrile since arrival. However in setting of recent vomiting
and diarrhea, pt is likely dehydrated and her BP has responded
appropriately to IV fluids. Presentation may be consistent with
viral gastroenteritis. Pt did have recent admission in [**Month (only) 359**]
for possible endocarditis and was noted to have a mobile
echodensity on TEE that was believed to be chronic and no
antibiotics were started. In the ICU patient had negative TTE
and blood cultures remained negative. ID was consulted and
thought this was viral gastroenteritis, sent off EBV and CMV
titers which were pending at discharge. Patient improved
clinically, diarrhea resolved and was taking fluids and eating
by mouth.
.
# Syncope
Multiple episodes in past, attributed to hypoglycemia. Pt now
w/ hypotension which may account for her syncope. Also
congenital coarctation of aorta s/p repair. TTE negative for
valvular process, telemetry was unremarkable. Patient given salt
tablets and told to mantain adequate hydration. Consider
outpatient neurology consultation for autonomic dysfunction.
Patient was not orthostatic at any point during hospitalization.
She was scheduled follow up appointment the following day after
discharge with her cardiologist Dr. [**Last Name (STitle) **].
.
# h/o Mediastinal LN
Noted incidentally on chest CT obtained for blood-streaked
sputum at last admission in [**Month (only) 359**]. Pt seen by heme-onc who
recommended radiographic surveillance. CT surgery believes this
is thymic remnant. Pt does have h/o weight loss over past months
but no other concerning signs or symptoms. She will f/u with
heme-onc and CT sx as outpt w/ surveillance CTs.
.
# Weight loss
Likely due to recent diarrhea, nausea and vomiting alongside
poor oral fluid intake. Sent off for tissue transglutaminase to
evaluate celiac sprue, this test returned back negative. If
patient continues to lose weight and has repeated diarrhea, will
need colonoscopy to evaluate question of IBD. She is also
followed by heme/onc and CT surgery for question of mediastinal
lymphadenopathy.
Medications on Admission:
Iron
Discharge Medications:
1. Sodium Chloride 1 gram Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Viral gastroenteritis
Discharge Condition:
Good, stable, ambulating well, blood pressure stable
Discharge Instructions:
You were admitted with nausea, vomiting, and diarrhea. You were
diagnosed with viral gastroenteritis. No antibiotics were needed
to treat this condition. Your symptoms resolved with IV fluids,
other tests came back negative or are currently pending for
specific viral sources. You have an appointment scheduled for
tomorrow with Dr. [**Last Name (STitle) **] to follow up at 2PM. You also have a
primary care appointment set up for 1 week with Dr. [**First Name (STitle) **].
Return to the ER if you have any further nausea, vomiting,
diarrhea or any other worrisome symptoms.
Followup Instructions:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2109-12-3**] at 2 PM (tomorrow)
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 815**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2109-12-9**]
3:30
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2109-12-10**] 2:00
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD Phone:[**0-0-**]
Date/Time:[**2109-12-10**] 3:00
ICD9 Codes: 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1070
} | Medical Text: Admission Date: [**2105-6-1**] Discharge Date: [**2105-6-29**]
Date of Birth: [**2037-7-9**] Sex: F
Service: SURGERY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
[**6-9**] Exploratory laparotomy, lysis of adhesions,
enteroenterostomy
[**6-13**] Exploratory laparotomy
History of Present Illness:
67 year old female with poorly differentiated pelvic carcinoma
(status post surgery, chemo, XRT), with recurrent
admissions/emergency room visits for abdominal pain, presenting
again with nausea, vomiting, abdominal pain, found to have a
small bowel obstruction in the emergency room. Her previous
admissions were in [**Month (only) 547**] and [**Month (only) **] with similar complaints. CT
scan ([**2105-3-15**]) demonstrated some minimal wall thickening of deep
loops of small bowel. GI was consulted and felt that the
patient's history was most consistent with partial SBO. A
small-bowel follow-through demonstrated a slightly thickened,
irregular, aperistaltic loop of small bowel in the distal pelvis
but no evidence of obstruction. Her last CT in [**Month (only) **] showed an
obstruction at a deflection point in the left lower quadrant.
She was again medically treated and improved.
She now returns with similar symptoms of nausea, vomiting and
abdominal pain since day prior to admission and again is found
to have a partial SBO on CT. She has not had a BM in 10 days.
She complains of pain worse in RLQ. She says she has lost weight
since surgery. No melena or hematochezia. No hematemesis.
Past Medical History:
1) Poorly differentiated pelvic carcinoma: From last discharge
summary: "Diagnosed with pelvic mass [**5-20**] after having
difficulty with urination. MRI was notable for a 4.0 x 4.3 x 7.2
cm heterogeneous cystic and solid pelvic mass anterior to the
bladder. Biopsy was consistent with poorly differentiated
malignancy. Underwent radical vaginectomy, radical vulvectomy,
and anterior pelvic exenteration on [**2104-7-18**]. With urostomy. Taxol
on [**2104-9-24**] and then palliative radiation therapy. MRI on [**2104-12-18**]
was notable for interval decrease in size of the soft tissue
density immediately adjacent to and posterior to the pubic
symphysis, compatible with scar and no evidence of disease
recurrence elsewhere in the pelvis.
2) Cerebrovascular accident x 2 (cerebellar)
3) Anemia: B12 deficient
4) Asthma
5) Hypertension
6) Hypothyroidism status post thyroidectomy
Social History:
She is from [**Male First Name (un) 1056**]. She worked as an office cleaner. She
has three children. She lives with her brother. She reports a
47-pack year smoking history. She quit after she was diagnosed
with cancer. She consumes alcohol on social basis.
Family History:
Sister died of cancer in [**2100**], type unknown, positive for
hypertension, diabetes.
Physical Exam:
T: 96.8 HR: 102 BP: 110/80 RR: 18 98% RA
Gen: no apparent distress
HEENT: neck supple, no masses
Card: regular rate and rhythm, no murmurs, rubs, or gallops
Lungs: clear to auscultation bilaterally, no wheezes, rales, or
rhonchi
Abd: soft, nontender, incision clean, dry, and intact, ostomy
pink and viable
Ext: no clubbing, cyanosis, or edema
Neuro: CNII-XII grossly intact
Pertinent Results:
[**6-1**] CT abd/pelvis
1. Small bowel obstruction, at least partial. No distinct
transition point is identified, though it appears to be located
within the pelvis involving the ileum. There is no free air or
significant ascites at this time. Obstructed bowel loops are
more dilated than seen in [**2105-5-15**].
2. Moderate right-sided hydronephrosis, unchanged from the prior
exam.
Pathology specimen from [**2105-6-9**]
Small bowel (3.3 cm):
Mild mucosal edema, otherwise unremarkable small bowel.
[**6-23**] abdominal Xray
No evidence of underlying bowel obstruction. Probable
constipation/impaction with a large amount of stool noted within
the descending colon, sigmoid, and rectum.
Brief Hospital Course:
Ms. [**Known lastname 43251**] was admitted to the hospital on [**6-1**] for partial
small bowel obstruction. She treated with a nasogastric tube,
IV fluids, nothing by mouth, and pain control. PICC placed on
[**6-4**] and transferred to general surgery care. TPN started at
that time. NGT was clamped and she had significant nausea.
She was taken to the operating room on [**6-9**] for LOA and
enteroenterostomy and tolerated the procedure well.
On POD#1 she had an episode of hypotension and responded well to
fluid boluses only transiently so was transferred to the ICU.
[**Last Name (un) **] stim test was ordered and was nromal. Levo and flagyl were
given and TPN restarted. Was transfused one unit of blood for
Hct of 21. Levo and Flagyl were dc'ed after 4 days.
Again on [**6-13**] the patient was taken to the OR for exploratory
laparotomy to r/o anastomotic leak/peritonitis. No leaks or
peritonitis was found on laparotomy.
One episode of tachycardia was responsive to fluid bolus,
otherwise the patient was hemodynamically stable the remainder
of the hospitalization. She was evaluated for confusion and
serial neuro exams showed no focal or cognitive deficits below
baseline. As bowel function returned diet was advanced and she
was weaned from TPN. Pain was controlled on oral pain meds. Pt
began working with PT on walking, transfers, and stairs. She was
cleared by PT to go home with services. The pt was discharged
home with services on POD 20/16.
Medications on Admission:
Lipitor 20mg
Plavix 75mg
levothyroxine 137 mcg
Combivent
Albuterol
Fentanyl patch 50mcg q72
Colace
Senna
Bisacodyl
Oxycodone
Fluoxetine 20
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): to prevent narcotic-induced constipation.
Disp:*60 Capsule(s)* Refills:*2*
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
Disp:*120 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Small Bowel Obstruction
pelvic carcinoma
Discharge Condition:
Good
Tolerating Regular diet, no nausea or vomiting.
Denies pain, well regulated
Discharge Instructions:
Please call your surgeon if you develop chest pain, shortness of
breath, fever greater than 101.5, foul smelling or colorful
drainage from your incisions, redness or swelling, severe
abdominal pain or distention, persistent nausea or vomiting,
inability to eat or drink, or any other symptoms which are
concerning to you.
No tub baths or swimming. You may shower. If there is clear
drainage from your incisions, cover with a dry dressing. Leave
white strips above your incisions in place, allow them to fall
off on their own.
Activity: No heavy lifting of items [**9-28**] pounds until the
follow up
appointment with your doctor.
Medications: Resume your home medications. You should take a
stool softener, Colace 100 mg twice daily as needed for
constipation. You will be given pain medication which may make
you drowsy. No driving while taking pain medicine.
Followup Instructions:
10 days to 2 weeks in Dr. [**Last Name (STitle) **] clinic. Please call ([**Telephone/Fax (1) 32046**] to schedule appointment
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1071
} | Medical Text: Admission Date: [**2160-10-20**] Discharge Date: [**2160-10-22**]
Date of Birth: [**2083-11-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Rigid bronchoscopy with argon ablation and lung biopsy
History of Present Illness:
This is a 76 y.o. man with a history of COPD, HTN and recurrent
NSCLC presenting with hemoptysis. On the evening prior to
admission, the patient had multiple episodes of hemoptysis with
bloody sputum. The patient went to sleep and awoke at 5AM with
further bloody sputum production. On the way to the ED, the
patient coughed up an estimated [**11-19**] cups of frank blood by
report of the patient's son. In the ED, the patient was noted to
have stable vital signs with a stable hematocrit and
radiographic evidence of progression of his known RUL mass. The
patient was admitted for further management.
.
The patient was initially diagnosed approximately 30 years ago
with non-small cell lung cancer and underwent a Left upper
lobectomy at that time. He was recently admitted in [**Month (only) 359**] with
hemoptysis requiring intubation, found to have a new RUL mass
and underwent bronchoscopy with laser excision found on
pathology to be undifferentiated large cell CA. The [**Hospital 228**]
hospital course was complicated by a PE without DVT's and was
discharged on lovenox. Staging screening revealed locally
advanced disease with Right hilar and mediastinal
lymphadenopathy. PET and CT did reveal other lesions including
renal and splenic masses felt to not be consistent with
metastatic disease. The patient was seen by outpatient Heme/Onc
and CT surgery. Outpatient recommendations from [**Hospital **]
included combined chemo and radiation therapy. Dr. [**Last Name (STitle) 952**] of CT
surgery saw the patient within the past 2-3 weeks. By report of
the patient and his son, Dr. [**Last Name (STitle) 952**] wanted to proceed with
possible surgical resection of the mass. The patient underwent
pre-op evaluation including outpatient stress testing. The
patient was scheduled for outpatient bronchoscopy on Thursday
[**10-24**] for further biopsy and imaging of the lesion.
.
ROS: Denies fevers, chills, nightsweats, nausea, vomiting,
diarrhea, constipation, chest pain.
Past Medical History:
Onc History: NSCLC first diagnosed at age 45 s/p Left upper
lobectomy at age 45 without adjuvant therapy at that time. The
patient presented to an OSH on [**2160-9-5**] with massive hemoptysis
requiring intubation. Bronchospopy revealed obstructive lesion
of the Right mainstem due to a RUL tumor. The patient underwent
tumor excision with rigid bronchoscopy. Pathology revealed
undifferentiated large cell CA. The patient underwent staging
scans. PET scan from [**2160-10-2**] demonstrates an FDG avid right
hilar mass and mediastinal lymphadenopathy, there was an unusual
focus of FDG uptake and soft tissues prominence along the left
posterior psoas of unclear significance. He had a CT of the
chest, abdomen and pelvis on [**2160-9-14**], which demonstrated
pulmonary embolus, mediastinal and right hilar lymphadenopathy,
ground glass and consolidative opacities concerning for
hemorrhage, marked scarring and emphysema in the right upper
lobe, nonspecific pulmonary nodules, several subcentimeter vague
hypoattenuating foci in the liver, a large 3 to 4 cm nonspecific
lesion in the spleen, and a 30 mm lesion along the lower pole of
the left kidney. A [**Year (4 digits) 500**] scan on [**2160-9-15**] showed no definitive
evidence for metastatic disease. An MRI of the head on
[**2160-9-14**] showed no evidence of intracranial metastases.
.
PMH:
CAD status post three angioplasties, with the last requiring
stenting all of which occurred approximately 13 years ago.
Patient underwent recent stress test as part of pre-op eval for
possible lung mass excision.
HTN
COPD
Social History:
Lives with family and worked 25 years as a plumber. Has a 60
pack year history of smoking and has been exposed to asbestos in
the past. He socially drinks alcohol.
Family History:
Mother died at 82 of stomach CA. Brother with unknown CA death
at 76. Sister with [**Name2 (NI) 500**] CA at 53. Daughter with breast CA in her
40's.
Physical Exam:
VS 97.1 72 149/67 18 95% RA
Gen: Well appearing. NAD.
Integumentary: No rashes or lesions.
HEENT: PERRL. Pink, moist oral mucosa without lesions.
CV: RRR. Normal S1 and S2. No M/R/G.
Pulm: Decreased breath sounds in the RUL and LUL.
Abd: Soft, nontender, nondistended.
Ext: No edema.
Neuro: A&Ox3. Grossly intact.
Psych: Appropriate mood and affect.
Pertinent Results:
EKG: Sinus rhythm. Normal axis and intervals. No acute ST or T
wave changes.
.
CTA chest ([**2160-10-20**]): 1. Increase in size of right hilar
enhancing mass with probable extension into the right main stem
bronchus. This results in partial occlusion of the right main
stem bronchus, but there are no postobstructive changes. 2.
Near complete resolution of right lower lobe airspace opacities
seen on the prior examination.
3. No evidence of pulmonary embolus. The possible filling
defect in the right lower lobe pulmonary artery has resolved. 4.
Unchanged appearance of emphysematous and fibrotic changes in
the right upper lobe.
.
Portable CXR ([**2160-10-20**]): Near complete resolution of right lower
lobe consolidation, with unchanged right upper lobe opacities.
Right hilar neoplastic mass slightly increased on the concurrent
CT.
.
PET Scan ([**2160-10-2**]): 1. FDG avid right hilar mass and
mediastinal lymphadenopathy. 2. Unusual focus of FDG uptake in a
soft tissue prominence along the left posterior psoas of unclear
[**Name2 (NI) 68402**]. The location of this lesion is not typical of
metastatic disease. 3. FDG uptake associated with a previously
described indeterminate 13 mm left renal lesion, along the left
lower pole. The FDG uptake heightens concern for a solid nodule
such as a renal cell carcinoma.
.
Lower extremity ultrasound ([**2160-9-15**]): No evidence of lower
extremity DVT.
.
MRI ([**2160-9-14**]): No evidence of intracranial metastasis.
.
[**Month/Day/Year **] Scan ([**2160-9-15**]): No definite evidence for osseous
metastases.
.
CT abd/pelvis ([**2160-9-14**]): 1. Appearance raising concern for the
possibility of a pulmonary embolus in a right lower lobe branch
of the right pulmonary artery, although indeterminate. 2.
Mediastinal and right hilar lymphadenopathy. 3. Bibasilar mixed
ground-glass and consolidative opacities, which given their
recent onset, are most suspicious for an infection,
inflammation, or in the appropriate clinical setting,
hemorrhage. 4. Marked scarring and emphysema in the right upper
lobe. 5. Nonspecific pulmonary nodules, for which short-term
followup is recommended. 6. Several subcentimeter vague
hypoattenuating foci in the liver which are nonspecific.
Metastatic disease cannot be excluded. 7. Large 3-4 cm
nonspecific lesion in the spleen. To evaluate the significance
of this finding, further correlation with prior studies could be
most helpful. 8. A 13 mm lesion along the lower pole of the
left kidney with indeterminate
characteristics and too small to characterize here. It could be
helpful to use an ultrasound to determine whether this
definitely represents a mildly dense cyst, if clinically
indicated.
.
[**2160-10-20**] 09:50AM GLUCOSE-136* UREA N-14 CREAT-0.7 SODIUM-138
POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-30 ANION GAP-12
[**2160-10-20**] 09:50AM WBC-7.6 RBC-4.61 HGB-13.6* HCT-38.0* MCV-82
MCH-29.6 MCHC-35.9* RDW-16.5*
[**2160-10-20**] 09:50AM PT-16.5* PTT-33.9 INR(PT)-1.5*
Brief Hospital Course:
76 y.o. man with a history of COPD, HTN and recurrent NSCLC
presenting with hemoptysis.
.
# Hemoptysis secondary to the patient's known RUL mass with
bronchus involvement. On most recent admission, the patient
suffered significant bleeding requiring intubation for airway
protection. Patients HCT was stable throughout his hospital
course. Because of his increased hemoptysis, the patient was
transfered to the MICU. IP was made aware and scheduled patient
for the OR. Pt underwent rigid bronchoscopy and argon ablation
for neovascularization in the right mainstem bronchi. A biospy
was also done of the left lung. After the procedure, the
patient had small amounts of blood tinged sputum which resolved
one day after the procedure. The patient's hematocrit was
stable throughout the stay.
.
# Lung mass. Known undifferentiated RUL large cell CA. The
patient was recently seen by outpatient heme/onc and outpatient
CT surgery. Bronchoscopy for visualization of bleed and mass,
biopsies were to rule out a bronchogenic component of the
cancer.
.
# PE. This likely represented a complication of
hypercoaguability of malignancy. The patient is without signs of
PE on today's CTA. Had recently negative LENI's. Because of the
risk of hemoptysis anticoagulation was held.
.
# COPD. Stable. Continue Spiriva, Advair, Albuterol IH PRN.
.
# h/o CAD. Stable. Continue beta blocker.
.
# HTN. Stable. Continue diuretic and beta-blocker.
.
# CODE: Full Code
Medications on Admission:
Hydrochlorothiazide 25 mg QD
Lopressor 50 mg [**Hospital1 **]
Lovenox 60 mg [**Hospital1 **]
Advair [**Hospital1 **]
Spiriva QD
Albuterol inhaler PRN
Discharge Medications:
1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Discharge Disposition:
Home
Discharge Diagnosis:
Right upper lobe mass
Left lung mass
Hypertension
Coronary artery disease
COPD
Discharge Condition:
Good
Discharge Instructions:
Return to the emergency department for persisent cough,
worsening blood in sputum, weakness, fever, chills, chest pain,
shortness of breath, nausea, vomiting, or other concerning
symptoms.
Because of the bleeding with your cough, we have stopped your
lovenox injections. You should not take this medication until
you have talked with your oncologist. Please follow up with
your oncologist within one week about this matter.
Our interventional radiologists recommend the following:
You should begin chemo-radiation urgently, please consult with
your oncologist about this therapy
You should also be considered for possible photodynamic therapy.
please consult with your oncologist about this therapy.
You are currently not a candidate for surgery.
You should resume all of your home medications upon discharge
including oxygen as needed.
Followup Instructions:
Follow up with your oncologist. If you wish to transfer your
care to [**Hospital1 69**], please call
[**Telephone/Fax (1) **] to schedule an appointment
ICD9 Codes: 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1072
} | Medical Text: Admission Date: [**2157-12-22**] Discharge Date: [**2157-12-30**]
Date of Birth: [**2157-12-22**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 38828**] is a former 2.095 kg
product of an estimated gestational age pregnancy of 32 weeks
born to a 26-year-old G2, P1, now 2 woman.
Prenatal screens - blood type A negative, antibody negative,
rubella immune, RPR nonreactive, hepatitis B surface antigen
negative, group beta strep status unknown. The mother was a
late registrant for prenatal care. She presented to [**Hospital 1474**]
Hospital with preterm labor on [**2157-12-18**]. At that time
her urine toxicology screen was positive for cocaine. Her
preterm labor persisted. She was treated with magnesium
sulfate and given betamethasone, and transferred to the [**Doctor First Name **]-
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Hospital. On the day of delivery she had
progressive preterm labor and was delivered by repeat
cesarean section. The infant emerged vigorous with Apgars of
9 at 1 minute and 9 at 5 minutes. He was admitted to the
neonatal intensive care unit for treatment of prematurity.
PHYSICAL EXAMINATION: Upon admission to the neonatal
intensive care unit weight was 2.095 kg, length 44 cm, head
circumference 31 cm. GENERAL: Nondysmorphic, vigorous preterm
male in mild respiratory distress. HEENT: Normocephalic,
positive red reflexes bilaterally. EARS: Normal. Palate
intact. NECK: No masses. CHEST: Intermittent shallow
breathing. Mild grunting and flaring, improving over the
first hour of life. CARDIOVASCULAR: Regular rate and rhythm.
No murmurs. Good perfusion. ABDOMEN: No masses. No
hepatosplenomegaly. Soft, nontender, nondistended.
GENITOURINARY: Glandular hypospadias with bruised appearance
on the sides of the penis. Anus patent. SKIN: Pink, petechiae
on head and neck. NEUROLOGIC: Normal tone, strength and
activity. Appropriate reflexes.
Discharge weight: 2105 gm
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA: RESPIRATORY: [**Known lastname **] has been in room air for his entire
neonatal intensive care unit admission. The respiratory
distress noted at birth resolved over the first few hours of
life. He has had no episodes of spontaneous apnea or
bradycardia.
CARDIOVASCULAR: [**Known lastname **] has maintained normal heart rates and
blood pressures. No murmurs have been noted. Baseline heart
rate is 130 to 160 beats per minute with a recent blood
pressure of 64/31 mm of mercury with a mean arterial pressure
of 44 mm of mercury.
FLUIDS, ELECTROLYTES AND NUTRITION: [**Known lastname **] was initially NPO
and maintained on intravenous fluids. Enteral feeds were
started on day of life 1 and gradually advanced to full
volumes. At the time of discharge he is taking in minimal of
130 ml per kg per day of special care formula 24 calorie per
ounce. All his feedings are PO. Weight on the day of
discharge is 2.105 kg. Serum electrolytes were checked in the
first week of life and were within normal limits.
INFECTIOUS DISEASE: [**Known lastname **] was evaluated for sepsis upon
admission to the neonatal intensive care unit. Complete blood
count was within normal limits. Blood culture was obtained
prior to starting intravenous ampicillin and gentamycin.
Blood culture showed no growth at 48 hours and the
antibiotics were discontinued.
HEMATOLOGICAL: Hematocrit at birth was 54.2%. [**Known lastname **] is blood
type A negative and direct antibody test negative.
GASTROINTESTINAL: [**Known lastname **] was treated for unconjugated
hyperbilirubinemia with phototherapy. Peak serum bilirubin
occurred on day of life 4, a total of 12 mg per dL. He
received approximately 72 hours of phototherapy. Rebound
bilirubin on day of life 7 was total of 6.4 mg per dL.
GENITOURINARY: As noted on his admission physical examination
[**Known lastname **] has hypospadias. He was evaluated by the urology consult
team from [**Hospital3 **]. He will need surgery at a
later date. Follow up is recommended with Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) 45267**] at
[**Hospital3 **] [**Location (un) 86**] at 3 to 4 months of age. Dr. [**Last Name (STitle) 45267**]
can be reached at [**Hospital3 **] at [**Telephone/Fax (1) 46385**].
NEUROLOGY: [**Known lastname **] has maintained a normal neurological
examination during admission.
SENSORY: Audiology hearing screening has not yet been
performed and will be required prior to discharge.
PSYCHOSOCIAL: Mother's name is [**Name (NI) **] [**Name (NI) 38828**] and father's
name is [**Name (NI) 3403**] [**Name (NI) 70444**]. [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **]
[**Last Name (Titles) **] social work has been involved with this family. The
contact social worker is [**Name (NI) 4457**] [**Name (NI) 43088**] and she can be
reached at [**Telephone/Fax (1) 70445**]. The meconium toxicology screen sent
on the infant at birth was positive for marijuana and cocaine
metabolites. A 51A has been filed as of [**2157-12-26**].
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: Transferred to [**Hospital 1474**] Hospital for
continuing level II care.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 70446**], [**Hospital3 63339**] of [**Hospital1 1474**].
CARE RECOMMENDATIONS:
1. Feeding: ad lib po feeding with 130 ml per kg per day of
special care 24 calorie per ounce formula.
2. No medications.
3. Car seat position screening is recommended prior to
discharge.
4. State newborn screen was sent on [**2157-12-16**] and repeated on
[**2157-12-30**].
5. Hepatitis B vaccine was administered on [**2157-12-26**].
6. Immunizations Recommended:
7. Synagis RSV prophylaxis should be considered from
[**Month (only) **] through [**Month (only) 958**] for infants who meet any of the
following three criteria.
1. Born at less than 32 weeks.
2. Born between 32 and 35 weeks with two of the
following:
8. daycare during the RSV season.
9. a smoker in the household, neuromuscular disease, airway
abnormalities, or school age siblings.
10. with chronic lung disease.
1. Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the
child's life, immunization against influenza is
recommended for household contacts and out of home
caregivers.
Follow up appointments recommended:
Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) 45267**], Pediatric Urology at [**Hospital3 1810**]
[**Location (un) 86**]. Tel No. [**Telephone/Fax (1) 46385**].
DISCHARGE DIAGNOSES:
1. Prematurity at estimated gestational age of 32 weeks
gestation.
2. Transitional respiratory distress.
3. Suspicion for sepsis ruled out.
4. Hypospadias.
5. In utero cocaine and marijuana exposure.
6. Unconjugated hyperbilirubinemia.
[**Doctor First Name **] [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 62348**]
Dictated By:[**Name8 (MD) 62816**]
MEDQUIST36
D: [**2157-12-30**] 00:22:06
T: [**2157-12-30**] 01:17:02
Job#: [**Job Number **]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1073
} | Medical Text: Admission Date: [**2101-10-11**] Discharge Date: [**2101-10-18**]
Date of Birth: [**2024-6-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Percocet
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
increasing dyspnea on exertion x6 months
Major Surgical or Invasive Procedure:
coronary artery bypass grafts x 3(LIMA-LAD,SVG-DG,SVG-OM) [**2101-10-14**]
History of Present Illness:
This 77 year old man with increasing dyspnea on exertion for
several weeks, had a positive stress test and underwent cardiac
cath at [**Hospital1 **] which showed multivessel disease. He was
transferred to [**Hospital1 18**] for surgical evaluation.
Past Medical History:
Noninsulin dependent Diabetes Mellitus
h/o nephrolithiasis
h/o bladder stones
Gout
hypercholesterolemia
Prostate CA
diverticulosis
s/p Right knee replacement
s/p Right hip replacement
s/p nerve sparing prostatectomy
obstructive sleep apnea
Social History:
Last Dental Exam:Friday [**10-7**] for cleaning-has upper plate
Lives with: wife(has four children)
Occupation: retired engineer/currently works for [**Last Name (un) **] [**Last Name (un) **]
as driver
Tobacco: none
ETOH: none
Family History:
maternal grandmother MI @76yo
Physical Exam:
Admission Physical Exam
Pulse:75 Resp: 14 O2 sat:96% on RA
B/P Right:140/75 Left:
Height: Weight:
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x], 2.5 cm soft, well
circumscribed, soft mass on R upper anterior chest-?lipoma
Heart: RRR [x] Irregular [] no Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] no Edema/Varicosities:
None []
Neuro: Grossly intact[x]
Pulses:
Femoral Right:2+-cath site-no hematoma/bruit Left:2+
DP Right:1+ Left:2+
PT [**Name (NI) 167**]:1+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2101-10-15**] 01:58AM BLOOD WBC-18.6* RBC-4.34* Hgb-13.4* Hct-37.3*
MCV-86 MCH-31.0 MCHC-36.0* RDW-14.6 Plt Ct-188
[**2101-10-11**] 09:25PM BLOOD WBC-8.3 RBC-4.37* Hgb-13.5* Hct-38.0*
MCV-87 MCH-30.9 MCHC-35.5* RDW-14.5 Plt Ct-223
[**2101-10-14**] 01:57PM BLOOD PT-14.4* PTT-29.3 INR(PT)-1.2*
[**2101-10-11**] 09:25PM BLOOD PT-13.8* PTT-24.7 INR(PT)-1.2*
[**2101-10-15**] 01:58AM BLOOD UreaN-14 Creat-0.8 Na-133 K-4.4 Cl-100
HCO3-22 AnGap-15
[**2101-10-11**] 09:25PM BLOOD Glucose-111* UreaN-14 Creat-0.9 Na-143
K-3.7 Cl-106 HCO3-25 AnGap-16
[**2101-10-11**] 09:25PM BLOOD ALT-13 AST-21 AlkPhos-61 Amylase-80
TotBili-0.8
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Inpatient DOB: [**2024-6-28**]
BP (mm Hg): 132/60 Wgt (lb): 212
HR (bpm): 71 BSA (m2): 2.19 m2
Indication: Coronary artery disease going for CABG;
Pre-operative evaluation of vavular function
ICD-9 Codes: 786.05
Test Information
Date/Time: [**2101-10-12**] at 12:11 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Doppler: Full Doppler and color Doppler Test Location: West
Inpatient Floor
Contrast: None Tech Quality: Adequate
Tape #: 2010W000-0:00 Machine: Vivid q-1
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.0 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.6 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.6 m/s
Left Atrium - Peak Pulm Vein D: 0.4 m/s
Left Atrium - Peak Pulm Vein A: 0.3 m/s < 0.4 m/s
Right Atrium - Four Chamber Length: 4.5 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.2 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.3 cm
Left Ventricle - Fractional Shortening: 0.45 >= 0.29
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Left Ventricle - Lateral Peak E': *0.08 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.08 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 9 < 15
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aorta - Arch: 2.1 cm <= 3.0 cm
Aortic Valve - Peak Velocity: 1.1 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 18
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A ratio: 0.78
Mitral Valve - E Wave deceleration time: 169 ms 140-250 ms
Tricuspid Valve - Peak Velocity: 1.7 m/sec
TR Gradient (+ RA = PASP): 18 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). No resting LVOT
gradient. No VSD.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild thickening of mitral valve
chordae. No MS. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. No TS. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: There is an anterior space which most likely
represents a fat pad, though a loculated anterior pericardial
effusion cannot be excluded.
Conclusions
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is an anterior space which most likely
represents a prominent fat pad.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2101-10-12**] 13:07
Brief Hospital Course:
Preoperative testing included a Sleep consult for presumed
obstructive sleep apnea. A sleep study was performed and
pulmonary recommended the use of Autoset CPAP at night. A
machine was arranged for at home at the time of discharge.
On [**2101-10-14**] Mr.[**Known lastname 87184**] was taken to the Operating Room and
underwent coronary artery bypass graft x3,(left internal mammary
artery graft to left anterior descending, reverse saphenous vein
graft to the marginal branch and diagonal branch) with
Dr.[**Last Name (STitle) **]. Please refer to the operative report for further
details. He tolerated the procedure well and was transferred to
the CVICU intubated and sedated in critical but stable
condition.
He awoke neurologically intact and was weaned and extubated
without difficulty. All lines and drains were discontinued in a
timely fashion. Beta-Blocker/Aspirin/Statin and diuresis was
initiated. POD#1 he was transferred to the step down unit for
further monitoring.
Physical Therapy evaluated for stregnth and mobility. The
remainder of his postoperative course was essentially
uneventful, except for some nocturnal confusion which cleared
easily. All narcotics were discontinued and he did well.
On POD#4 he was ready for discharge. All follow up appointments
were advised.
Medications on Admission:
Aspirin 81'
Atenolol 25'
Glucotrol XL 10'
Colchicine 0.6'
Metformin 500"
Allopurinol 300'
Lipitor 20'
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for fever or pain.
2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
7. Glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO once a day.
8. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for fever/pain.
11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
12. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
13. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
14. cpap
Autoset CPAP Machine at HS
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts
s/p right knee replacement
s/p right hip replacement
s/p prostatectomy
hypercholesterolemia
gout
h/o nephrolithiasis
noninsulin dependent diabetes mellitus
obstructive sleep apnea
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) at [**Hospital1 **]
([**Telephone/Fax (1) 6256**]on Thursday, [**11-10**] at 9am
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5874**] ([**Telephone/Fax (1) 6256**]) in [**5-16**] weeks
office will call with this
Please call to schedule appointments with:
Primary Care Dr. [**First Name11 (Name Pattern1) 6644**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 17744**] ([**Telephone/Fax (1) 43460**]) in [**5-16**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2101-10-18**]
ICD9 Codes: 2720, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1074
} | Medical Text: Admission Date: [**2158-2-12**] Discharge Date: [**2158-3-3**]
Date of Birth: [**2097-9-7**] Sex: M
Service: MEDICINE
Allergies:
Simvastatin / Tape [**12-18**]"X10YD / Hydrochlorothiazide /
Eptifibatide / CellCept
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
intubation
mechanical ventilation
arterial line placement
internal jugular venous line placement
ultrasound guided renal biopsy
bronchoscopy with bronchoalveolar lavage
History of Present Illness:
60 M w/ ESRD [**1-18**] Wegener's granulomatosis s/p kidney transplant
([**4-/2154**]) on tacro/cellcept, severe CAD s/p five-vessel CABG
with PFO closure [**12/2154**] and s/p multiple previous PCIs (most
recently in [**2-22**]), sCHF (EF=35%), COPD, PAF, HTN, HLD p/w cough
productive of whitish sputum, sinus tightness, and muscle pain.
He was recently discharged [**2158-1-15**] after a 3-day stay for
evaluation of dyspnea and productive cough when he was found to
have positive Influenza A DFA and was treated w/ 5 day course of
osetalmavir.
.
In the ED VS: , exam was notable for elevated JVD, tachypnea and
bibiasilar rales. He required 4L O2 and SaO2 was 93%. CXR
revealed a new retrocardiac opacity and labs were notable for a
leukocytosis to 15 and BNP of 30,000. O2 was increased to 6L and
pt was satting 93%. He had a BNP of 30,000 (double what it was
last month) and was given 20mg IV lasix with 500cc UOP. He was
empirically tx w/ vanc/levo for PNA per CXR. He was also found
to be in AF w/ rate in 100s, as high as 120s, so was given 25 mg
metoprolol. He was also given IV potassium for a K=2.9.
.
In the ED, initial VS: 100 110 118/76 20 93% 4L
.
In the ICU, pt states his breathing is very difficult, and feels
like when he had flu, except doesn't have the same
fatigue/myalgias he had at that time. Also endorses diarrhea
(nonbloody, nonmelenotic) 4x/day.
.
Denies CP, palpitations, lower extremity edema or orthopena. Has
not increased pillows (baseline 2). Denies dietary or medication
noncompliance.
.
ROS: Denies night sweats, vision changes, sore throat, chest
pain, abdominal pain, nausea, vomiting, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
- Major depression
- CHF EF%35-40%
- Paroxysmal Atrial fibrillation, not on coumadin
- ESRD s/p living donor (sister) renal transplant in [**5-/2154**]
- CAD: s/p CABG CABG x 5 [**2154-12-23**] (LIMA-->LAD, SVG-->D,
SVG-->OM,
SVG-->R-PL-->R-PLV) and PFO closure, (occluded OM and RCA
grafts)
- s/p acute MI [**2143**] with Palmaz LAD and RCA stents
- s/p rotablation and hepacoat stent to the D1 in [**6-/2149**],
treated with brachytherapy for instent restenosis in [**10/2149**]
- s/p Taxus stent in RPL in [**10/2151**]
- s/p two Cypher stents placed in the RCA [**10/2152**]
- cath in [**7-23**] with 60-70% ostial stenosis of LAD, moderate
diffuse disease of LCx, 60% proximal of RCA with in stent
restenosis with a 70% in the PL branch Taxus stent
- Denies h/o DM; however, sugars have been elevated in past
- Chronic angina
- Hypertension
- Hypercholesterolemia
- Wegener's granulomatosis (renal/pulmonary involvement)
diagnosed [**2143**] s/p cytoxan/prednisone x 1y initially, ANCA neg.
since (chronic proteinuria); now s/p renal transplant in [**5-/2154**]
- Idiopathic pericarditis [**2150**]
- GERD
- Anxiety
- Gout
- Umbilical hernia repair
- Restless leg syndrome
- basal cell carcinoma
Social History:
- married for 30+ years with very recent separation from spouse
- 3 adult children whith whom he is very close, and put them all
through college
- bachelor's degree in finance
- was a teacher for numerous years, which he loved and then used
to work in computer sales until his disease progressed
- on SS/SSDI
- loves to play music and write (except cannot motivate himself
to do so currently)
- remote history of smoking, quit 30 years ago, no alcohol or
ilicits.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother had CVA at 46. Sister with scleroderma
and another sister with [**Name (NI) 18109**].
Physical Exam:
Admission Physical Exam:
VS: AF, 97 109/65 28 SaO2 high 80s-low 90s on 100% face tent +
3L NC
GEN: Pleasant man, speaking full sentences w/o HEENT:
Normocephalic, atraumatic. No conjunctival pallor. No scleral
icterus. PERRLA/EOMI. MMM. OP clear, no throat erythema, no
sinus tenderness. Neck Supple, No LAD, No thyromegaly.
CV: Irregularly Irregular , faint. no rubs or gallops. JVP=10cm.
LUNGS: b/l bases with decreased BS, rhonchi, wheezes b/l. No
rales, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXT: Trace edema, 2+ dorsalis pedis/ posterior tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**12-18**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
.
Transfer Physical Exam:
Gen: NAD, very sleepy and difficult to arouse
HEENT: sclera anicteric, OP clear, MMM
CV: irregularly irregular
Lungs: clear anteriorly
Abd: soft, patient reports diffuse tenderness on palpation,
non-distended
Ext: no edema
Neuro: CN II-XII intact, full strength in all extremities
(although requires significant prompting to lift right lower
extremity), alert to person and place, odd affect
Pertinent Results:
ADMISSION LABS:
[**2158-2-12**] 12:10AM BLOOD WBC-15.2*# RBC-4.08* Hgb-11.6* Hct-34.6*
MCV-85 MCH-28.5 MCHC-33.6 RDW-15.0 Plt Ct-181
[**2158-2-12**] 12:10AM BLOOD Neuts-88.7* Lymphs-7.7* Monos-2.4 Eos-0.8
Baso-0.3
[**2158-2-12**] 07:54AM BLOOD PT-14.7* PTT-24.8 INR(PT)-1.3*
[**2158-2-12**] 12:10AM BLOOD Glucose-139* UreaN-37* Creat-2.4* Na-139
K-2.9* Cl-105 HCO3-19* AnGap-18
[**2158-2-12**] 07:54AM BLOOD ALT-20 AST-19 LD(LDH)-222 CK(CPK)-76
AlkPhos-73 TotBili-0.9
[**2158-2-12**] 07:54AM BLOOD Albumin-3.5 Calcium-7.9* Phos-3.7 Mg-1.2*
.
DISCHARGE LABS:
.
MICROBIOLOGY:
[**2158-2-17**] BAL: no bacterial growth, no [**Month/Day/Year 14616**], no PCP, [**Name10 (NameIs) **] AFB,
no CMV
**All blood, urine, and sputum cultures were negative**
.
IMAGING:
[**2158-2-13**] CT SINUS: Bilateral sphenoid sinus, frontal sinuses, and
ethmoidal air cell mucosal thickening. Bilateral mucus-retention
cysts or polyps in the maxillary sinuses.
.
[**2158-2-13**] CT CHEST: Progression of bibasilar consolidations and
pleural effusions concerning for progression of pneumonia.
Opacities previously noted in the right middle lobe, however,
have resolved. Cardiomegaly, but no evidence for CHF. Increased
mediastinal lymphadenopathy, likely reactive in the setting of a
progressive pneumonia. Distended gallbladder.
.
[**2158-2-13**] RENAL TXP US: No hydronephrosis. Resistive indices
ranging from 0.63 to 0.73, slightly increased as compared to the
previous study. Patent main renal artery and renal vein.
.
[**2158-2-20**] CT HEAD: Left middle cerebral artery distribution
infarction without evidence of mass effect or hemorrhage.
.
[**2158-2-21**] TTE: No atrial septal defect or patent foramen ovale is
seen by 2D, color Doppler or saline contrast with maneuvers. LV
systolic function appears depressed. The apex is akinetic. No
masses or thrombi are seen in the left ventricle (Definity
contrast [**Doctor Last Name 360**] used). The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. There is
no pericardial effusion.
.
[**2158-2-22**] CAROTID US: No evidence of stenosis on the right. The
left system was not visualized due to presence of a central
line.
Brief Hospital Course:
60 M w/ ESRD [**1-18**] Wegener's granulomatosis s/p kidney transplant
[**4-/2154**] on tacro/cellcept, severe CAD s/p five-vessel CABG w/
PFO closure in [**2154-12-17**] and s/p multiple previous PCIs,(most
recently in [**2-22**]), sCHF (EF=30%), PAF, HTN/HLD gout, and
depression/anxiety p/w 3 weeks of productive cough and SOB.
.
# HYPOXIC RESPIRATORY DISTRESS: Mr. [**Known lastname 5850**] was admitted from
the ED in respiratory distress w/ increasing O2 requirement,
likely [**1-18**] post-infectious bacterial PNA given recent admission
for Influenza. He was covered broadly for HCAP with
Vanc/Zosyn/Levofloxacin. There was also likely a component of
volume overload that contributed to his respiratory dysfunction
given IVF and antibiotics given in ED in the setting of pt's
poor forward flow (CHF w/ EF~30%). Due to increasing work of
breathing, patient was intubated later on the admission day
[**2158-2-12**]. Chest CT on [**2158-2-13**] demonstrated bibasilar
consolidations and pleural effusions concerning
for progression of pneumonia. As ANCA returned moderately
positive (see below), patient underwent bedside bronchoscopy on
[**2158-2-17**] to rule out bronchial or alveolar hemorrhage.
Bronchoscopy revealed erythematous airways but no obvious
hemorrhages. BAL was negative for PCP, [**Name10 (NameIs) **], AFB, CMV,
fungus or micro-organisms. Patient's vent settings continued to
be weaned and he was extubated on [**2158-2-21**]. Unfortunately, during
a speech and swallow evaluation the following day, he had a
significant aspiration event, which shortly required
reintubation secondary to respiratory distress. He was liberated
from the ventilator on [**2158-2-24**] following the placement of a
large bore NG tube. He did well following extubation. He
completed a 7 day course of levofloxacin for aspiration
pneumonia. He was diuresed with lasix as needed and received
nebs/mucolytics as needed. He underwent another speech and
swallow evaluation and was able to tolerate POs He was stable
on room air at discharge. Recommend continuation of incentive
spirometry and ambulation with PT
.
# ACUTE ON CHRONIC RENAL INSUFFICIENCY: Mr. [**Known lastname 18118**] baseline
Cr was 2.4 as he is s/p renal transplant ([**2153**]) and his
creatinine slowly increased during his admission, with Cr peak
at 5.4. This was thought to be [**1-18**] ATN from poor perfusion due
to hypotension and hypoxemia. The renal transplant team followed
the patient closely during his hopsital course, monitoring his
renal function and immunosuppression with tacrolimus and
mycophenolate. Tacro levels were checked daily and adjusted
accordingly. Pt's urine sediment was consistent w/ ATN showing
muddy brown casts but no acanthocytes indiciative of glomerular
injury. Due to a reported moderately positive ANCA sent from
[**Hospital1 2025**], there was concern for recrudescence of Wegener's
granulomatosis and patient underwent urgent bedside renal biopsy
on [**2158-2-17**]. He was given DDVAP 1 hr prior to biopsy given uremic
platelets as well as 6 units of platelets. Cardiology was
consulted to determine whether patient could safely go off
[**Date Range **]/[**Date Range **] for biopsy but given pt's multiple cardiac risk
factors and severe CAD, he was kept on [**Date Range **]/[**Date Range **], with only SC
heparin being held for the biopsy. Biopsy was consistent with
ATN without evidence of Wegener's or rejection, but final
pathology is pending. Creatinine started to trend down after
peak of 5.4 on [**2-16**] and was 3.7 at discharge. All medications
were renally dosed. He should continue sodium bicarbonate
supplementation. He should continue to have creatinine
monitored as well as tacrolimus trough (weekly) and should
follow-up with renal as an outpatient.
.
# ATRIAL FIBRILLATION: Pt has hx paroxysmal atrial fibrillation.
Prior records show that he was initially anticoagulated on
Coumadin until [**2153**] when it was discontinued due to severe
epistaxis requiring transfusions as well as difficulty
controlling his INR. Pt's rate was initially controlled on home
metoprolol 150mg [**Hospital1 **] but he frequently was tachycardic in atrial
fibrillation and required some additional IV lopressor. On [**2-18**]
he was changed to 100mg metoprolol q6h, which helped somewhat,
and he was also loaded with amiodarone on [**2-22**], with a
significant improvement in his rate control. His cardiologist,
Dr.[**Name (NI) **], was contact[**Name (NI) **] for advice on continuing the
amiodarone and a formal cardiology consult was initated.
Additionally, he was started on a heparin drip for bridge to
coumadin given stroke (see below). He will be discharged on
amiodarone 200 mg daily and metoprolol 100 mg q6. He should
follow-up with cardiology as an outpatient.
.
# LMCA INFARCT: On [**2-20**] while examining patient to determine
mental status for potential extubation, it was noted that
patient's affect was abnormal, he did not track past midline and
was not following commands. His right side was noted to be
weaker than the left and he seemed to have some right-sided
neglect but this was difficult to assess given sedation. A STAT
head CT revealed an infarct in the left middle cerebral artery
territory, that was likely several days old per radiology
without mass effect, midline shift or hemorrhage. Neurology was
consulted who felt the patient's exam was out of proportion to
the size of the infarct and that his mental status changes could
be secondary to toxic/metabolic encephalopathy. Neurology also
recommended repeat TTE w/ bubble study which showed no LV or
atrial thrombus and no clear PFO although this was a limited
study. Neurology felt that the source of the infarct was likely
embolic and he was started on a heparin gtt/coumadin. PT/OT
worked with patient and he will be discharged to rehab facility.
He will be discharged on coumadin with INR goal 2.0 - 3.0 and
should continue to have coag panel monitored
.
# DIARRHEA: Mr. [**Known lastname 5850**] suffered from significant diarrhea
while hospitalized. He had several negative stool cultures and
Cdiff tests. It was felt that this diarrhea was attributable to
his immunosuppressant, Mycophenolate. He has had this issue in
the past and was successfully switched to a different formula,
however this formulation was not available in a form that could
be given while he was intubated. A flexiseal was placed to help
protect his skin from breakdown given his volume of stool. After
passing the speech and swallow evaluation, the diet was advanced
and his normal formulation of mycophenolate was restarted. The
rectal tube was removed. He should follow-up with the renal
team as an outpatient
.
#Abdominal Wall Hematoma: On transfer from the unit to the
medical floor, it was observed that the patient complained of
significant pain on palpation of his RLQ (location of renal
graft). A KUB was unremarkable. Renal US was performed and was
initially read as a renal hematoma w/ concern for ?renal
aneursym. Transplant surgery recommended a CT scan which
revealed that the hematoma was actually an abdominal wall
hematoma with concern for active bleeding from R inferior
epigastric artery. Due to a drop in Hct, the patient was taken
for IR embolization on [**2158-2-28**]. He tolerated the procedure well
without complication. He was transfused PRBC and his Hcts
remained stable. His heparin gtt/coumadin was held for the
procedure and was restarted 4 hours after the procedure per IR
recs.
.
# CHRONIC SINUS CONGESTION: Mr [**Known lastname 18118**] main concern on
admission was his chronic debilitating sinus congestion which
has been evaluated extensively as an outpatient. He underwent CT
sinus on [**2158-2-13**] revealed sinus air cell tickening. [**Date Range **] was not
consulted in the ICU given patient's multiple pressing issues.
It is recommended that he follow-up with [**Date Range **] as an outpatient.
.
#CAD/CHF: Patient has extensive cardiac history including 5
vessel CABG and multiple PCI as well as a history of CHF.
[**Date Range **] and aspirin were continued throughout his hospital stay.
He received IV lasix for diuresis while in the unit and was
transitioned to his home dose of lasix. Lisinopril was held
given his renal issues described above. Nifedipine was
initially held and was gradually re-introduced at a low dose.
He should be seen by cardiology for further medication
adjustments and consideration of cardiac rehab in the future.
.
# DEPRESSION: His home zoloft was continued. He was evaluated by
psychiatry as an inpatient in the contect of agitation/delirium.
Haldol was started and will be continued at discharge per
recommendatino of the accepting facility. We recommend weaning
it off over the next week as the patient continues to improve.
The patient has an extensive history of depression in the past
and is at risk for post-stroke depression. He should have
follow-up with neurology/social work.
Medications on Admission:
ASPIRIN - 325 MG daily
ATORVASTATIN [LIPITOR] - 10 mg daily
AZELASTINE [ASTELIN] - 137 mcg Aerosol 2 puffs [**Hospital1 **]
CLOPIDOGREL [[**Hospital1 **]] - 75 mg daily
FLUTICASONE - 50 mcg Spray [**12-18**] sprays Qdaily
FUROSEMIDE [LASIX] - 40 mg daily
IPRATROPIUM BROMIDE - (Not Taking as Prescribed) - 21 mcg Spray
[**Hospital1 **]
LISINOPRIL - 40 mg Tablet - 2 Tablet(s) by mouth once a day (??
dose per patient)
METOPROLOL SUCCINATE - 150 mg [**Hospital1 **]
METRONIDAZOLE [METROLOTION] - 0.75 % Lotion [**Hospital1 **]
MYCOPHENOLATE SODIUM [MYFORTIC] - 360 mg Tablet, 2 tabs [**Hospital1 **]
NIFEDIPINE - 90 mg daily
PANTOPRAZOLE [PROTONIX] - 40 mg [**Hospital1 **]
PIOGLITAZONE [ACTOS] - 15 mg [**Hospital1 **]
SERTRALINE - 150mg daily
TACROLIMUS - 1.5 mg [**Hospital1 **]
CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit daily
GENERIX T - Tablet - 1 Tablet(s) by mouth daily
GUAIFENESIN [MUCINEX]
SENNA
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Astelin 137 mcg Aerosol, Spray Sig: Two (2) Nasal twice a
day.
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. fluticasone 50 mcg/Actuation Spray, Suspension Sig: [**12-18**]
Sprays Nasal [**Hospital1 **] (2 times a day).
6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. ipratropium bromide Nasal
8. metronidazole 0.75 % Lotion Sig: One (1) application Topical
twice a day as needed for as needed .
9. mycophenolate sodium 360 mg Tablet, Delayed Release (E.C.)
Sig: Two (2) Tablet, Delayed Release (E.C.) PO twice a day.
10. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
11. sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
12. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
13. generix Sig: One (1) once a day.
14. Mucinex Oral
15. senna Oral
16. nifedipine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO DAILY (Daily).
Disp:*30 Tablet Extended Release(s)* Refills:*2*
17. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 PM: monitor INR weekly and adjust dose accordingly.
Disp:*30 Tablet(s)* Refills:*2*
18. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
19. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours): hold for heart rate < 60 or SBP < 100.
Disp:*240 Tablet(s)* Refills:*2*
20. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours): renally adjust dose.
Disp:*30 Capsule(s)* Refills:*2*
21. insulin lispro 100 unit/mL Solution Sig: as directed
Subcutaneous ASDIR (AS DIRECTED).
Disp:*30 mL* Refills:*2*
22. haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*30 Tablet(s)* Refills:*1*
23. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
24. calcium acetate 667 mg Tablet Sig: One (1) Tablet PO three
times a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
PRIMARY:
Atrial Fibrillation with RVR
Stroke
acute tubular necrosis
pneumonia, post-infections bacterial
pneumonia, aspiration
SECONDARY:
End stage renal disease s/p transplant
Congestive heart failure
Coronary artery disease s/p cagb and multiple PCI
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you Mr [**Known lastname 5850**]. You were
admitted to the hospital with difficulty breathing which was
likely due to a post-infectious bacterial pneumonia given your
recent bout of influenza. Because it was so difficult to
breathe, you required mechanical ventilation (breathing machine)
and were treated with antibiotics. You also had a stroke while
you were in the hospital and you were started on anticoagulation
medications. Your renal function worsened and you had a renal
biopsy which showed acute tubular necrosis. Your renal function
gradually improved. You were found to have an abdominal wall
hematoma and you underwent an interventional radiology procedure
to stop the bleeding.
The following changes were made to your medications:
-START amiodarone 200 mg once a day
-START warfarin 2.5 mg once a day. This dose may be adjusted
based on your INR. You should have your INR checked weekly
-STOP Metoprolol Succinate.
- START Metoprolol tartrate 100 mg every 6 hours.
-STOP lisinopril
-DECREASE nifedipine to 30 mg once a day
-STOP pioglitazone
-START Insulin according to sliding scale
-DECREASE tacrolimus to 1 mg twice a day
-START Sodium Bicarbonate 650 mg twice a day
-STOP Sevelamer
-START Calcium Acetate 667 mg three times a day
-START Haloperidol 0.5 mg twice a day - the duration of this
medication will be determined by your primary physician.
.
Please continue your other home medications
Followup Instructions:
The following appointments have been made for you:
Department: CARDIAC SERVICES
When: TUESDAY [**2158-3-14**] at 11:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: TUESDAY [**2158-5-2**] at 7:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
You have been placed on a cancellation list for this
appointment.
Department: WEST [**Hospital 2002**] CLINIC (Nephrology)
When: WEDNESDAY [**2158-3-8**] at 12:00 PM
With: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
ICD9 Codes: 5845, 2762, 2760, 2851, 4280, 496, 2724, 5859, 311, 2768, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1075
} | Medical Text: Admission Date: [**2205-10-13**] Discharge Date: [**2205-10-18**]
Date of Birth: [**2134-9-28**] Sex: F
Service: MEDICINE
Allergies:
Dapsone / Cyclosporine / Cefepime / Aztreonam / Azithromycin /
Vancomycin
Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
Diarrhea and weakness
Major Surgical or Invasive Procedure:
thrombectomy
History of Present Illness:
70-year-old woman with a history of non-Hodgkin's lymphoma s/p
SCT in [**2199**] with complications of chronic GVHD and
nephrotoxicity, ESRD on HD (T/Th/S), who presented with diarrhea
and weakness. She has had URI this past week with a sore throat,
mild cough, malaise associated with worsening pain in her left
eye (has chronic post-herpetic neuralgia which can be worse w/
colds) for which she saw her PCP and was prescribed an eye
ointment. Patient had fever Thursday to 100.4, otherwise
afebrile but having chills.
.
Also had watery, non-bloody diarrhea starting on Wednesday and
continuing through today. Initially improved some, but was worse
again today and after large volume diarrhea she felt weak/faint
and needed support from her husband to walk. She called the
oncology office and was told to come into ED for eval. In
addition, the patient's AV graft could not be accessed yesterday
at HD so she did not have dialysis.
.
In the ED, initial VS were: 98.0 100 107/66 20 98%. Labs were
remarkable for a K of 5.2. CXR showed clear lungs, Patient
initially spiked fevers to 100.4. Blood cultures were sent and
patient recived linezolid 600 mg IV x1. She then spiked a fever
to 102 degrees and developed a new oxygen requirement (89% on
RA, came up to 97% on 4L NC) and became hypotensive (SBPs 70s -
80s). Given fever, antibiotics were broadened to IV zosyn,
patient received tylenol 1 gram PO x1, 300 cc bolus of NS. Her
blood pressure remained low - patient received a total of 1.3L
NS, but required levophed gtt at 0.3. On transfer vitals were
102, 120, 18, 120/57 on 0.3 of Norepinephrine.
.
On arrival to the MICU, patient feels better than she did
earlier today. She complains of sore throat. No nausea,
vomiting, abdominal pain, melena, BRBPR, cough, chest pain,
shortness of breath.
.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness. Denies cough, shortness of breath,
or wheezing. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
.
Past Medical History:
PMH:
- Large Cell Lymphoma: Diagnosed [**2197**], initially received RCHOP
and ICE then relapsed and now s/p allogeneic SCT in [**6-12**], c/b
GVHD.
- Chronic Graft vs Host Disease, mild (cutaneous, liver)
- ESRD: Unclear if secondary to chemo, cyclosporine, or GVHD.
Had LUE AV fistula placed but has occluded L brachiocephalic
vessel on fistulagram then had graft placed in RUE which
required required angioplasty in [**1-/2205**]
- s/p thyroidectomy for thyroid mass, pathology was benign
- herpes zoster c/b post-herpetic neuralgia s/p nerve block
- hyperlipidemia
- prior moderate-to-severe mitral regurgitation and nonischemic
cardiomyopathy (EF 30-40%). Possible etiologies include focal
myocarditis, coronary artery disease (although coronary disease
on catheterization did not fit a coronary territory),
cardiotoxic chemotherapy
- E Coli bacteremia
- Parainfluenza Type 3 Virus bronchitis [**4-/2204**]
Social History:
18-pack-year smoker, quit 40 years ago. She drinks alcohol
rarely. She is married and lives with her husband. She has two
adult children. She is now retired. Formerly worked in human
resources at a department store.
Family History:
No fam history of blood clots. Mother deceased age 87 of
cerebral hemorrhage. Father deceased age 48 of malignant
hypertension. Aunt deceased from breast cancer. Brother deceased
of massive MI at the age of 66. Additional brother with
hypertension and emphysema.
Physical Exam:
Vitals: T: 98.2 BP: 127/40 P: 115 R: 18 18 O2: 100% on 4L NC,
CVP of 4
General: Alert and oriented x3, appears slightly uncomfortable
HEENT: Sclera anicteric, slightly dry mucus membrane, PERRLA,
EOMI, left eyelid droop (documented in prior notes)
Neck: supple, JVP not elevated, no LAD
CV: Tachy, S1, S2, [**1-13**] apical systolic murmur, nonradiating
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, RUE graft with no thrill
Neuro: CNII-XII grossly intact, 5/5 strength upper/lower
extremities, grossly normal sensation
.
On discharge patient's tachycardia had resolved. The thrill had
returned in her fistula. He overall plume status was euvolvemic
with resolution of lower extremity edema.
Pertinent Results:
[**2205-10-17**] 10:29AM BLOOD WBC-9.8 RBC-2.76* Hgb-9.0* Hct-27.0*
MCV-98 MCH-32.7* MCHC-33.5 RDW-15.2 Plt Ct-286
[**2205-10-13**] 07:25PM BLOOD Neuts-82.8* Lymphs-7.6* Monos-3.1
Eos-6.3* Baso-0.1
[**2205-10-14**] 04:39AM BLOOD PT-14.0* PTT-36.4* INR(PT)-1.2*
[**2205-10-17**] 10:29AM BLOOD Glucose-127* UreaN-40* Creat-6.0*# Na-133
K-3.6 Cl-99 HCO3-20* AnGap-18
[**2205-10-13**] 12:20PM BLOOD ALT-12 AST-26 AlkPhos-65 TotBili-0.2
[**2205-10-17**] 10:29AM BLOOD Calcium-7.8* Phos-3.4 Mg-2.4
[**2205-10-13**] 07:25PM BLOOD Cortsol-20.6*
[**2205-10-14**] 04:58PM BLOOD IgG-741 IgA-LESS THAN IgM-30*
[**2205-10-15**] 06:30AM BLOOD Type-ART Temp-35.8 Rates-/20 O2 Flow-2
pO2-111* pCO2-37 pH-7.52* calTCO2-31* Base XS-7 Intubat-NOT
INTUBA
.
C difficile Toxin PCR POSITIVE
Semi-Urgent Result
Specimen Source: Stool
This test was developed and is performance characteristics
determined by
Laboratory Medicine and Pathology, [**Hospital3 14659**]. This test has
not been
cleared or approved by the U.S. Food and Drug Administration.
Special Information
Specimen received in transport media.
Report Status: Final
Result reported to Dr [**Last Name (STitle) **] [**10-17**] am.
.
PA AND LATERAL CHEST, [**10-16**]
HISTORY: 71-year-old woman with cough, rule out pneumonia.
IMPRESSION: PA and lateral chest compared to [**10-13**] through
8:
There is still residual consolidation in the left lung, close to
the posterior
heart border and lower lobe, but probably improved since the
yesterday's
examination. Lungs are otherwise clear. Heart size is normal.
Small left
pleural effusion has increased since [**10-14**]. Heart size is
normal. Right
jugular line ends in the mid SVC. [**Month (only) **] clips denote prior
surgery in the
region of the thyroid.
.
Final Report
CT TORSO DATED [**2205-10-14**]
INDICATION: A 71-year-old woman with history of non-Hodgkin's
lymphoma status
post stem cell transplant, presenting with diarrhea, fevers, and
hypertension.
The patient also with new oxygen requirement. Evaluate for
pneumonia.
Evidence of GI infection. Evaluate for possible GI source of
infection,
colitis or abscess.
TECHNIQUE: Axial MDCT images acquired from the thoracic inlet to
the pubic
symphysis following oral and uneventful IV Optiray
administration. Coronal
and sagittal reformats were obtained.
COMPARISON: Comparison is made to multiple previous PET-CTs most
recently
[**2204-12-26**].
FINDINGS: Previous thyroidectomy noted. The previously noted
2-mm right
lower lobe nodule is not identified on the current study. There
is no
pathologically enlarged axillary, mediastinal, hilar or
supraclavicular
adenopathy. There are small bilateral pleural effusions which
are new with
overlying atelectasis. NG tube with tip within the stomach.
Right-sided
internal jugular central venous catheter with tip at the distal
SVC.
There is diffuse ground-glass opacity within both lungs with
interlobular
septal thickening which may be due to pulmonary edema. There is
diffuse
peribronchial wall thickening involving the lower lobe bronchi
bilaterally
which is more marked than previously.
CT ABDOMEN: The liver, spleen, and both adrenal glands are
normal in
appearance. Stable gallstone within the gallbladder. There is no
gallbladder
wall thickening or pericholecystic fluid.
Both kidneys are atrophic in appearance. There are bilateral
hypodensities in
both kidneys, which are too small to characterize. The common
bile duct
measures 6.5 mm within the head of the pancreas which is
unchanged from
previous CTs. The pancreas is normal in appearance. The spleen
is normal in
appearance. There is an oblong area measuring 1.9 x 0.5 cm in
the left
periaortic region (3:57), which may represent a vessel or less
likely a lymph
node and is unchanged in appearance from previous CTs.
There is no free fluid. There is no free air. There is fluid
within the
ascending colon. There is no evidence of colonic wall thickening
or edema.
There is no evidence of obstruction or free air.
CT PELVIS: There is a persistent area of thickening along the
left side of
the anorectal junction (3:123), which is unchanged from previous
and poorly
delineated by CT. There is a Foley catheter within the bladder.
There are
bilateral fat-containing inguinal hernias. There is no free
fluid.
VASCULATURE: There is 50% stenosis at the origin of the celiac
artery. The
SMA is patent. There is mild-to-moderate atherosclerotic
calcification of the
intraabdominal aorta which is of normal caliber. The IVC is of
normal caliber.
OSSEOUS STRUCTURES: There are degenerative changes throughout
the lumbar and
thoracic spine without evidence of suspicious osseous lesions.
IMPRESSION:
1. Diffuse ground-glass opacity with interlobular septal
thickening, most
likely due to pulmonary edema. No evidence for pneumonia.
2. Bilateral lower lobe peribronchial wall thickening, which may
be due to
infection including severe bronchitis, although neoplastic
involvement
(lymphoma) cannot be excluded. This appears worse than previous
CT of
[**2204-12-26**].
3. Small bilateral pleural effusions with overlying atelectasis.
4. Atrophic kidneys with bilateral hypodense areas, which are
too small to
characterize.
5. Persistent apparent thickening of the left anorectal
junction, which is
unchanged from previous CTs, and could be better assessed with
MRI, US or
direct visualization if clinically indicated.
6. 50% stenosis of the origin of the celiac artery.
7. Cholelithiasis without evidence of acute cholecystitis.
Wet read provided by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4033**] on [**2205-10-14**] at 2:13am on
CCC.
1. No definite radiographic explanation for patient's
fever/hypotension. 2.
Fluid in the ascending colon is consistent with provided history
of diarrhea,
although there is no associated bowel wall thickening or
significant
pericolonic fat stranding to suggest colitis. 3. No evidence of
pneumonia.
Bilateral lower lobe bronchial wall thickening and
bronchiectasis could be due
to small airways disease or chronic aspiration. 4.
Cholelithiasis, as on CT
from [**2204-12-26**]. 5. Atrophic kidneys, as before. Small right renal
hypodensity is
too small to characterize.
.
[**10-14**] Echo
The left atrium and right atrium are normal in cavity size. The
estimated right atrial pressure is 0-5 mmHg. Left ventricular
wall thickness, cavity size, and global systolic function are
normal (LVEF>55%). Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. Mild mitral regurgitation. Pulmonary artery
hypertension.
Compared with the prior study (images reviewed) of [**2204-10-29**],
aortic regurgitation is not seen on the current study (may be
due to technical issues) and PA systolic hypertension is now
identified. The remaining findings are similar.
CLINICAL IMPLICATIONS:
Based on [**2200**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
.
Head CT
INDICATION: 71-year-old woman with head trauma to the occiput
status post
fall, evaluate for trauma.
COMPARISON: CT head with and without contrast [**2203-12-7**].
FINDINGS:
There is no evidence of intracranial hemorrhage, masses, mass
effect, or shift
of normally midline structures. Ventricles and sulci are
prominent consistent
with age-related involutional changes. Mild periventricular and
subcortical
white matter low-attenuating regions are consistent with
sequelae of chronic
small vessel ischemic disease. There is no evidence of acute
fracture.
Bilateral mastoid air cells are clear. Mild mucosal thickening
is noted in
bilateral maxillary sinuses, right greater than left as well as
within the
anterior ethmoid air cells. Calcifications are noted within the
carotid
siphons. Minimal scalp hematoma over the left fronto-parietal
region is noted.
IMPRESSION:
Minimal scalp hematoma over the left fronto-parietal region is
noted.
Otherwise normal examination.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 8575**] [**Name (STitle) 8576**]
.
Sputum Culture
GRAM STAIN (Final [**2205-10-14**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2205-10-18**]):
SPARSE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. SPARSE GROWTH.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- R
Brief Hospital Course:
70-year-old woman with a history of NHL s/p SCT in [**2199**] with
complications of chronic GVHD and nephrotoxicity, ESRD on HD,
who initially presented with diarrhea and weakness, now with
hypotension requiring pressors.
.
# Hypotension: The patient had hypotension. She was started on
broad spectrum antibiotics. Although initial imaging was
negative, subsequent films showed a pneumonia and a sputum grew
MSSA. A Cdiff PCR was positive. The patient was treated with
dicloxacillin and flagyl and discharged for a total 21 day
course. She completely stabilized on this regimen. Her
antihypertensives were held during this stay and her primary
outpatient team should consider restarting them if clinically
indicated.
.
# Altered Mental Status: Patient presented with confusion in ED
in setting of fever. Likely toxic metabolic encephalopathy in
setting of possible infection. CT scan of head in ED showed no
acute intracranial process. No evidence of seizure. Patient with
slight confusion on admission to ICU, but was A&Ox3. This
cleared completely as her infections resolved.
.
# Thrombosis of AV fistula: The patient had a thromboses
fistula. IR was unable to remove the thrombus and left a piece
of wire in the fistula. Transplant surgery subsequently removed
the foreign body and the thrombosis. The fistula was used
successfully prior to discharge.
.
# ESRD on HD: Continued on HD.
.
# Hypothyroidism: Continued levothyroxine 112 mcg daily
.
# Dyslipidemia: Continued simvastatin 60 mg daily
.
CODE STATUS: DNR, ok to intubate
Medications on Admission:
Dexamethasone 0.5 - 1 mg TID as needed for GVHD
Epoetin with dialysis
Gabapentin 100 mg QID
Levothyroxine 112 mcg daily (except [**12-9**] tab on sunday)
Lidocaine-prilocaine 2.5% - 2.5% cream apply as directed before
dialysis
Lisinopril 2.5 mg daily (hold on day of dialysis)
Metoprolol succinate 12.5 mg qPM
Nortriptyline 10 mg qHS
Oxycontin 10 mg daily
Oxycodone 5 mg Q6 - 8 H PRN
Prednisone 2.5 mg daily
Simvastatin 60 mg qHS
Zolpidem 5 - 10 mg qHS
Aspirin 81 mg daily
Nephrocaps
Calcium carbonate 2 tabs TID
Cholecalciferol 400 units [**Hospital1 **]
Discharge Medications:
1. Cepacol Sore Throat 15-2.6 mg Lozenge Sig: One (1) lozenge
Mucous membrane five times a day as needed for sore throat.
2. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
3. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
5. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
8. OxyContin 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO once a day as needed for pain.
9. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily): take [**12-9**] tab on Sunday.
10. nortriptyline 10 mg Capsule Sig: One (1) Capsule PO at
bedtime.
11. gabapentin 100 mg Capsule Sig: One (1) Capsule PO four times
a day as needed for pain.
12. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 17 days.
Disp:*51 Tablet(s)* Refills:*0*
13. dicloxacillin 500 mg Capsule Sig: One (1) Capsule PO four
times a day for 17 days.
Disp:*68 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
MSSA pneumonia
C diff infection
hypotension
thrombosed fistula
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with low blood pressure and
diarrhea. You were found to have a pneumonia and an infection
in your colon, and both have improved with antibiotics. Your
fistula was shown to have a clot in it that was removed by our
transplant surgeons.
Medication changes:
1) START Metronidzole 500mg orally 3x a day for 17 days
2) START Dicloxacillin 500mg 4x a day for 17 days.
3) STOP Lisinopril
4) STOP Metoprolol
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Please follow up with your providers as below.
Followup Instructions:
Provider: [**Name10 (NameIs) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2205-10-29**]
10:00
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2205-11-29**] 12:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2206-3-31**] 11:00
[**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]
Completed by:[**2205-10-20**]
ICD9 Codes: 0389, 5856, 2762, 4254, 4280, 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1076
} | Medical Text: Admission Date: [**2113-4-24**] Discharge Date: [**2113-4-30**]
Date of Birth: [**2039-2-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Hypokalemia, weakness.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
74 year old female with metastatic breast cancer on chemo (CMF,
last tx [**2113-4-7**]) x3 wks with mucositis since presents with
increasing fatigue/weakness and hypokalemia to 2.1. Of note, the
patient was treated for ATN due to port-a-cath infection with
sepsis and she has been on lasix at home since discharge in [**Month (only) **]
[**2112**]. She reports poor po's due to mucositis and thrush over
the past several weeks. Routine blood work revealed the
hypokalemia and she was referred into the ED this afternoon for
further treatment.
.
In the ED, initial vitals were 97.8, HR 96, BP 96/60, RR 16,
O2sat 100%. Electrolyte abnormalities included K 2.1 and Mg 2.0
for which she received 40 mEq IV KCl and 2 gm IV magnesium
sulfate as well as an additional 3L IV NSS. EKG was without QTc
or U waves. SBP's were 85-low 90's. Of note, one lumen of her
power PICC was clotted so TPN was instilled prior to transfer.
Vitals on transfer were T 98.0 HR 90 BP 90/60 RR 16 Sats 100% on
RA.
.
The patient reports persistent fatigue. She denies fever or
chills, nausea, vomiting or diarrhea.
Past Medical History:
Past Oncologic History:
Her breast cancer was first diagnosed in [**2098**]. She has undergone
lumpectomy in both breasts with XRT. She has been on Zometa for
several years. Chemotherapies included Arimidex, then Faslodex,
then Xeloda, then Navelbine, then Taxotere, then Gemzar, then
Doxil x11 cycles, then Abraxane/Avastin, which she continues
currently. C9 was completed in [**12-7**].
.
Other Past Medical History:
Mild Asthma- cough variant
HTN
Hyperlipidemia
Social History:
Lives with daughter in [**Name (NI) 1411**].
- Tobacco: none
- etOH: very rare
- Illicits: none
Family History:
father - CHF, COPD
mother - mesenteric cancer
Physical Exam:
Tmax: 35.3 ??????C (95.5 ??????F), Tcurrent: 35.3 ??????C (95.5 ??????F), HR: 90 (90
- 91) bpm, BP: 111/11(39) {111/11(39) - 111/11(39)} mmHg, RR: 14
(14 - 15) insp/min, SpO2: 98%
General Appearance: Well nourished, No acute distress, Non-toxic
Eyes / Conjunctiva: PERRL, Pupils dilated, Mucous membranes
tacky
Head, Ears, Nose, Throat: Normocephalic
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : b/l)
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right lower extremity edema: 1+, Left lower
extremity edema: 1+
Skin: Not assessed
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Tone: Not assessed
Pertinent Results:
Admission Labs:
[**2113-4-24**] 06:32PM BLOOD WBC-2.1* RBC-3.49* Hgb-10.4* Hct-31.5*
MCV-90 MCH-29.8 MCHC-33.0 RDW-19.7* Plt Ct-299#
[**2113-4-24**] 06:32PM BLOOD Neuts-35* Bands-3 Lymphs-37 Monos-15*
Eos-7* Baso-0 Atyps-3* Metas-0 Myelos-0
[**2113-4-24**] 11:30AM BLOOD UreaN-33* Creat-1.7* Na-130* K-2.1*
Cl-92* HCO3-21* AnGap-19
[**2113-4-24**] 11:30AM BLOOD ALT-26 AST-61* AlkPhos-288* TotBili-1.2
[**2113-4-25**] 03:11AM BLOOD LD(LDH)-204
[**2113-4-24**] 11:30AM BLOOD Calcium-8.7 Phos-3.7 Mg-2.0
[**2113-4-25**] 03:35AM BLOOD Lactate-1.8
.
Potassium Trend:
[**2113-4-24**] 11:30AM K-2.1*
[**2113-4-24**] 06:32PM K-2.5*
[**2113-4-25**] 03:11AM K-2.9*
CXR: 1. Unchanged course of the left PICC catheter with tip
projecting over distal SVC. 2. Persistent small pleural
effusions with associated atelectasis. 3. Diffuse osseous
metastasis and old rib fractures.
TTE: The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 70%). The right ventricular cavity is dilated The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. There is a
trivial/physiologic pericardial effusion. There is an anterior
space which most likely represents a prominent fat pad. Compared
with the findings of the prior study (images reviewed) of [**2113-1-13**], probably no major change but the technically
suboptimal nature of the present study precludes definitive
comparison.
Brief Hospital Course:
Ms. [**Name (NI) 13337**] is a 74 year old female with metastatic breast
cancer on chemo (CMF, last tx [**2113-4-7**]) x3 wks with mucositis
presents with increasing fatigue/weakness and hypokalemia to 2.1
in the setting of dehydration and diuretic use.
* [**Name (NI) **] Pt hypotensive to 80s-low 90s in ED, down from
baseline of 90s to low 100s. Thought most likely [**1-31**]
dehydration, although given her positive PICC line culture,
there may have been a component of sepsis. Pt does have a
history of a small pericardial effusion and low voltage on EKG
in the ED, although no other overt signs of tamponade. TTE was
obtained and showed a small pericardial effusion and no signs of
tamponade. IVF resuscitation was continued overnight with an
additional 2L overnight in addition to the 3L the patient
received in the ED, with improvement in her blood pressures to
100's to 110's systolic, which remained stable during her
hospitalization.
* Bacteremia - On the day of admission, had blood culture drawn
that returned positive for enterococcus and GNR, which were
later identified as Enterobacteria. Additionally, the tip of
the catheter was "tortuous" as seen in her CXRs. Given these
two factors, her PICC line was pulled and was given a 48 hour
line holiday. The PICC was replaced on [**2113-4-28**]. She was
started empirically on vanco/cefepime. Once sensitivities
returned, she was transitioned to ampicillin and cefepime.
While Enterobacteria was sensitive to Cipro, Cefepime will be
continued since it is cheaper, is once a day, and patient is
paying out of pocket for IV antibiotics. TTE was negative for
vegetations. She refused a CT scan in the hospital for further
work up her bacteremia.
* [**Name (NI) 13338**] The pt received 40 mEq IV KCl in the ED then an
additional 40 mEq IV KCl immediately on arrival to the MICU.
She then received 2L of D5NS with 40 mEq KCl/L and an additional
20 mEq IV KCl, with improvement in her potassium to. She was
given 50mEq KCL to take daily, and Lasix moved to 40mg [**Hospital1 **] (8am
& 1pm). Outpatient Labs to be checked Mon [**2113-5-1**] and sent to
Dr.[**Name (NI) 13339**] office. It was thought that admission hypokalemia
was due to non-compliance with potassium supplements.
* Hypomagnesemia- Received 2g Magnesium repletion in the ED with
resolution.
* Chronic renal insuffiency (stage 3) - Lasix was initially
held, but restarted on [**2113-4-28**], and adjusted to 40mg [**Hospital1 **] on
discharge. She will go home with potassium supplements. She
will need chem panels checked at home on Monday by VNA after
discharge to ensure stability.
* Port a cath wound infection - She suffered from this wound
infection in [**12/2112**], but the wound remains open. Wound care was
consulted and they had made recommendations to obtaining a
surgical consultation. Surgery was called and felt no need for
debridement, but recommeded plastics consult and breast consult
in future given wound and h/o breast cancer. This can be done as
an outpatient. She will need continued VNA care of her wound
after discharge.
Medications on Admission:
1. Advair 100/50 one inhalation b.i.d.
2. Pravastatin 40 mg once at night.
3. Compazine 10 mg every six hours as needed for nausea.
4. Metolazone 5 mg once daily.
5. Furosemide 40 mg once daily. (Reduced from 120 mg daily for
decreased po's)
6. Potassium 120 mEq daily.
7. Nystatin 5 ml four times a day swish and swallow.
8. Colace 100 mg b.i.d.
9. Spironolactone 12.5 mg daily
Discharge Medications:
1. Nystatin 100,000 unit/mL Suspension Sig: One (1) PO Q8H
(every 8 hours).
[**Year (4 digits) **]:*30 ml* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Ampicillin Sodium 1 gram Recon Soln Sig: One (1) grams (Recon
Soln(s)) Injection Q6H (every 6 hours): through [**2113-5-11**].
[**Month/Day/Year **]:*50 doses* Refills:*0*
6. Cefepime 2 gram Recon Soln Sig: Two (2) grams (Recon Soln(s))
Injection Q24H (every 24 hours): Give through [**2113-5-11**] unless
otherwise specified by primary MD.
[**Last Name (Titles) **]:*15 doses* Refills:*0*
7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
8. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig:
Five (5) Tab Sust.Rel. Particle/Crystal PO once a day.
[**Last Name (Titles) **]:*180 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice daily:
take at 8AM and 1PM.
[**Last Name (Titles) **]:*60 Tablet(s)* Refills:*2*
10. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Three
(3) ML Intravenous Q8H (every 8 hours) as needed for line flush.
[**Last Name (Titles) **]:*500 ML(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Bacteremia
Hypokalemia
Mucositis
Breast Cancer
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with low blood pressures and
low potassium. You were initially sent to the ICU and had your
potassium repleted. Your blood cultures returned positive for
bacteria and you were started on 2 IV anitbioics. The PICC line
was removed and replaced. Your oncologist will need to follow
the culture data and adjust your antibiotics as needed.
You will need your potassium checked, and this will be arranged
for tomorrow by VNA, and results sent to Dr.[**Name (NI) 13339**] office.
Your chest wound was evaluated by the wound nurse and general
surgical service. Recommendation was made to have this evaluated
by breast and plastics surgical services. This recommendation
has been relayed to Dr. [**Last Name (STitle) 2036**] who can arrange to have this done
as an outpatient. The VNA will continue to care for your wound.
The following medication changes were made:
1. Potassium 40mEq daily
2. Lasix 40mg twice a day (8am, 1pm)
2. Addition of two antibiotics
Followup Instructions:
Please follow up with your primary care provider. [**Name10 (NameIs) **] below
[**Female First Name (un) 13340**] (Dr.[**Name (NI) 13339**] office administrator) said she is going to
call you at home on Monday with a follow up appointment for when
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2036**] would like to see you. If you have any questions
or haven't heard by TUESDAY please call the office at
[**Telephone/Fax (1) 13341**].
ICD9 Codes: 7907, 2768, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1077
} | Medical Text: Unit No: [**Numeric Identifier 63151**]
Admission Date: [**2119-10-22**]
Discharge Date: [**2119-10-26**]
Date of Birth: [**2119-10-22**]
Sex: F
Service: NB
DIAGNOSIS: Presumed bacteremia
HISTORY OF PRESENT ILLNESS: This is a term infant born by
primary C-section under general anesthesia for failure to
progress, to a 36 year old gravida 2, para 0 woman. Prenatal
screens done, B-negative, A antibody negative, rubella
immune, RPR non-reactive, hepatitis B surface antigen
negative, group B strep positive.
The pregnancy was uncomplicated until [**2119-9-25**], when mother
had group B strep bacteruria. On [**2119-10-20**], she again
presented with fever of 101.9. Ampicillin, gentamicin, and
clindamycin were initiated on [**2119-10-20**] at [**2114**] hours and
labor was induced. Her urine from the time of admission has
since grown group B strep. Mother's T-max in 24 hours prior
to delivery was 99.6. Rupture of membranes 10 hours prior to
delivery with clear fluid. Fetal tachycardia to 170s was
noted during time mother was febrile.
NICU team then attended the delivery at the request of Dr.
[**Last Name (STitle) 34302**]. Infant emerged vigorous with Apgars of 8 at one minute
and 9 at five minutes. Initial physical exam as follows:
Birth weight of 2805, infant vigorous, non-dysmorphic, full
term. Sutures approximated, palate intact. Neck supple
without masses. Clavicles intact. Normal S1 and S2, no
murmur. Breath sounds were clear. Abdomen soft, nontender,
nondistended. Normal hip exam. Left hip was mildly lax.
Anus patent. No sacral anomalies. Normal digits. Skin
noncontributory.
Initial D-stick of 76.
COURSE AS FOLLOWS BY SYSTEMS: INFECTIOUS DISEASE: The
infant had an initial CBC (WBC 22.8, 56 polys, 4 bands) with
blood culture (no growth). Due to the maternal course, the
infant was started on antibiotics, ampicillin and gentamicin, and
t reated for seven days with antibiotics. The infant has not had
any clinical signs of sepsis throughout the stay. The infant did
have a spinal tap that was performed on [**2119-10-23**], which was
normal with a WBC of 0, 9 RBC, culture negative. The
initial white count was 22.8 with 56 polys and 4 bands.
OTHER: The infant did have a hepatitis B vaccine on [**2119-10-25**]. The
blood type of the infant is 0-positive, Coombs negative. A
bilirubin was done on [**2119-10-24**], which was 9.0.
The infant is now being discharged to home and will have followup
with pediatrician on Monday, [**2119-10-30**]. The pediatrician is Dr.
[**First Name8 (NamePattern2) 1743**] [**Last Name (NamePattern1) 37517**] at [**Hospital 1887**] Pediatrics.
Discharge Diagnosis: presumed bacteremia, s/p 7 days
antibiotics
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD
Dictated By:[**Last Name (NamePattern4) 57175**]
MEDQUIST36
D: [**2119-10-28**] 12:30:16
T: [**2119-10-28**] 14:03:00
Job#: [**Job Number 63152**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1078
} | Medical Text: Admission Date: [**2173-2-24**] Discharge Date: [**2173-2-26**]
Date of Birth: [**2123-9-22**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Toradol
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization
RCA stent placement
History of Present Illness:
49 yo male with h/o IMI in '[**67**], HTN, hypercholesterolemia,
former cocaine user, + tob user, s/p PTCA + stent of RCA which
was shown in 4/00 to have mild restenosis, also with poor
medication complicance (not taking BB or Plavix x2 years)
presented to [**Hospital3 417**] Hospital on [**2-13**] with SSCP radiating
to neck and arm, CE neg but persistent CP not relieved by [**Hospital 19298**]
transfered to [**Hospital1 18**] [**2-15**] for PTCA. Last cath [**11-7**] with mild 1VD
with 50% RCA stenosis just proximal to previous minimally
restenosed stent. During hospitalization at [**Hospital1 18**] from [**2-15**] to
[**2-18**], pt was taken to cath showing 70% mild RCA occlusion, but
could not receive drug coated stent d/t aspirin allergy. Pt was
supposed to stay for elective aspirin desensitization in the
MICU prior to stent placement, but chose to leave AMA and follow
up for future elective stenting. He presents now for aspirin
desensitization and cardiac cath.
.
On interview, pt reports decrease in exercise tolerance x 3
weeks and numerous episodes of [**2178-8-15**] SSCP associated wtih SOB
and radiation to he R arm at rest. No associated
N/V/diaphoresis. CP episodes not more with activity. Denies PND,
orthopnea, LE edema. CP episodes last 20-30 minutes, resolved
wtih SLNTG. Denies recent cocaine use.
Past Medical History:
CAD (IMI in 99 s/p RCA stent, angio of jailed PDA in '[**67**], No
increasing CAD 00,00,02,02.
HTN (on atenolol 100mg at home, not taking)
h/o rheumatic Heart Dz in [**2142**] in [**Country 2784**] (after Strep throat)
c/p pericarditis.
Chronic cresendo angina (all started after his Pericarditis)
Hyperlip. Not taking his lipitor
Meniere's dx (deaf in Right ear)
Laminectomy x 2
Social History:
The patient has a one half to two pack per day times 30 years.
The patient drinks roughly 32 ounces of alcohol per day, on
weekends, and sometimes drinks three to four bottles of wine or
hard liquor. No intravenous drug abuse. Denies recent cocaine.
The patient is married with children. He works for the postal
office.
Very noncompliant with meds (on no medications X 2 years).
Physical Exam:
98.6 72 114/81 16 96%RA
Well-app, sitting upright in chair, NAD
No JVD appreciated
No o/p erythema or lesions
RRR, s1s2 nl, no murmurs, 1+ femoral pulses bilaterally without
bruits, R pulse > L. DP 2+ bilaterally
Lungs CTA B
Legs without edema
Pertinent Results:
[**2173-2-24**] 07:06PM WBC-9.2 RBC-4.37* HGB-15.2 HCT-44.0 MCV-101*
MCH-34.7* MCHC-34.5 RDW-12.6
[**2173-2-24**] 07:06PM PLT COUNT-324
[**2173-2-24**] 07:06PM NEUTS-60.8 LYMPHS-30.8 MONOS-4.3 EOS-3.2
BASOS-0.9
.
[**2173-2-24**] 07:06PM GLUCOSE-75 UREA N-12 CREAT-0.7 SODIUM-140
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13
[**2173-2-24**] 07:06PM CALCIUM-8.9 PHOSPHATE-2.4* MAGNESIUM-2.1
.
[**2173-2-24**] 07:06PM PT-12.5 PTT-36.9* INR(PT)-1.0
.
Left Heart Cath on previous admission ([**2173-2-15**]):
Selective coronary angiography revealed a right-dominant system.
The LMCA, LAD and LCx were all non-obstructed with no evidence
for flow-limiting stenoses. The RCA had a 70% lesion just
proximal to the previously placed stent with minimal instent
restenosis.
2. Left ventriculgraphy was deferred.
3. Resting hemodynamics revealed a mildly elevated central
aortic pressure (systolic 145mmHg).
4. ASA allergy previously documented requires ASA
densensitization prior to drug-coated stenting.
.
Cath [**2173-2-25**]:
1. Selective coronary angiography demonstrated single vessel
disease.
The RCA had an 80% lesion just proximal to the previously placed
stent.
The LMCA, LAD, and LCX were angiographically normal vessels.
2. Successful PCI of the RCA with a 3.0 x 13 mm Cypher DES
(overlapping with the prior stent).
3. Successful closure of the right femoral arteriotomy site
with a 6
French Angioseal device.
Brief Hospital Course:
1. CAD:
- The patient was admitted at night for aspirin desensitization
in preparation for cath the following day. After admission, he
began to complain of [**9-15**] mid L chest pain radiating to the
shoulder and neck. EKG showed non-specific TW flattening in the
inferior leads. The pt was given SL NTG x 3 without effect,
followed by 2mg morphine without effect, followed by
heparin/integrilin and nitro drips. After several hours, the
pain was reduced. The pt was ruled out for MI by enzymes x 3
sets.
- The pt described this pain on the night of admission as
similar to that at home, but more severe. The following morning
he still described himself as having pain -- his "baseline [**4-15**]
chest pain" that has been present for years. He looked
comfortable.
- The patient was begun on aspirin, plavix, and also maintained
on heparin/integrilin drips overnight. He received pre-cath
hydration with D5W/bicarb.
- Aspirin desensitization was begun with aspirin, ranitidine,
and solumedrol. Given his IVP dye rash history, he received
additional solumedrol, pepcid, and benadryl.
- The pt underwent RCA stent with a cipher drug-coated stent the
morning after admission. He had no further c/o chest pain after
cath and was d/c'ed to home wthout complication.
.
2. Hyperlipidemia: Statin was continued during this
hospitalization.
3. FEN - NPO the night of admission, followed by cardiac healthy
diet.
4. Access - PIV
5. Prophylaxis - Heparin and H2 blocker
Medications on Admission:
Discharge Medications from previous admission several days
prior:
.
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO HS
(at bedtime).
Disp:*60 Tablet(s)* Refills:*2*
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
Disp:*30 Tablet, Sublingual(s)* Refills:*2*
5. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
5. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Darvocet-N 100 100-650 mg Tablet Sig: One (1) Tablet PO every
4-6 hours as needed for pain for 6 doses.
Disp:*6 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Chest pain
Discharge Condition:
Stable and improved
Discharge Instructions:
Please call your doctor or return to the ER if you have any
return of chest pain, difficulty breathing, weakness, or
bleeding.
.
Please take all your medications as directed.
.
Please stop smoking.
Followup Instructions:
Please follow up with your cardiologist Dr. [**Last Name (STitle) **] on Monday,
[**3-1**] at 11am. [**Telephone/Fax (1) 3183**]
ICD9 Codes: 4111, 4019, 2720, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1079
} | Medical Text: Unit No: [**Numeric Identifier 70041**]
Admission Date: [**2161-10-24**]
Discharge Date: [**2161-11-9**]
Date of Birth: [**2161-10-24**]
Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: The patient was born at 34-3/7
weeks' gestation to a 28-year-old, G1 P01, mother, blood type
A+, antibody negative, hepatitis B surface antigen unknown,
rubella immune, RPR nonreactive, GBS unknown. The pregnancy
was notable for in [**Last Name (un) 5153**] fertilization, di-chorionic, di-
amniotic twin gestation and was unremarkable until the mother
presented with upper respiratory infection symptoms,
proteinuria and elevated uric acid consistent with pre-
eclampsia. Given advanced gestational age and severity of
symptoms of pre-eclampsia, the babies were delivered.
Biophysical profile of twin 2 was 8 out of 8. Last estimated
fetal weight was [**2154**] g on [**2161-10-7**]. Cesarean section
was performed and twin B had moderate tone and good cry with
Apgar scores of 7 and 9 receiving brief blow-by oxygen.
Physical examination on admission was a weight of 2145 g, 25-
50th percentile, head circumference was 30.5 cm, 25-50th
percentile, length 43.5 cm, 25-50th percentile. The patient
had symptoms of respiratory distress and was admitted to the
neonatal intensive care unit for further evaluation.
HOSPITAL COURSE: Respiratory: No surfactant or ventilation
necessary. The patient was on room air from day of life 0. No
supplemental oxygen was required at any point.
Cardiovascular: No issues. No history of hypotension.
Fluids, electrolytes and nutrition: The patient was initially
on intravenous fluids of D10W and increased enteral feeds
rapidly to full feeds on day of life 4. Since that time, he
has increased kilocalories. He is currently taking breast
milk supplemented to 24 kcal/oz with Similac powder ad lib
p.o. taking spontaneous volumes greater than 140 ml/kg/day.
GI: Maximum bilirubin 15.4 on day of life 3. The patient is
status post several days of phototherapy. Total bilirubin of
6.4 on day of life 7, and then a repeat on day of life 10
showed a bilirubin of 2.5. A second rebound was obtained for
concern that the patient's color was still mildly jaundiced.
Additional repeat obtained on [**2161-11-7**], on day of
life 14, showed a total bilirubin of 7.7, still well below
limit for initiation concern to the point of reinitiating
phototherapy.
Both mother and babies' blood types are A+, antibody
negative.
Hematology: As noted above. The patient is not a set-up for
[**Doctor First Name **] or Rh incompatibility. Although the patient had a mildly
high bilirubin on day of life 3, he has been able to maintain
acceptable levels for 1 week off phototherapy. Initial
hematocrit 52 at birth.
Infectious disease: No antibiotics were required at any point
during admission. Prophylactic antibiotics not given at birth
given delivery due to maternal indications and no significant
distress on course of infant.
Neurology: Not applicable.
Sensory: Hearing screening was performed on [**2161-11-8**], with automated auditory brain stem responses and
results were passed.
Ophthalmology: Not applicable.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: Home.
PRIMARY PEDIATRICIAN: Dr. [**First Name (STitle) **] [**Name (STitle) **]- [**Location (un) **].
CARE RECOMMENDATIONS: Feeds at discharge: Breast milk 24 or
Similac 24 ad lib p.o. The patient at this time is still
taking approximately 140 cc/kg/day on top of breast feeding.
Medications: Iron, vitamin E.
Car seat positioning screening: Was successfully undertaken
on [**2161-11-9**].
State newborn screening status: Initially newborn screen sent
on [**2161-10-27**], was termed unsatisfactory. Repeat was
sent on [**2161-11-7**], and is pending at this time.
Immunizations received: Hepatitis B was given on [**2161-11-7**].
Immunizations recommended: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria: 1) born at less than 32
weeks, 2) born between 32 and 35 weeks with 2 of the
following: Day care during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities, or
school-age siblings, or 3) with chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age (and for the first 24 months of the child's life),
immunization against influenza is recommended for all
household contacts and out-of-home caregivers.
FOLLOW UP: Visiting nurse scheduled for Wednesday, [**2161-11-11**]. Pediatrician Dr. [**Last Name (STitle) **] scheduled on Tuesday, [**2161-11-10**]. Early intervention referral also placed prior to
discharge.
DISCHARGE DIAGNOSIS:
1. Prematurity at 34 and 3/7 weeks.
2. Rule out sepsis.
3. Transient Tachypnea of the Newborn.
4. Hyperbilirubinemia.
5. Feeding immaturity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**]
Dictated By:[**Name8 (MD) 68276**]
MEDQUIST36
D: [**2161-11-9**] 11:16:57
T: [**2161-11-9**] 12:11:25
Job#: [**Job Number 70042**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1080
} | Medical Text: Admission Date: [**2127-7-23**] Discharge Date: [**2127-8-4**]
Date of Birth: [**2083-9-20**] Sex: M
Service: MEDICINE
Allergies:
Reglan
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
altered mental status, nausea/vomiting, failure to thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
43 year old man with end-stage liver disease admitted from
clinic with N/V x 3 days and somnolence, thought to be [**2-3**] mild
encephalopathy. Patient was somnolent in Dr.[**Name (NI) 8653**] office
and continues to be somnolent on exam. He is unable to give a
full history and is reluctant to perform physical exam. He has
not taken any lactulose today and it is not certain if he has
missed doses prior to today, in light of recent nausea/vomiting.
No know history of head trauma. Also, c/o "pain all over," but
cannot localize source of pain.
.
Also unclear is whether or not feeding tube is in correct
position (feeds were stopped at 4am by wife). The patient had a
4.2L paracentesis in ultrasound. Cell count negative for SBP. BP
initially 99/59, SBP 89 after tap (93/64 prior to transfer). He
received 25g albumin and has been admitted for altered mental
status and acute renal failure. His creatinine is 2.6 (baseline
is about 1.0). The patient had a recent admission in early [**Month (only) 205**]
for abdominal pain, n/v, and was found to have portal vein
thrombosis, no SBP.
.
On the floor, T=96.9, BP=100/69, HR=84, RR=20, O2sat=100RA
.
Past Medical History:
-Alcoholic cirrhosis diagnosed [**3-9**] c/b portal vein thrombosis,
severe portal htn gastropathy, 3 cords of grade I varices; no
history of variceal bleed; currently gets paracentesis q1-2
weeks.
-Seizures from EtOH withdrawal
-no evidence of HCC on recent CT
-MELD=17; has completed liver [**Month/Year (2) **] work up
Social History:
Lives on cape with wife, no kids, previous heavy etoh(vodka),
sober since [**3-9**], no other drugs or smoking. Worked as a chef.
Family History:
nc
Physical Exam:
GENERAL: Somnolent, cachectic man in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MM dry. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP flat
LUNGS: CTA b/l, decreased breath sounds at b/l bases
ABD: +BS, mild distension, no TTP
EXTREMITIES: dry, warm and well perfused
SKIN: No rashes/lesions, ecchymoses. No jaundice
NEURO: Somnolent but awakens to name. Unwilling to answer
questions regarding orientation. Unwilling to participate with
neuro exam. +asterixis.
Pertinent Results:
[**2127-7-23**] 11:52AM WBC-8.0 RBC-3.52* HGB-11.4* HCT-33.0* MCV-94
MCH-32.5* MCHC-34.6 RDW-14.3
[**2127-7-23**] 11:52AM NEUTS-80.0* LYMPHS-15.3* MONOS-3.9 EOS-0.6
BASOS-0.2
[**2127-7-23**] 11:52AM PLT COUNT-129*
[**2127-7-23**] 11:52AM PT-15.9* INR(PT)-1.4*
[**2127-7-23**] 11:52AM GLUCOSE-117* UREA N-73* CREAT-2.6*
SODIUM-130* POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-21* ANION
GAP-18
[**2127-7-23**] 11:52AM ALT(SGPT)-34 AST(SGOT)-59* ALK PHOS-128* TOT
BILI-1.8*
[**2127-7-23**] 11:52AM ALBUMIN-4.0 CALCIUM-9.7 PHOSPHATE-3.2
MAGNESIUM-3.2*
[**2127-7-23**] 11:52AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2127-7-23**] 02:00PM ASCITES WBC-45* RBC-650* POLYS-0 LYMPHS-32*
MONOS-0 MESOTHELI-1* MACROPHAG-67*
[**2127-7-23**] 02:00PM TOT PROT-1.3* ALBUMIN-LESS THAN
IMAGING:
CT head ([**2127-7-23**]):
IMPRESSION: No acute intracranial process.
CXR ([**2127-7-23**]):
NG tube tip appears to terminate post-pylorically.
Cardiomediastinal contours are normal. The lungs are clear.
There is no pneumothorax or pleural effusion.
ABDOMINAL U/S WITH DOPPLERS ([**2127-7-24**]):
1. Extremely sluggish/slow flow within the portal vein, which
remains
hepatopetal. No thrombus identified.
2. Patent umbilical vein.
3. Findings of cirrhosis including ascites and splenomegaly.
CT HEAD ([**2127-7-29**])
No acute intracranial hemorrhage or obvious abnormality
identified. However, early cerebral edema may be difficult to
identify and
needs clinical correlation for exclusion. If there is a
continued clinical
concern, imaging followup is recommended to assess for any
interval changes.
ABDOMINAL U/S WITH DOPPLERS ([**2127-7-29**])
1. Exceedingly slow flow tending toward no flow in the portal
veins. This
appears to be worse than the ultrasound of [**2127-7-24**].
2. Large amount of ascites.
3. Cirrhotic-appearing liver with no focal liver lesion
identified, and no
biliary dilatation.
DUPLEX ([**2127-7-30**])
IMPRESSION:
1. Extremely slow to no flow within the portal vein, which is
unchanged when compared to the prior examination.
2. Dampened hepatic vein waveforms, consistent with cirrhosis.
3. Sludge within the gallbladder.
CULTURES:
[**2127-8-3**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2127-8-3**] FLUID RECEIVED IN BLOOD CULTURE BOTTLES Fluid Culture
in Bottles-PENDING INPATIENT
[**2127-8-3**] PERITONEAL FLUID GRAM STAIN-negative FINAL; FLUID
CULTURE-PRELIMINARY; ANAEROBIC CULTURE-negative, PRELIMINARY
INPATIENT
[**2127-8-3**] URINE URINE CULTURE-PENDING INPATIENT
[**2127-8-3**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2127-8-2**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-negative
FINAL INPATIENT
[**2127-7-29**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2127-7-29**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-negative; Cryptosporidium/Giardia (DFA)-FINAL;
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-negative FINAL INPATIENT
[**2127-7-29**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2127-7-29**] URINE URINE CULTURE-negative FINAL INPATIENT
[**2127-7-29**] MRSA SCREEN MRSA SCREEN-positive FINAL {STAPH AUREUS
COAG +} INPATIENT
[**2127-7-29**] PERITONEAL FLUID RECEIVED IN BLOOD CULTURE BOTTLES
Fluid Culture in Bottles-PRELIMINARY INPATIENT
[**2127-7-29**] PERITONEAL FLUID GRAM STAIN-negative FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-PRELIMINARY INPATIENT
[**2127-7-29**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2127-7-24**] URINE URINE CULTURE-FINAL INPATIENT
[**2127-7-23**] PERITONEAL FLUID GRAM STAIN-negative FINAL; FLUID
CULTURE-negative FINAL; ANAEROBIC CULTURE-negative FINAL
[**2127-7-23**] BLOOD CULTURE Blood Culture, Routine-negative FINAL
Brief Hospital Course:
43 year old man with a history of EtOH cirrhosis since [**3-9**] c/b
diuretic refractory ascites, portal hypertensive gastropathy,
and portal vein thrombosis on the liver [**Month/Year (2) **] list admitted
with 3 days of nausea/vomiting and somnolence thought to be due
to mild encephalopathy.
1. ALTERED MENTAL STATUS: His neurological exam on admission
showed the patient was somnolent, but would awaken to name,
unwilling to answer questions but said he was in the hospital,
+asterixis. His altered mental status was thought to be due to
hepatic encephalopathy vs. toxic-metabolic in the setting of
possibly not tolerating lactulose (given his n/v prior to
admission). Tox screen was negative. CT scan was negative for
acute intracranial process. He had a paracentesis for 4.2 L
removed which was not consistent with SBP. Encephalopathy
improved with lactulose and rifaximin and the patient was AAOx3
until the morning of [**2127-7-29**]. He was then transferred to the
MICU for acute change in mental status with decreased
responsiveness to sternal rub. Non contrast Head CT and CXR were
negative for acute process. EEG showed no seizure. Reglan,
megase, and H2 blocker were held. Lactulose was continued.
Mental status improved the next AM, at which point he was again
AAOx3. The acute change in mental status was likely secondary to
either changes in portal vein flow or decreased clearance of
reglan [**2-3**] renal failure.
On discharge, the patient was AAOx3.
2. ACUTE RENAL INSUFFICIENCY: Patient's Cr was 2.6 on admission
from a recent baseline of 1.0-1.5. Creatinine improved to 2.2
overnight with IVF and albumin, but remained in the 2.1-2.3
range in the days thereafter. Urine lytes were consistent with
prerenal vs. hepatorenal etiology. He was started on octreotide
and midodrine, but creatinine remained persistently elevated.
Creatinine gradually improved on this regimen and was 1.7 on
discharge.
3. ABDOMINAL PAIN: Pain was consistent with "bloating" sensation
and [**2-3**] discomfort associated with nausea. He was given reglan
and tube feeds were slowed (from goal of 45cc/hr) as needed.
This improved his pain and emesis. Paracentesis was negative for
SBP and ultrasound showed slowed portal vein flow, consistent
with past ultrasounds. After MICU transfer, reglan was switched
to zofran.
Abdominal pain subsided with alterations in tube feeds. At
discharge he was tolerating tube feeds at 45cc/hr.
4.ETOH cirrhosis-Patient has history of withdrawal seizures,
though he states that his last drink was in [**2126-3-2**]. He
paracentesis twice during this hospitalization having 4.2 L and
3.25 L which did not show SBP. He has diuretic refractory
ascites, portal hypertensive gastropathy, and portal vein
thrombosis on the liver [**Year (4 digits) **] list. His discharge Meld
score was 18. He has grade I varices. Currently on lactulose to
titrate to [**3-6**] BMs per day and on rifaximin as above.
5.FAILURE TO THRIVE: Patient extremely cachectic on admission.
When at goal tube feeds of 45cc/hr, patient complained of
bloating and nausea. Tube feeds reduced accordingly. Patient
with poor appetite; megace and ensure TID were added. After MICU
transfer, megace was stopped. Patient gained weight with
continuous tube feeds and was supplementing with an oral diet as
well upon discharge.
Medications on Admission:
1. Ranitidine HCl 150 mg
2. Folic Acid 1 mg
3. Thiamine HCl 100 mg
4. Multivitamin
5. Lactulose 30mL TID
6. Senna 8.6 mg Capsule
7. Docusate Sodium 100 mg [**Hospital1 **] PRN
8. Simethicone 60 mg
9. Clotrimazole 10 mg Troche Sig: One (1) tablet Mucous membrane
five times a day: dissove one in mouth five times a day
Discharge Medications:
1. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
5 TIMES A DAY ().
Disp:*150 Troche(s)* Refills:*0*
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
Disp:*60 Tablet, Chewable(s)* Refills:*2*
7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO [**3-5**]
times per day: You should have [**3-6**] bowel movements daily.
Disp:*1 Month supply* Refills:*2*
8. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO as needed as
needed for constipation.
Disp:*30 Tablet(s)* Refills:*2*
10. Colace 100 mg Capsule Sig: One (1) Capsule PO BID PRN as
needed for constipation.
Disp:*30 Capsule(s)* Refills:*2*
11. Outpatient Lab Work
Please check a CBC,Na,K,Cl,HCO3,BUN,creatinine on Thursday
[**2127-8-7**] and fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] at [**Telephone/Fax (1) 82304**].
Discharge Disposition:
Home
Discharge Diagnosis:
1. Hepatic Encephalopathy
2. Acute renal failure
3. Malnutrition
Discharge Condition:
Afebrile, stable vital signs. AAOx3.
Discharge Instructions:
You were admitted to the hospital with confusion,
nausea/vomiting, and kidney failure. Your confusion improved
with lactulose and rifaximin, and you had normal mental status
on discharge.
We gave you reglan for nausea which made you very drowsy and you
should avoid taking this medication in the future. Your nausea
improved, we slowed your tube feeds. You should also supplement
your meals with a nutritional supplement drink called Ensure.
Your kidney failure improved with hydration. You will have
outpatient labs to follow your kidney function and these will be
sent to your doctor.
We have made the following changes to your medications:
-Started on Rifaximin to prevent confusion
Please return to the ER or call your doctor if you experience
worsening confusion, chest pain, shortness of breath,
fevers/chills, abdominal pain, bloody stools, or any other
symptoms concerning to you.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name10 (NameIs) **],ORIENTATION [**Name10 (NameIs) **] CENTER -
Date/Time:[**2127-8-14**] 3:00
PROVIDER: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 497**], Gastroenterology, on [**2127-8-13**] at
2:00PM at [**Hospital 1326**] Clinic, [**Hospital Unit Name **] [**Location (un) 436**]. [**Hospital1 18**]
Office Phone: ([**Telephone/Fax (1) 3618**] Office Fax: ([**Telephone/Fax (1) 4409**]
BLOOD DRAW: Please come to the lab to have your blood draw on
[**Last Name (un) **], [**2127-8-7**]
ICD9 Codes: 5849, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1081
} | Medical Text: Admission Date: [**2192-5-22**] Discharge Date: [**2192-5-30**]
Date of Birth: [**2115-10-7**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2108**]
Chief Complaint:
tachycardia and hypotension
Major Surgical or Invasive Procedure:
R PICC line removal
L PICC line placement
History of Present Illness:
Mrs. [**Known firstname 40107**] [**Last Name (NamePattern1) 40108**] is a 76 year-old woman with HTN, HL,
hypothyroidism, h/o strokes with dementia who was found to have
acute renal failure at Rehab and was sent to our ED for
evaluation, but developped tachycardia an hypotension. She was
in her prior state of health until aproximately 8-9 weeks ago
when she started to be progressively tired, weak and not able to
take care of herself. She was driving and managing all her ADLs.
She made one of her long-time friends her HCP given she has no
family. One day she was unable to walk from one room to another
and she was taken to our ED on [**2192-4-13**]. She was diagnosed with
chronic aspiration and a Zenker's diverticula and was placed on
TPN. She was discharged to [**Hospital **] Rehab ([**Telephone/Fax (1) 40109**]) on
[**2192-4-18**] where she had been able to walk, interactive, chatting
and doing well. Plans were to bring her back to fix the
diverticulum. There were discussions about fixxing it with
endoscopic techniques. She also developped a PNA that was
treated with 10-day course of Vancomycin/CTX (last day [**2192-5-4**]).
The course was finished at Rehab.
.
During the last week she has been progressively confused. She
keeps talking about her husband [**Name (NI) 40110**] her (who died 5 years
ago). Yesterday when at rehab they noted that she started to be
very "anxious" and confused. Normally, she can follow commands
and is oriented x2 (person and place). She started to pull her
oxygen off her face and be less verbally responsive. Labs were
drawn and they noted acute renal failure (creatinine of 1.7) at
Rehab and decided to send her to our hospital for evaluation.
She was febrile to [**Age over 90 **] yesterday at Rehab per nursing report.
She was being treated for pneumonia with levofloxacin. On her
way to our ED she developped AFIb with RVR and became
hypotensive.
In our ED her initial VS were FS=113, 97.4 138 105/72 24 95%
NRB. She was oriented in self and mildly agitated. She had a
clonidine patch on that was removed. She was screaming "Help".
Her lungs were clear. Her CXR showed a multi-focal PNA in the
right lung. She was "broadened" to Vancomycin 1g IV/Levofloxacin
750 mg (got at rehab today the later). Her HCP was [**Name (NI) 653**] and
made aware that patient was here. The DNR was confirmed, but
CVLs would be ok (per ED resident's conversation). Her initial
labs were significant for: WBC 18.3 with N:90 Band:0 L:4 M:6 E:0
Bas:0, H&H of 7.9/25, PLTs 307, Ca: 7.9 Mg: 2.6 P: 4.1, Na 156,
3.7, Cl 123, CO2 23, BBUN 97, Cr 1.9, glucose 95, Lactate:1.9.
Blood and urine cultures wre sent. Her ECG showed AFib with RVR
up to 150s. She also received ativan for unclear reasons,
calcium gluconate for her low calcium and diltiazem 10 mg IV for
rate control. Her initial BP dropped up to 70 SBP, but responded
to fluids. It has been ranging from 70-130. She has had only 40
cc of dark urine. She has a PICC line and an IV in the left
forearm. Foley catheter was placed. She got a total of 3 L NS
and 1 L NS with 40 mEq of KCl. Her urine output was ~400 cc.
Past Medical History:
HTN
Hypothyroidism
Hypercholesterolemia
h/o tonsillar cancer s/p RT >20 yrs ago and discharged from the
[**Hospital3 328**] Cancer Institute after surveillance and follow-up
CVA or R MCV (critical R ICA stenosis [**4-4**] CT)
Vertebral fracture
Fracture of the right olecranon.
Ischemic colectomy is listed as part of her past medical history
which the patient denies
JAK2 postive
TAH-BSO
Social History:
She used to smoke, but quit 20 years ago. Has history of 30
pack-years. Has a drink per day when at home. Denies any current
or past use of illegal substances. She was exposed to radiation
in her tonsils, but denies any other exposures. She is widowed
and used to live alone.
Family History:
Father: deceased from heart condition @ 57
Other: neg for lung or esophageal disease
Physical Exam:
Physical Exam on Admission to [**Hospital Unit Name 40111**] SIGNS - Temp 95.7 F, BP 101/63 mmHg, HR 118 BPM, RR 28 X',
O2-sat 97% RA
GENERAL - ill-appearing woman in NAD, yelling "help", not
appropriate, not jaundiced (skin, mouth, conjuntiva), only
responding to her name, good speech, moving all 4 extremities,
lying in bed, breathing comfortably on room air, cachectic
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
slyghtly dry mucous membranes
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - expiratory wheezes, mostly in both bases (R>L), good air
movement, resp unlabored, no accessory muscle use
HEART - PMI in L ant axillary line 6th intercostal space,
irregular, no MRG, nl S1-S2, tachycardic,
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox1 (person), CNs II-XII grossly intact, muscle
strength 5/5 throughout, sensation not evaluated, DTRs 2+ and
symmetric, cerebellar exam defered, gait defered
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
[**2192-5-22**] 02:30PM BLOOD WBC-18.3*# RBC-2.58* Hgb-7.9* Hct-25.0*
MCV-97# MCH-30.4# MCHC-31.4 RDW-18.5* Plt Ct-307
[**2192-5-22**] 02:30PM BLOOD Neuts-90* Bands-0 Lymphs-4* Monos-6 Eos-0
Baso-0
[**2192-5-23**] 06:29AM BLOOD PT-17.4* PTT-35.3* INR(PT)-1.5*
[**2192-5-22**] 02:30PM BLOOD Ret Aut-0.3*
[**2192-5-22**] 02:30PM BLOOD Glucose-95 UreaN-97* Creat-1.9*# Na-156*
K-3.7 Cl-123* HCO3-23 AnGap-14
[**2192-5-22**] 02:30PM BLOOD ALT-41* AST-20 LD(LDH)-258* AlkPhos-92
TotBili-0.3
[**2192-5-22**] 02:30PM BLOOD cTropnT-0.06*
[**2192-5-22**] 02:30PM BLOOD Albumin-2.5* Calcium-7.9* Phos-4.1 Mg-2.6
Iron-41
[**2192-5-22**] 02:30PM BLOOD calTIBC-142* Ferritn-1169* TRF-109*
[**2192-5-22**] 02:30PM BLOOD TSH-2.5
[**2192-5-22**] 02:33PM BLOOD Lactate-1.9 K-3.3*
[**2192-5-22**] 04:15PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.013
[**2192-5-22**] 04:15PM URINE RBC-10* WBC-4 Bacteri-FEW Yeast-MANY
Epi-0
[**2192-5-22**] 04:15PM URINE CastHy-3*
[**2192-5-22**] 04:15PM URINE Mucous-OCC
[**2192-5-22**] 04:15PM URINE Eos-NEGATIVE
[**2192-5-22**] 05:40PM URINE Hours-RANDOM UreaN-644 Creat-72 Na-16
K-94 Cl-19
[**2192-5-22**] 05:40PM URINE Osmolal-440
[**2192-5-26**] 06:15PM BLOOD Vanco-18.6
[**2192-5-27**] 04:07AM BLOOD ALT-25 AST-8 AlkPhos-79 TotBili-0.4
[**2192-5-28**] 04:52AM BLOOD WBC-10.5 RBC-2.41* Hgb-6.9* Hct-22.7*
MCV-94 MCH-28.5 MCHC-30.3* RDW-19.1* Plt Ct-381
[**2192-5-28**] 04:52AM BLOOD Glucose-149* UreaN-104* Creat-3.4* Na-143
K-3.9 Cl-113* HCO3-17* AnGap-17
DISCHARGE LABS:
[**2192-5-28**] Na 143, K 3.9, Cl 113, Bicarb 17, BUN 104, Cr 3.4
Glucose 149
Ca 7.8 Mg 2.4, Phos 5.1
WBC 10.5, HCT 22.7, Plt 381
MICROBIOLOGY
[**2192-5-22**]
- Blood Culture, Routine (Final [**2192-5-26**]):
[**Female First Name (un) **] ALBICANS.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
Fluconazole = S. sensitivity testing performed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
This test has not been FDA approved but has been
verified
following Clinical and Laboratory Standards Institute
guidelines
by [**Hospital1 69**] Clinical
Microbiology
Laboratory..
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Aerobic Bottle Gram Stain (Final [**2192-5-23**]):
BUDDING YEAST CELLS.
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Numeric Identifier 40112**]) [**2192-5-23**] @
11:00 AM.
Anaerobic Bottle Gram Stain (Final [**2192-5-23**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 28089**] ([**Numeric Identifier 40113**])
[**2192-06-21**] @1630.
- Blood Culture, Routine (Final [**2192-5-28**]):
[**Female First Name (un) **] ALBICANS.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
323-2775B
[**2192-5-22**].
Aerobic Bottle Gram Stain (Final [**2192-5-24**]):
BUDDING YEAST WITH PSEUDOHYPHAE.
- URINE CULTURE (Final [**2192-5-23**]):
YEAST. >100,000 ORGANISMS/ML..
- Urine legionella antigen: negative
[**2192-5-23**]
- PICC catheter tip: no significant growth
[**2192-5-25**]
- Blood culture: NGTD
[**2192-5-26**]
- Blood culture: NGTD
IMAGING:
[**2192-5-22**] ECG: Atrial fibrillation with mean ventricular rate of
152. Non-diagnostic repolarization abnormalities. No previous
tracing available for comparison.
[**2192-5-22**] CXR:
Multifocal pneumonia. A repeat chest radiograph with a lateral
view is
recommended after adequate treatment to assess resolution.
[**2192-5-23**] ECHO: The left atrium is normal in size. The right atrium
is moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular ejection fraction is moderately depressed (LVEF= 35
%) (tachycardia and adverse interventricular interaction are
likely playing a significant role in the reduction of left
ventricular ejection fraction). The right ventricular free wall
is hypertrophied. The right ventricular cavity is dilated with
depressed free wall contractility. There is abnormal septal
motion/position consistent with right ventricular
pressure/volume overload. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate to severe (3+) mitral regurgitation is seen.
The tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. Significant
elevation of pulmonary artery systolic pressure is likely
present [In the setting of at least moderate to severe tricuspid
regurgitation, the tricuspid regurgitation pressure gradient may
signficantly underestimate the pulmonary artery systolic
pressure due to a very high right atrial pressure.]
[**2192-5-26**] CXR:
In comparison with the study of [**5-25**], there is continued
enlargement of the cardiac silhouette with large bilateral
pleural effusions and compressive atelectasis as well as mild
elevation of pulmonary venous
pressure. The central catheter has been pulled back to the mid
portion of the SVC.
[**2192-5-28**] Right upper extremity ultrasound:
Nonocclusive thrombi in the right subclavian, axillary, basilic,
and one of the brachial veins.
Brief Hospital Course:
Mrs. [**Known firstname 40107**] [**Last Name (NamePattern1) 40108**] is a 76 year-old woman with HTN, HL,
hypothyroidism, h/o strokes with dementia who was found to have
acute renal failure at Rehab and was sent to our ED for
evaluation, but developped tachycardia an hypotension.
Septic shock/candidemia: The patient did not respond to initial
IV fluid boluses and so a central line was placed, she was
started on dopamine. She remained on this until the decision
was made to transition to CMO. The source of the candidemia was
likely a PICC line infection, increased risk given the TPN. Her
PICC was removed and then replaced. From her severe sepsis she
developed severe acute renal failure and associated uremia, also
she was noted to have acute systolic heart failure with an EF of
35% and severe 3+ mitral regurgitation. She also had new atrial
fibrillation with a rapid ventricular rate. She was noted also
to have multifocal pneumonia on chest x ray and a right upper
extremity dvt which was picc line associated. She was treated
with micafungin initially for candidemia, then fluconazole, on
[**5-28**] therapy was discontinued as the patient was transitioned to
CMO. She was transferred to an inpatient hospice facility
(Riverbend in [**Location (un) 1110**]) and was on morphine for comfort. She was
sleeping, opening eyes briefly to voice but non verbal on
discharge. She appeared comfortable in terms of pain and
shortness of breath.
Access ?????? PICC
[**Name (NI) **] - HCP: [**Name (NI) **] [**Name (NI) **] (friend) [**Telephone/Fax (1) 40114**] mobile and
[**Telephone/Fax (1) 40115**] home.
Medications on Admission:
Ativan 0.25-0.5 mg PO q6 hrs PRN
Dulcolax 10 mg PR PRN
heparin 5,000 unit/mL Injection
Synthroid 37.5 mcg PO Daily
clonidine 0.1 mg patch QMondays
Albuterol sulfate 2.5 mg/3 mL (0.083 %) Neb Q6 hrs PRN
ipratropium bromide 0.02 % Soln q6hrs PRN
Lidoderm 5 % TP [**Hospital1 **]
Levaquin 500 mg PO Daily
TPN Electrolytes
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for SOB / Wheezing.
2. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for SOB / Wheezing.
3. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic [**Hospital1 **] (2 times a day).
4. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
5-15 mg PO Q1H (every hour) as needed for SOB, pain.
5. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q6H PRN () as needed for aggitation.
Discharge Disposition:
Extended Care
Facility:
Riverbend of [**Location (un) 40116**]
Discharge Diagnosis:
Primary Diagnosis:
Candidemia, sepsis
acute systolic heart failure
acute renal failure
Discharge Condition:
Level of Consciousness: Lethargic but arousable. (opens eyes to
voice)
Mental Status: Confused - always.
Activity Status: Bedbound.
Discharge Instructions:
[**Known firstname 40107**] was admitted to the hospital with a severe infection caused
by [**Female First Name (un) **] (a fungus) in the blood stream, this caused a low
blood pressure and damage to her kidneys and heart. A decision
was made between the [**Hospital 228**] health care proxy and the ICU
team to move treatments towards comfort measures and avoid any
invasive procedures, with a goal of improving quality of life.
Followup Instructions:
Follow up with inpatient hospice physician
ICD9 Codes: 486, 5845, 2760, 5990, 2762, 4280, 4019, 2724, 2449, 4240, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1082
} | Medical Text: Admission Date: [**2117-9-5**] Discharge Date: [**2117-9-5**]
Date of Birth: [**2078-4-17**] Sex: F
Service: MEDICINE
Allergies:
Prochlorperazine
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
Endocarditis: Heart Block
Major Surgical or Invasive Procedure:
Temporary pacing wire: placement of quadripolar catheters for
pacemaker function
History of Present Illness:
This is a 39 y/o female with MMP and multiple episodes of
bacteremia who presented obtunded from nursing home. The
patient was noticed to have decreased mental status after
hemodialysis yesterday which worsened on the day of
presentation. The patient was febrile to 101 and brought to the
ED. An EKG done showed AV block, inferior ST elevations. An
echo showed significant aortic valce vegetation(1cm), thickened
anterior MR leaflet (no frank vegetation, inferior wall motion
abnormality and thickening. The patient was transferred to the
CCU.
Past Medical History:
1. ESRD due secondary to diabetes, on hemodialysis three times
weekly. She had a failed renal transplant ([**2104**])
2. Diabetes mellitus type I with retinopathy, nephropathy and
peripheral vascular disease, diagnosed as a child, brittle
3. CVA ([**2113**], [**2116**]) with hydrocephalus status post VP shunt
(removed in [**12-10**] as CSF grew out coag negative staph), right
basal ganglia hemorrhage
4. Hypercholesterolemia
5. Hypertension
6. Unclear history of grand mal seizure during dialysis
7. MRSA line tip infection with right atrial thrombus (line tip
pulled [**2116-6-16**])
8. Diffuse lymphadenopathy of unknown etiology.
9. Chronically elevated alkaline phophatase
10. History of naphthelene induced coma from inhaling moth balls
11. H.O VRE bacteremia (completed linezolid in 11/[**2116**]).
12. Status post parathyroidectomy
13. Status post multiple amputations (right BKA, left digit,
left metatarsal)
14. Exploratory laparotomy and appendectomy for appendicitis in
[**2116-3-8**]
15. Prior history of tracheostomy
Social History:
Ms [**Known lastname **] usually lives in JP with her daughter and
granddaughter, although she came from rehab. Her sister-in-law,
[**Name (NI) 1060**], helps her with management of her multiple medications.
No tobacco or alcohol use. Her baseline is such that she can
feed herself, knows when to take medicines and when to go to
dialysis.
Family History:
Family history of diabetes mellitus in children.
Physical Exam:
VS: T 104, HR 60-108, R 30-33, BP 88-101/40-60
General: Obtunded
HEENT: no conjunctival lesions
NECK: multiple scars, trachea midline
Heart: 4/6 systolic murmur, [**3-14**] diastolic murmur
Lungs: difficulty due to shallow breathing
Abdomen: multiple surgical scars
Neurologic: unable to assess
Pertinent Results:
[**2117-9-5**] 09:49AM PT-15.8* PTT-31.3 INR(PT)-1.7
[**2117-9-5**] 09:49AM PLT COUNT-307
[**2117-9-5**] 09:49AM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL
TARGET-OCCASIONAL BURR-OCCASIONAL
[**2117-9-5**] 09:49AM NEUTS-89.0* BANDS-0 LYMPHS-6.7* MONOS-3.7
EOS-0.3 BASOS-0.3
[**2117-9-5**] 09:49AM WBC-17.7*# RBC-4.34# HGB-11.3* HCT-38.0
MCV-88# MCH-25.9* MCHC-29.6* RDW-18.1*
[**2117-9-5**] 09:49AM cTropnT-5.83*
[**2117-9-5**] 03:31PM CK-MB-7 cTropnT-4.45*
[**2117-9-5**] 03:31PM CK(CPK)-107
[**2117-9-5**] 03:31PM GLUCOSE-195* UREA N-47* CREAT-6.3* SODIUM-136
POTASSIUM-5.7* CHLORIDE-96 TOTAL CO2-23 ANION GAP-23*
[**2117-9-5**] 08:05PM GLUCOSE-275* UREA N-48* CREAT-6.5*
SODIUM-131* POTASSIUM-7.1* CHLORIDE-91* TOTAL CO2-13* ANION
GAP-34*
[**2117-9-5**] 08:34PM TYPE-[**Last Name (un) **] PO2-19* PCO2-52* PH-7.01* TOTAL
CO2-14* BASE XS--20
Brief Hospital Course:
This is a 39 y/o female with multiple medical problems who was
admitted with endocarditis and found to be in complete heart
block. In the emergency department the patient was in sepis:
hypotensive, lethargic and febrile to 104. Infectious disease
was initially [**Last Name (un) 4221**]. They agreed with the plan to place the
patient on gentamycin and vancomycin. In addition, they
suggested adding daptomycin and ceftriaxone. They also
recommended further imaging to rule out septic emboli.
While in the CCU, after multiple attempts for central access a
temporary pacer was placed through the left femoral groin.
Cardiac surgery evaluated the patient for surgery, but they
recommended hemodynamic stabilization and administration of
intravenous antibiotics. Renal was also [**Last Name (un) 4221**]. At the time,
there was no acute indication for hemodialysis. They recommended
renal dosing of antibiotics.
At approximately 7 or 8pm in the evening the patient went into
pulseless electrical asystole X 3-5 minutes. The patient was
coded. It was suspected that the patient went into hyperkalemic
arrest (K+ 7.1). The patient received epi/ bicarb/ insulin/ D50/
calcium with return of rhythm. The health care proxy was
notified and she informed us that the patient would not have
wanted repeated resuscitations. The patient code was reversed
to DNR. The patient later passed.
Medications on Admission:
Prozac 30
Aspirin
Colace
Folate
Protonix
Metoprolol
Norvasc
Atorvastin
ISS
Reglan
Vancomycin
Glargine
Sevelamer
Benadryl
Discharge Medications:
Patient died within 24 hours of admission
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient went into pulseless electrical asystole. Patient had
been full code for cardiac interventions, but the code was later
reversed to DNR/DNI.
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2117-11-15**]
ICD9 Codes: 0389, 4275, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1083
} | Medical Text: Admission Date: [**2135-4-19**] Discharge Date:
Date of Birth: [**2064-10-26**] Sex: F
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old
female with known history of coronary artery disease referred
for outpatient cardiac catheterization secondary to a
positive stress test. The patient had a PTCA stent to the
right coronary artery on [**2131-6-2**]. Cardiac catheterization
in [**2132-4-2**] showed 50% right coronary artery with a patent
stent, 50% mid left anterior descending, 75% circumflex, 95%
OM, and 70% diagonal.
The patient had been doing well and denied any chest pain.
She did report having dyspnea on exertion over the past 1-2
months and had been getting shortness of breath from walking
about a quarter of a mile. She also had recently been
feeling very tired in general.
On [**2135-4-18**], the patient had an ETT Thallium with
report which showed that the
patient exercised for 4?????? min with chest pain.
Electrocardiogram showed 2-[**Street Address(2) 2051**] depressions from inferior
to laterally.
The patient denied any claudication, orthopnea, paroxysmal
nocturnal dyspnea, or light-headedness, but did have some
trace edema.
PAST MEDICAL HISTORY: The patient has a history of Meniere's
disease and hypertension.
PAST SURGICAL HISTORY: Hysterectomy. The patient also has a
history of a transient ischemic attack 25 years prior.
ALLERGIES: DIURIL.
MEDICATIONS ON ADMISSION: Aspirin 325 mg q.d., Lopressor 100
mg b.i.d., 50 mg q.h.s., Diovan 160 mg q.d., Lipitor 40 mg
q.d., Premarin 0.625 mg q.d., Meclizine 12.5 mg q.d.
LABORATORY DATA: White count 5.8, hematocrit 32.4, platelet
count 167; electrolytes within normal limits; INR 1.1;
baseline creatinine 1.0.
The patient underwent a cardiac catheterization on [**2135-4-19**], which revealed elevated LDEDP. Left ventricular
ventriculography showed mitral regurgitation. The patient
had a short LMCA, a 70% lesions to the mid
left anterior descending, 85% origin, large diagonal, ramus
at 60%, 95% origin OM1, 95% OCX after OM1 affecting large more
distal second OM. AV groove left circumflex occlusion before
PLV branch. Right coronary artery showed mild mid right
coronary artery lesion, 90%, just before very large PVA with
just collateral source to the left circumflex and left
anterior descending diagonal territory.
Cardiac Surgery was consulted, and the patient underwent a
coronary artery bypass grafting times four with LIMA to the
left anterior descending, saphenous vein graft to the
diagonal and to the OM, and saphenous vein graft to the
posterior descending artery. The patient tolerated the
procedure without complications but postoperatively the
patient had bleeding due to a coagulopathy and severe
hypertension which necessitated return to the
operating room for mediastinal exploration and cauterization
of several small bleeding sites and correction of the
coagulopathy with platelets, FFP and red cells.
The patient had an episode of atrial fibrillation and
ventricular tachycardia on postoperative day #2. The patient
was extubated on postoperative day #3 and had other of
ventricular tachycardia and premature atrial contractions.
On postoperative day #5, a carotid ultrasound was obtained
which showed less than 40% bilateral plaques.
Electrophysiology was consulted for assistance with
arrhythmias. The patient remained in the unit until on
postoperative day #8 secondary to problems with hypertension
management. Eventually a suitable regimen was obtained.
The patient was transferred to the floor and continued to do
well but did have early morning blood pressure elevations
which were eventually controlled by adding more hypertension
medications.
The patient began to have decreased bowel movements on
postoperative day #11 which prompted checking of a C-diff
with results that are pending at the time of this dictation.
Due to the hypertensive episodes, a renal ultrasound for
evaluation of possible renal artery stenosis was requested
and again is still pending at the time of this dictation.
On postoperative day #12, the patient had achieved relatively
good blood pressure control in the 140-160s over 50-70s. The
patient was started on oral Flagyl prophylactically for
continued bowel movements. The patient was pending physical
therapy clearance or evaluation for a rehabilitation facility
for the near future.
The patient is to follow-up in the EP Service, Dr. [**Last Name (STitle) 5914**]
or Dr. [**Last Name (STitle) 284**], [**Hospital3 4527**] for follow-up after
discharge.
This discharge summary will have an addendum upon discharge.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 5915**]
MEDQUIST36
D: [**2135-5-2**] 11:34
T: [**2135-5-2**] 12:31
JOB#: [**Job Number 5916**]
cc:[**CC Contact Info 5917**]
ICD9 Codes: 4111, 4240, 4271, 5990, 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1084
} | Medical Text: Admission Date: [**2191-5-23**] Discharge Date: [**2191-5-27**]
Date of Birth: [**2142-3-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10435**]
Chief Complaint:
found down, Somnolence
Major Surgical or Invasive Procedure:
None
History of Present Illness:
49 yo M with HIV (CD4 155, VL 17,5000 from [**2191-3-25**]), HCV, who
presents after being found down at his group home. Patient
reportedly mumbling words this morning. Patient lives in group
home. He was found lying in bed confused and incoferent. EMS was
called and he was [**Last Name (un) 4662**] to the ED
.
Presented to the ED where initial VS were: 97.6 72 160/102 20
100%. Received 1mg ativan x 1. Labs significant for >2:1
AST:ALT elevation, Tbili 3.0, INR at baseline 1.4. Ultrasound
showed no evidence of ascites. CXR showed no focal
consolidation and CT head was unremarkable. Discussion held with
hepatology fellow in ED and was admitted to further workup for
suspicion of hepatic encephalopathy. Upon reaching floor, pt
minimally responsive, not reactive to sternal rub. NGT placed on
second attempt and lactulose started. Utox was positive for
cocaine. Trasnferred to MICU for altered mental status and
somnolence.
.
On arrival to the MICU, patient is somnolent, but responds to
sternal rub and withdraws from painful stimuli. Further history
is unattainable.
Past Medical History:
# HIV: on HAART r-atazanivir+tenofovir+emtricitabine # Hepatitis
C(genotype 1a) with Cirrhosis (Duke B)Hep C:
- hepatic encephalopathy,
- on Lactulose and spironolactone.
- EGD [**2184**] no varices.
- Treated with 18 months of interferon and ribavrin ending in
[**2181-11-9**], virus relapsed after the end of therapy.
Currently not considered candidate for treatment d/t drug abuse
and psych history.
# Psyciatric history:
- Multiple prior admissions for dual diagnosis and detox.
- polysubstance abuse - EToh, Cocaine
- depression
- bipolar, here for followup.
- multiple suicide attempts
- medication non compliance.
- Outpt psychiatristis Dr. [**Last Name (STitle) 14303**] and therapist [**First Name5 (NamePattern1) 1022**] [**Last Name (NamePattern1) 34635**]
at [**Hospital 1680**] hospital.
Social History:
- Lives in [**Hospital3 **] in studio Apartment.
- On disability
- Previous partner and [**Name2 (NI) 1685**] sister passed away 5 yrs ago,
causing him to go into a cycle of alcohol and drug abuse.
- Graduated from rehab in [**2189-3-9**] and is now 8+ months drug
free, denies alcohol.
- Tobacco [**1-10**] cigarettes/ day. [**1-12**] to 1 pack per day since age
11.
Sexual Hx: Completely inactive since [**2189-1-9**]. Prior to that
active with men, no anal sex for a while, practices receptive
and insertive oral sex w/o condoms.
Family History:
- Mother with diabetes, passed away 5 yrs ago.
- Father with cardiovascular disease, alcoholic.
- Sister alcoholism and drug abuse, died of overdose 5 years ago
Physical Exam:
admission exam
Vitals: T: 98.8 BP: 133/93 P: 79 R: 21 O2: 97% on RA
General: Somnolent, responsive to sternal rub and painful
stimuli, resists opening eyes
HEENT: PERRL 3-2mm bilaterally
Neck: does not resist side to side movement or flexion/extenion,
but unable to touch chin to neck, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: somnolent, withdraws from painful stimuli in all four
extremities, responds to sternal rub, resists eye opening
Pertinent Results:
admission labs
[**2191-5-23**] 11:55AM BLOOD WBC-3.8*# RBC-4.26* Hgb-13.4* Hct-43.0
MCV-101* MCH-31.6 MCHC-31.3 RDW-16.2* Plt Ct-38*
[**2191-5-23**] 11:55AM BLOOD Neuts-49.1* Lymphs-44.7* Monos-3.7
Eos-2.1 Baso-0.4
[**2191-5-23**] 11:55AM BLOOD PT-14.5* PTT-38.0* INR(PT)-1.4*
[**2191-5-23**] 07:33PM BLOOD WBC-4.0 Lymph-37 Abs [**Last Name (un) **]-1480 CD3%-77
Abs CD3-1146 CD4%-8 Abs CD4-112* CD8%-67 Abs CD8-986*
CD4/CD8-0.1*
[**2191-5-23**] 11:55AM BLOOD Glucose-110* UreaN-12 Creat-0.9 Na-141
K-4.1 Cl-112* HCO3-24 AnGap-9
[**2191-5-23**] 11:55AM BLOOD ALT-32 AST-80* LD(LDH)-547* AlkPhos-124
TotBili-3.0*
[**2191-5-23**] 11:55AM BLOOD Calcium-8.1* Phos-2.0* Mg-2.0
[**2191-5-23**] 11:55AM BLOOD Ammonia-362*
[**2191-5-24**] 03:38AM BLOOD AFP-3.0
[**2191-5-23**] 07:33PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2191-5-23**] 07:51PM BLOOD Type-[**Last Name (un) **] pH-7.42 Comment-GREEN-TOP
[**2191-5-23**] 07:51PM BLOOD Lactate-2.3*
[**2191-5-23**] 07:51PM BLOOD freeCa-1.17
.
urine
[**2191-5-25**] 06:33AM URINE Color-DkAmb Appear-Cloudy Sp [**Last Name (un) **]-1.025
[**2191-5-25**] 06:33AM URINE Blood-LG Nitrite-POS Protein-100
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-2* pH-6.0 Leuks-LG
[**2191-5-25**] 06:33AM URINE RBC-58* WBC->182* Bacteri-MOD Yeast-NONE
Epi-0
[**2191-5-25**] 06:33AM URINE Mucous-MANY
[**2191-5-23**] 08:49PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-POS amphetm-NEG mthdone-NEG
.
micro:
blood cultures pending
urine culture pending
.
imaging
CT head
1. No acute intracranial process.
2. Small subgaleal hematoma at the right skull vertex without
underlying
fracture or parenchymal contusion.
3. Mild age-inappropriate cortical atrophy.
.
CXR
REPORT: Markedly suboptimal evaluation technically. Allowing
for this,
respiratory motion and some suboptimal inspiratory effort, the
lungs are
probably grossly clear and no definitive infiltrate is noted.
CONCLUSION: No definitive acute findings.
.
CXR:
The NG tube tip is in the stomach. Heart size and mediastinum
are unchanged within this short-term interval. Lungs are
essentially clear. There is no appreciable pleural effusion or
pneumothorax.
.
RUQ ultrasound:
IMPRESSION: Limited study with patent main portal vein and no
gross ascites.
.
CXR
Minimal interstitial abnormality in lower lungs developed over 3
hours on [**5-23**], probably mild edema. Lungs clear of any
evidence of pneumonia. Heart size normal. Pleural effusion
minimal, if any.
UCx: E coli >100,000 colonies
DISCHARGE LABS:
[**2191-5-27**] 06:35AM BLOOD WBC-3.8* RBC-3.73* Hgb-12.1* Hct-37.3*
MCV-100*# MCH-32.5*# MCHC-32.5 RDW-15.6* Plt Ct-40*
[**2191-5-27**] 06:35AM BLOOD PT-15.9* PTT-68.3* INR(PT)-1.5*
[**2191-5-27**] 06:35AM BLOOD Glucose-96 UreaN-12 Creat-0.7 Na-134
K-3.7 Cl-108 HCO3-22 AnGap-8
[**2191-5-27**] 06:35AM BLOOD ALT-23 AST-53* LD(LDH)-389* AlkPhos-98
TotBili-2.4*
[**2191-5-27**] 06:35AM BLOOD Calcium-7.8* Phos-2.6* Mg-1.7
Brief Hospital Course:
49 yo M with history of HIV on HAART (last CD4 155 in [**3-21**]), HCV
presenting after being found down at group home and transferred
to MICU for increasing somnolence likely related to hepatic
encephalopathy caused by substance abuse and medication
non-compliance. The patient was stabilized and transfered out of
the ICU for further management.
.
1, Altered mental status - Primarily due to hepatic
encephalopathy in the setting of missing his home lactulose and
rifaxamin. Also found to have urine tox on admission positive
for cocaine and a urinary tract infection further contributing
to his AMS. Patient was initially admitted to the liver service,
however given increased somnolence he was transferred to the
MICU. CT head unremarkable. Patient had an NG tube placed and
was administered lactulose with good effect. His mental status
gradually improved with increasing stool output. The NG tube was
removed and patient was able to tolerate po diet. He spiked a
fever on his second night in the MICU and was pancultured. Urine
showed evidence of infection, the urine grew E coli, and he was
started on ceftriaxone IV. On discharge he was narrowed to cipro
500mg [**Hospital1 **] to complete a 14 day course. He was continued on
rifaxmin in addition to his lactulose for hepatic
encephalopathy.
.
2. Hep C/ Alcohol Cirrhosis - Pt has cirrhosis [**2-10**] chronic HCV
genotype 1a and alcohol. MELD 15. Complicated by Grade 1
varices on EGD [**5-/2190**], no h/o variceal bleed and hepatic
encephalopathy. LFTs and tbili now improving. Patient was
continued on lactulose, rifaxamin, and aldactone. The patient
will follow-up with the liver clinic on discharge.
.
3. UTI: Patient spiked a fever to 101 during MICU stay. He was
pancultured. UA positive for infection. Treatment per above.
.
4. HIV - CD4 of 155 on [**2191-3-25**] down from 195 in [**Month (only) 359**], VL
[**Numeric Identifier 10489**] up from 64 in [**Month (only) 359**]. On Atazanavir and truvada as
outpatient though disease clearly worsening and unclear if
patient has been compliant with his medications. Repeat CD4
count is 112. Per patients outpatient ID doctor, okay to hold
HAART during admission and will be restarted as an outpatient.
He was continued on bactrim for ppx.
.
5. Bipolar Disease- On seroquel and bupropion as outpatient.
Seroquel was held in the setting of altered mental status. He
was continued on his bupropion. The seroquel will be restarted
on discharge.
.
Transitional issues
- patient will need to follow up with his infectious disease
doctor to discuss appropriate HIV treatment regimen
Medications on Admission:
ATAZANAVIR [REYATAZ] - 150 mg Capsule - 2 Capsule(s) by mouth
once a day
BUPROPION HCL - 100 mg Tablet - 1 Tablet(s) by mouth 2 every
morning, then 1 at 4pm daily
EMTRICITABINE-TENOFOVIR [TRUVADA] - 200 mg-300 mg Tablet - one
Tablet(s) by mouth once a day
IBUPROFEN - 400 mg Tablet - [**1-10**] Tablet(s) by mouth every 8 hours
as needed for pain take with food
LACTULOSE - 10 gram/15 mL Solution - 30ml--45ml Solution(s) by
mouth 3 or 4 times daily until stools are soft (not diarrhea)
PANTOPRAZOLE - 20 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s)
by mouth once a day
QUETIAPINE [SEROQUEL] - 300 mg Tablet - 1 Tablet(s) by mouth
once
a day
RIFAXIMIN [XIFAXAN] - 550 mg Tablet - 1 Tablet(s) by mouth two
times a day
RITONAVIR [NORVIR SOFT GELATIN] - 100 mg Capsule - 1 Capsule(s)
by mouth once a day
SPIRONOLACTONE [ALDACTONE] - 50 mg Tablet - 1 Tablet(s) by mouth
daily
SULFAMETHOXAZOLE-TRIMETHOPRIM [BACTRIM] - 400 mg-80 mg Tablet -
1
Tablet(s) by mouth once a day
TRAMADOL - 50 mg Tablet - 1 Tablet(s) by mouth three times a day
Discharge Medications:
1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*0*
2. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day): You should have [**3-13**] bowel movements daily.
Disp:*1 bottle* Refills:*0*
5. pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day: Must be 12
hours aprat from the Reyataz.
6. atazanavir 150 mg Capsule Sig: Two (2) Capsule PO once a day.
7. bupropion HCl 100 mg Tablet Sig: Two (2) Tablet PO QAM (once
a day (in the morning)).
8. bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO QPM (once
a day (in the evening)).
9. quetiapine 300 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO DAILY (Daily).
10. ritonavir 100 mg Capsule Sig: One (1) Capsule PO once a day.
11. Truvada 200-300 mg Tablet Sig: One (1) Tablet PO once a day.
12. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 11 days.
Disp:*22 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Hepatic encephalopathy
Substance abuse
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Discharge Instructions:
You were admitted to the hospital with confusion after being
found down at home. You improved with lactulose to clear your
confusion. It is important that you regularly take your
medications and avoid alcohol and illicit drugs. We encourage
you to enter a drug rehab program. Please follow-up with your
PCP/ID Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 497**] (liver) as below.
The following changes were made to your medications:
Started ciprofloxacin for urinary tract infection
Followup Instructions:
Department: INFECTIOUS DISEASE, Primary Care
When: FRIDAY [**2191-6-3**] at 11:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: LIVER CENTER
When: FRIDAY [**2191-6-10**] at 2:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: RADIOLOGY
When: FRIDAY [**2191-8-12**] at 11:00 AM
With: ULTRASOUND [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 10438**]
ICD9 Codes: 2762, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1085
} | Medical Text: Admission Date: [**2111-8-3**] Discharge Date: [**2111-10-16**]
Date of Birth: [**2038-7-7**] Sex: F
Service: MEDICINE
Allergies:
Meperidine
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Diplopia.
Major Surgical or Invasive Procedure:
1. tracheostomy
2. sinus biopsy
3. arterial line
4. PICC placement
History of Present Illness:
The patient is a 73 year-old right-handed female with a history
of breast cancer, atrial fibrillation on coumadin, ulcerative
colitis (on prednisone) who presented with chief complaint of
diplopia. The patient noted double vision on the morning of
admission. She noted that the false image appeared diagonal to
the true image. Note was not made if the diplopia was worse in
any one direction. The pt noted that she also developed
numbness on the left half of her face below her eye, which she
first noticed on the morning of admission. She also complained
of feeling unsteady and fell to the left side on the morning of
admission. In addition, she noted her voice was hoarse and weak.
She denied headache, nausea, neck pain, parasthesiae, changes in
hearing, dysphagia, weakness. No incontinence or back pain. She
did admit to fever, nausea and vomiting for the past two days
prior to admission.
REVIEW OF SYSTEMS: denies chest pain, has shortness of breath
upon exertion at baseline, denies dysuria, hematuria, or bright
red blood per rectum.
Past Medical History:
-breast cancer, diagnosed in [**2102**]; bilateral with metastases to
lymph nodes, s/p lumpectomy, local radiation and 5FU/adriamycin
-osteoarthritis
-s/p R-knee and L-hip replacement ([**2109**])
-Atrial fibrillation
-rheumatoid arthritis
-h/o adriamycin-induced cardiomyopathy
-ulcerative colitis, s/p ileostomy
-restrictive lung disease (related to radiation and/or
amiodarone)
-dilated cardiomyopathy
Social History:
The pt denied use of tobacco or illicit drugs. She admitted to
occasional alcohol use. The pt lives alone, not married, no
children, gets assistance from health aids. At baseline walks
with a cane.
Family History:
No history of stroke or other neurologic disease.
Physical Exam:
Vitals: T100.5 Heart rate 82 Blood Pressure 148/72 RR 21, sO2 97
RA
General: no acute distress, not dyspneic, pleasant
Skin: no rash
Head, ear, nose and throat: no bruits over the skull, moist
mucous membranes
Neck: no Carotid Bruits; palpation of the paraspinal soft
tissues not painful, Brudzinski negative.
Lungs: bronchial breathing sounds bilaterally
Cardiovascular: Regular rate and rhythm, normal S1 and S2,
I/VIsystolic murmur above the apex.
Abdomen: normal bowel sounds, soft, nontender, nondistended. No
organomegaly. Multiple scars form previous surgery. Ileostoma,
site non-infected.
Extremities: ecchymoses on both knees and L-arm, bilateral non-
pitting edema lower extremities.
NEUROLOGIC EXAMINATION:
Mental Status:
Awake and alert, cooperative with exam, pleasant affect.
Oriented to person, place, month, day, date, and president
Attention: Can say months of year backward; can perform serial
subtractions.
Language: Fluent with good comprehension and repetition.
No paraphasic errors. Slight dysarthria. Naming is intact.
[**Location (un) **] intact. Writing intact.
Fund of knowledge normal. Able to calculate.
Registration: [**2-12**] items, Recall [**1-12**] at 3 minutes
No apraxia, No neglect (situation, space)
Cranial Nerves:
I: deferred
II: Visual acuity 20/200 L and R. Visual fields are full to
confrontation; Pupils equal, round and reactive to light both
directly and consensually, 1 mm bilaterally. Fundoscopic exam:
not able to see discs, no hemorrhages
or exudates.
III, IV, VI: Not able to move both eyes across the midline to
the
L. Able to move R eye laterally, but not sustained. Vertical eye
movements intact. Ptosis on the L.
V: Facial sensation intact in V1,V2, and V3 to light touch; not
able to feel pinprick and temperature (cold) in V1, V2, and V3
on the right. Jaw opening with deviation to the R.
VII: Facial paresis on L side both in upper and lower part of
the face.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palate elevates in midline.
[**Doctor First Name 81**]: Sternocleidomastoid [**4-14**] on left. Not able to keep head up in
sitting position ([**2-14**]), pointing to neck extensor weakness.
XII:Tongue protrudes to the right, able to move in both
directions, no fasciculations or atrophy.
Motor:
Normal bulk and tone bilaterally. No fasciculations, no pronator
drift; intermittent tremor in arms. No athethosis. No asterixis.
Strength:
D T B WF WE FiF [**Last Name (un) **] IP Gl Q H AF AE TF TE
Right 5 5 4 4 4 4 4 4 5 5 5 5 5 5 5
Left 4 5 4 4 4 4 4 4 5 5 5 5 5 5 5
Sensory:
Sensation was intact to light touch; pin prick was decreased in
upper extremity and lower extremity; vibration decreased in feet
only; proprioception intact in all extremities. No extinction to
double, simultaneous stimulation.
Reflexes: B T Br Pa Ach
Right 1 1 1 1 -
Left 1 1 1 1 -
Brisk masseter reflex.
Toes were equivocal bilaterally.
Coordination:
Finger-nose-finger slow and more difficult on L-side, possibly
related to double vision, rapid alternating normal, heel to shin
normal.
Gait: not tested; when sitting up patient she was not able to
hold her head up against gravity.
Pertinent Results:
Labs on admission:
[**2111-8-2**] 08:25AM BLOOD WBC-8.8 RBC-3.02* Hgb-10.6* Hct-32.8*
MCV-108* MCH-35.2* MCHC-32.4 RDW-15.3 Plt Ct-199
[**2111-8-2**] 08:25AM BLOOD Neuts-85* Bands-0 Lymphs-6* Monos-8 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2111-8-2**] 08:45AM BLOOD PT-13.6* PTT-20.7* INR(PT)-1.2
[**2111-8-2**] 08:25AM BLOOD Glucose-143* UreaN-20 Creat-1.1 Na-138
K-3.6 Cl-102 HCO3-27 AnGap-13
[**2111-8-3**] 04:25AM BLOOD Calcium-7.3* Phos-2.3* Mg-1.7
Cholest-216*
[**2111-8-3**] 04:25AM BLOOD Triglyc-68 HDL-117 CHOL/HD-1.8 LDLcalc-85
[**2111-8-3**] 04:25AM BLOOD %HbA1c-5.4 [Hgb]-DONE [A1c]-DONE
.
On discharge
INR 2.9, HCT 27.4, WBC 5.2, PLT 150, Creat 0.6, K 4.8
.
CSF:
Hematology
ANALYSIS WBC RBC Polys Lymphs Monos
[**2111-8-3**] 10:30AM 631 16* 84 3 13
TUBE #4
[**2111-8-3**] 10:30AM 471 37* 79 5 16
TUBE #1
CHEMISTRY TotProt Glucose
[**2111-8-3**] 10:30AM 110* 91
TUBE #2
.
Imaging:
[**2111-7-17**]: Chest CT (oupt): Bilateral apical consolidation with
traction bronchiectasis consistent with post-radiation changes.
Bilateral patchy ground-glass opacities in both upper lobes and
right lower lobe, which may be due to infectious or inflammatory
etiology. A
followup CT scan is recommended in 3 months. Stable right-sided
septal thickening and right pleural thickening.
.
[**8-2**] MRI head: Small (4 x 7 mm), ring-enhancing mass within the
left pontine tegmentum, with signal and enhancement
characteristics of some concern for an abscess. Neoplastic
disease would be a secondary consideration, in view of the
history of prior breast cancer. Rim enhancement would be very
atypical for an infarct.
.
[**8-4**]: Echo: Left ventricular wall thicknesses are normal.
The left ventricular cavity size is normal. Regional left
ventricular wall motion is normal (LVEF>=60%). No masses or
thrombi are seen in the left ventricle. Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened. No masses or vegetations are seen on the
aortic valve. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Mild to moderate ([**1-11**]+) mitral regurgitation is seen. Moderate
[2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
.
[**8-4**]: CT chest: New moderate bilateral pleural effusions with
bilateral basilar atelectasis. Bilateral apical consolidation
with traction bronchiectasis. No evidence of lymphangitic spread
of disease.
.
[**8-4**]: CT neck: No evidence of lymphadenopathy noted on this neck
CT. Sinus disease. Bilateral pleural effusion.
.
[**8-6**]: CT sinuses: The left sphenoid cell is almost completely
opacified. This may be secondary to inspissated secretions and
mucosal thickening. However, the bony margins are intact. There
is no evidence of bony disruption or erosion. The right
sphenoid air cell appears to have a small air fluid level within
it. There is ethmoid sinus mucosal thickening. The maxillary
sinuses appear normal. The septum is midline. The cribriform
plates are at the same level. There is a slight leftward septal
deviation.
.
[**8-4**]: CT pelvis: There has been interval left total hip
replacement, which is noted to cause a large amount of streak
artifact in the pelvis, slightly limiting evaluation for signs
of infection. Allowing for this, there are no bony destructive
changes. There is no evidence of hardware loosening. No fluid
collections are identified. A Foley catheter is present within
the collapsed bladder as well as note of a small amount of air,
which may be seen with recent manipulation. An ileostomy is
noted in the right lower uadrant. There is diffuse stranding of
the subcutaneous fat consistent with anasarca. Note is made of
calcified injection granulomas in the posterior subcutaneous
tissues. A cleft is noted along the midline of the posterior
subcutaneous tissues overlying the sacrum, which is most
consistent with a skinfold.
IMPRESSION:
1. No definite signs of infection given limitations of
technique and streak artifact. If there is strong clinical
suspicion, a MRI or white blood cell scan would be helpful.
2. Findings consistent with anasarca in the subcutaneous
tissues.
.
[**8-8**]- MRI lumbar spine: Moderate degenerative changes and two
perineural cysts at the S2 level.
.
[**8-11**]- CXR: Left lower lobe atelectasis. Mild congestive heart
failure with mild cardiomegaly. Small bilateral pleural
effusions.
.
[**8-12**]: Head MRI:
FINDINGS: Again, note is made of pontine abscess with ring
enhancement, which has increased in size compared to the prior
study and now spreading across the midline to the right side of
the pons, with increased amount of surrounding edema. Note is
made of high signal intensity on diffusion-weighted images
corresponding to the area of abscess, which also spread across
midline. Note is made of low signal intensities on gradient
echo at the location of the abscess, which may represent
hemorrhage content or free radicle. The rest of the brain
appears unremarkable.
Again, note is made of opacification of the left sphenoid sinus,
representing sinus disease. Note is made of fluid within the
bilateral mastoid cells.
IMPRESSION:
1. Progression of the pontine abscess with ring enhancement,
associated with increased edema and hemorrhage versus free
radicle formation, which now crossing the midline and extending
to the right side of the pons.
2. Chronic sinus disease in left sphenoid sinus.
.
[**8-15**]- MRI head: signal abnormality with hyperintensity to signal
is seen involving the posterior portion of the pons along the
floor of the fourth ventricle. In this region, rim-enhancing
areas are identified concerning for infectious etiology. Mild
brain atrophy.
.
[**8-13**]: CT sinuses: Again, note is made of fluid within the left
sphenoid sinus with multiple small collections of air probably
epresenting sinusitis. The septum of the sphenoid sinus inserts
at right carotid groove. Note is made of mucosal thickening of
bilateral ethmoid sinuses, unchanged compared to the prior
study. Bilateral maxillary sinuses are clear. Again, note is
made of fluid within bilateral mastoid air cells. Anterior
clinoid processes are not pneumatized. The patient is status
post intubation. No intracranial air is noted.
IMPRESSION: Continued left sphenoid fluid with air bubbles,
representing sinusitis. Mucosal thickening of bilateral ethmoid
sinuses.
.
[**8-21**]: MRI head: Decrease in size of the enhancing multi-cystic
lesion in the pons, with decreased amount of edema, surrounded
by high low signal intensity ring on T1-weighted images,
probably representing improving pontine abscess. Unchanged
appearance of opacification of the left sphenoid sinus.
Bilateral mastoid air cell opacification.
.
[**8-30**]: MRI head: Compared to examinations performed at the
beginning of [**Month (only) 216**], and even to the study of [**2111-8-21**],
there is less edema in the dorsal pontine body, than on previous
studies. The left paramedian abscess, which has susceptibility
artifact along its rim, is slightly smaller in size. Enhancement
in this area has also decreased. Diffusion signal
hyperintensity persists, and may
represent residual liquified material within the abscess.
There continues to be opacification of the mastoid air cells and
fluid or mucosal thickening within the sphenoid sinus. Overall,
the appearance of the remainder of the brain is unchanged. The
ventricles are not dilated.
.
[**9-4**]: GI bleeding study: Probably negative GI bleeding study,
indicating no active bleeding at the time of study. The left
upper quadrant accumulation of activity was not positively
confirmed as free pertechnetate; however, were this to represent
bleeding, the rate of bleeding was not brisk.
.
[**9-6**]: BILAT LOWER EXT VEIN: Limited study. No evidence of DVT,
but the right distal SFV and left politeal could not be imaged.
.
[**9-9**]: MRI Head: No significant interval change seen involving
the examination of the brain since [**2111-8-30**]. An area of
residual enhancement is still present along the posterior aspect
of the pons and upper medulla with some diffusion abnormality
still present suggestive of a partially resolving posterior
pontine abscess. Bilateral T2 hyperintensities within the
mastoid and sphenoid sinuses. Followup is recommended and
should be based on clinical
grounds.
.
[**9-12**]: Portable CXR: A left-sided PICC line terminates at the
junction of the left brachiocephalic vein, and upper superior
vena cava. A tracheostomy tube is in unchanged position. A
Dobhoff tube is seen extending towards the stomach antrum. When
compared with prior study, there is no significant interval
change in appearance of the lungs. The cardiac silhouette,
mediastinal and hilar contours are normal and stable. There
remains pulmonary vascular congestion and redistribution
bilaterally, and there are stable bilateral pleural effusions.
Again, noted are fibronodular opacities within bilateral lung
apices, as previously described. These are stable in size and
appearance. The surrounding soft tissue and osseous
structures are unremarkable.
IMPRESSION:
1. Stable interval appearance of pulmonary vascular congestion
and bilateral pleural effusions, consistent with congestive
heart failure.
2. Stable fibronodular opacities in bilateral lung apices, as
previously described.
3. Lines and tubes as indicated above.
EEG [**2111-9-30**] : Abnormal portable EEG due to the slow and
disorganized
background and bursts of generalized slowing. These findings
indicate a
widespred encephalopathic condition affecting both cortical and
subcortical structures. Medications, metabolic disturbances, and
infection are among the most common causes. There were no areas
of
persistent focal slowing, and there were no overtly epileptiform
features. There was a large amount of movement artifact. Some
artifact
appeared due to tremor or other head movement. No electrographic
seizures were recorded.
[**2111-9-9**] 03:19AM BLOOD WBC-6.1 RBC-3.03* Hgb-9.3* Hct-29.3*
MCV-97 MCH-30.8 MCHC-31.9 RDW-20.0* Plt Ct-51*
[**2111-9-9**] 03:19AM BLOOD Plt Ct-51*
[**2111-9-9**] 03:19AM BLOOD Glucose-80 UreaN-43* Creat-0.7 Na-144
K-4.1 Cl-109* HCO3-28 AnGap-11
[**2111-9-8**] 03:10AM BLOOD ALT-29 AST-35 LD(LDH)-387* AlkPhos-166*
Amylase-291* TotBili-0.5
[**2111-9-8**] 03:10AM BLOOD Lipase-85*
[**2111-9-9**] 03:19AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.0
[**2111-8-9**] 04:00AM BLOOD TSH-1.1
[**2111-8-9**] 04:00AM BLOOD Free T4-0.9*
[**2111-9-2**] 01:35PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
[**2111-9-5**] 01:02PM BLOOD [**Doctor First Name **]-NEGATIVE
Brief Hospital Course:
The patient was admitted to the ICU where she remained until
discharge.
1. Pontine abscess: It was originally thought that the symptoms
could be related to a brainstem ischemic event, as the MRI
performed on admission revealed an area of restricted diffusion
in the left pontine tegmentum. Upon further review of the
entire MRI study by the radiology service, it was felt that this
lesion more likely represented an abscess given that it was
ring-enhancing on T1 with gadolinium. In addition, the patient
had a persistent fever, supporting this hypothesis. A lumbar
puncture revealed pleocytosis and elevated protein; gram stain
was negative; serologic and laboratory studies on CSF remained
negative. An HIV antibody was sent and returned negative. In
addition, the pt was ruled-out for tuberculosis with acid fast
smear taken from endotracheal samplings. In addition, a TTE was
performed that revealed no valvular lesions or vegetations. A
dental consult, given a history of mandibular implants, provided
no evidence of infection at the site of the implants. A CT scan
of the left hip was performed which showed no evidence of
infection of the replacement hip. CT of the sinuses were
performed and showed evidence of mucosal thickening in the left
sphenoid sinus. A biopsy of the left sphenoid sinus demonstated
a group of cells that were suspicious for carcinoma. Further
workup should take place once the patient is in better
condition, i.e. as outpatient. Altogether, no pathogens could be
identified that might have caused the abces. A biopsy would have
been the only means to make the ultimated diagnosos, but this
procedure was considered to be too dangerous (per Neurosurgery).
The infectious disease consult team recommended treating for
presumptive bacterial infection with intravenous ceftriaxone,
ampicillin, vancomycin and metronidazole.
On hospital day ten, a repeat MR of the head was performed to
assess for response of the lesion to a course of antibiotics.
Unfortunately, the MR revealed extension in the size of the
lesion. The pt showed evidence of worsening clinically on
hospital day twelve with a small (1mm) but reactive right pupil
and sluggishly reactive (although normal-sized) left pupil as
well as evidence of a left cranial nerve twelve palsy. Yet
another MR of the head was performed which showed stable size of
the lesion from the study of two days prior. Neurosurgical
consultation was requested to assess whether the lesion would be
amenable to drainage in light of the extension seen
radiographically. It was felt that given the location of the
lesion, biopsy or drainage would entail too great a likelihood
of morbidity. The antibiotic regimen at this point was changed
to meropenem (to cover gram positive and negative organisms as
well as Nocardia) and ambisome to cover fungal pathogens.
High-dose dexamethasone was also added and later tapered.
A repeat MRI of the head was performed to reassess the lesion on
hospital day 18. This demonstrated decreased size of the lesion
and surrounding edema after treatment with antibiotics Given
the high suspicion for Listeria as the etiologic [**Doctor Last Name 360**], with
other possible pathogens including HSV, the antibiotic regimen
was changed to high-dose penicillin and acyclovir at this time.
She began to slowly improve clinically. Acyclovir was
discontinued after 10 days. Further MRI studies ([**8-30**] and [**9-9**])
showed continued improvement. Upon discharge, the patient had
regained slight horizontal eye movements. She is left with a
significant L-facial paresis, is able to move her tongue, but
with difficulties and remains unable to clear her secretions.
Her way of communicating is through writing, although this is at
times difficult due to a tremor. To evaluate an episode of
altered mental status, an EEG was obtained that showed no
epileptiform waves but did show patterns consistent with
metabolic encephalopathy. Neurology was consulted and did not
suggest that any of her altered mental status or tremors were
due to seizures. Her mental status cleared as her hypoglycemia
and infections resolved.
In addition to the problems involving her cranial nerves, she
has significant proximal muscle weakness in her upper and lower
extremities, mostly secondary to her infection and high dose
steroids. The steroids have been tapered down to prednisone 8 mg
daily, on which she needs to remain (i.e. her home dose was 10).
Follow up MRI was done on day if discharge. She will follow up
with neurology and infectious disease to evaluate improvement.
SHe completed course of penicillin G to treat the presumed
Listeria abscess.
.
2. Atrial fibrillation: On admission, the pt was in atrial
fibrillation with rapid ventricular rate to the 130s. She was
maintained on metoprolol and diltiazem was added to aid in
rate-control. Amiodarone was discontinued per her cardiologist,
Dr. [**Last Name (STitle) 1911**]. Anticoagulation was held early in the course
of the admission over concern for hemorrhage into the pontine
lesion, but was later restarted. The patient than developed a GI
bleed, while her INR was supratherapeutic and her platelets were
dropping. Coumadin was held until PLT had recovered (i.e.
>150.000). She was reloaded on amiodarone as it seemed to be the
only [**Doctor Last Name 360**] that adequately rate controlled her which was
necessary to improve filling times forward flow but this was
subsequently d/c. She is currently rate controlled on digoxin
(last level 1.1 on [**10-8**]) and metoprolol 25 mg QID with hr
ranging from 90-120. She is currently being reloaded on coumadin
as she is subtherapeutic.
.
3. Hypotension: the patient had several episodes of hypotension.
These might have been related to her primary brainstem lesion in
combination with sedation and blood loss (see below). For
support she was started on neosynephrine gtt when needed. Most
recently she again required pressors on [**10-6**] following a large
volume thoracentesis. DDX included adrenal insufficiency, fluid
shift, or new infection/early sepsis. She was able to be weaned
off pressors w/o stress dose steroids and stabilized on
vanc/meropenem. Cultures were only notable for MRSA in her
sputum. Thus, plan for 10 day course of vancomycin to end on
[**2111-10-17**]. Patient has now been stable off pressors x 7 days. She
is fluid overloaded on exam. She should be started on diureses
while at rehab, when her BP is stable. Her blood pressure has
been lowish with SBP in the loww 100's. We opted not to start
diuresis on discharge as we were titrating her metoprolol. We
recommend a dose of Lasix 10 IV BID with goal negative fluid
balance of 500-1000cc per day.
.
4. Respiratory:
Shortly after admission, the patient was intubated because she
was not able to swallow and clear her secretion. A tracheostomy
was performed on [**8-13**]. She was placed on ventilator support.
During her stay, she developed worsening respiratory distress.
Bronch specimen produced stenotrophomonas maltophilia and
patient completed a 21 day course of bactrim for this. As
described above, patient also being tx for MRSA PNA and is
currently d9/10. Currently she is vent dependent. Her current
settings are PS 15 w/ PEEP 5 and FiO2 40%. Of note, the patient
has a poor pulmonary baseline secondary to radiation (breast
ca).
.
5. Ophthalmology:
The patient has bilataral keratopathy (L>R) and evidence of
corneal abrasion on left. Ophthalmology was consulted.
Erythromycin gtt and artificial tearts should be continued. A
patch over her left eye will help her manage her diplopia. The
patch should be removed a few hours a day, this to train her
eyes. She should be seen by an ophthalmologist in one week after
discharge.
.
6. Hematology:
After the patient was restarted on coumadin, her Hct dropped.
She was transfused with pRBC to keep Hct>30. Gasteroenterology
was consulted to evaluated for GI bleed as her stools looked
tarry, suggesting an upper GI bleed. Their workup remained
negative (see below). In addition, her PLT trended down to the
50's. This drop might have been medication related. Bactrim was
therefore discontinued but later restarted without further
thrombocytopenia. Heparin Abs were negative and lab results did
not suggest intravascular hemolysis. Another etiology might
include pancytopenia secondary to her chronic disease.
Currently, hct stable around 28 and plt 150's and have remained
stable in the week prior to discharge. She is expected to
improve slowly.
.
7. Infectious disease:
-Brainstem abcess: Responded well to penicillin G i.v. She has
received a total of 8 week course with penicillin G.
-MRSA in sputum/sinus/stool culture, representing colonization.
She is due to finish course on [**2111-10-17**].
-stenotrophomonas in sputum, representing colonization. This was
treated with bactrim.
.
8. Gasteroenterology:
The patient has a stoma.
Following a drop in Hct and tarry stools, she was evaluated by
GI. an EGD [**9-3**] showed no active bleed but an AVM that might
have bled. A bleeding scan with tagged blood was negative for GI
bleed as well. The patient was started on PPI iv q 12hrs, to be
converted to PO BID upon discharge.
In addition, elevated LFT's and lipase/amylase were noted. These
abnormalities might be related to overall poor condition or
sludge/stones. The patient did not complain of abdominal
discomfort. Please continue to follow these enzymes. Further
workup should be considered only once she has recovered.
.
9. Endocrine: The patient's glucose levels were adjusted per
RISS and FSBS were followed. This is to be continued after
discharge. Please follow up on thyroid studies, i.e. monitor for
hypothyroidism. The patient's home dose of 6 units NPH [**Hospital1 **] was
discontinued since she had several hypoglycemic events as low as
30. FS during last week of hospitalization have been in 80-160.
.
10. FEN: The patient has a NGT and received TF that she
tolerates well. Consider to further improve her protein status
with supplements. The patient is significantly fluid overloaded.
This should be improved by ace-wraps, improvement of protein
status and mobilization. She was gently diuresed as pressure
allowed.
.
11. PPX: pneumoboots, PPI, "ski-boots" for contractures, [**Male First Name (un) **]
stockings or ace wraps for edema, OOB to chair.
Please provide skin care to coccygeal area.
Medications on Admission:
ACETAMINOPHEN 325MG.--2 tabs by mouth q4 hours
AMBIEN 5MG--One by mouth at bedtime as needed for sleep
AMIODARONE HCL 200MG--One daily
AQUAPHOR --Apply top as needed for -- to pruritic areas
DIOVAN 80MG--One daily
LASIX 20MG--One daily
LIPITOR 10MG--One daily
LOTRISONE .05%--Apply to foot twice a day
MEGACE 20MG--One tabl twice daily, in the morning and the
evening
MULTIVITAMINS --One tablet by mouth every day
OXAZEPAM 15 MG--One capsule by mouth as needed at bedtime
insomnia
PREDNISONE 5MG--Take 2-5mg tabs and 1-20mg tablet daily for 7
days; then, 3-5mg tabs daily for 7 days; then 2-5m tabs daily
for 7 days; then 1-5mg tablet daily for 7 days, then call us.
TAMOXIFEN 10 MG--One tablet by mouth three times a day
TAMOXIFEN CITRATE 10MG--One by mouth twice a day.
TOPROL XL 25MG--One twice daily
WARFARIN SODIUM 3MG--One daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Albuterol 90 mcg/Actuation Aerosol Sig: 6-8 Puffs Inhalation
Q4H (every 4 hours) as needed for wheezing.
3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-11**]
Drops Ophthalmic Q3H (every 3 hours).
4. Erythromycin 5 mg/g Ointment Sig: One (1) drop Ophthalmic
TID (3 times a day).
5. Erythromycin 5 mg/g Ointment Sig: One (1) drop Ophthalmic
QHS (once a day (at bedtime)).
6. Folic Acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily).
7. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
11. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO once a day.
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
13. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
14. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
15. Prednisone 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
16. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 36H () for 1 doses: last dose on [**2111-10-17**].
17. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
18. Lorazepam 2 mg/mL Syringe Sig: 0.5 mg Injection every eight
(8) hours as needed for agitation/anxiety.
19. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO QID
(4 times a day): hold for SBP<95, HR<65.
20. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-11**]
Drops Ophthalmic Q3H (every 3 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
1. pontine abcess
2. MRSA sinusitis, atypical cells to be evaluated by oncology as
outpatient
3. Atrial fibrillation with rapid ventricular response
4. gasterointestinal hemorrhage
5. thrombocytopenia
6. anemia
7. hypotension
8. steroid myopathy
9. sepsis
Discharge Condition:
Fair
Discharge Instructions:
Please continue medications as instructed.
.
Please provide care to the tracheostoma and colonostoma.
.
Please provide skin care to the coccygeal area.
.
Hold coumadin until INR<1.5 then have subclavian central line
pulled. Then re-start coumadin. Start 5 mg once, then 2 mg
daily, checking INR's 2x/week until on stable regimen
.
Re-start lasix at recommend dose of 10 IV BID when BP stable
(SBP>105)
Followup Instructions:
Please follow up with your Primary Care Physician after
discharge from rehab.
.
Please follow up at the [**Hospital 878**] Clinic: Provider: [**Name10 (NameIs) 5005**] [**Name Initial (NameIs) **]
[**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2111-10-23**] 9:30AM,
[**Hospital Ward Name 23**] [**Location (un) **].
.
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] OB/GYN PPS CC8 (SB) Where: OB/GYN
PPS CC8 (SB) Date/Time:[**2111-10-7**] 1:00
.
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] [**Hospital 2039**]
CARE CENTER Phone:[**Telephone/Fax (1) 6733**] Date/Time:[**2111-12-10**] 11AM, [**Hospital Ward Name 23**]
[**Location (un) 442**].
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6719**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2111-12-17**] 9:45
Have ophthalmology follow up with respect to the keratopathy
every two weeks.
You have follow up with Infectious Disease regarding your brain
abscess, Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2111-11-12**] 8:30AM, [**Last Name (NamePattern1) **]. Basement, Suite G
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
ICD9 Codes: 4280, 4254, 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1086
} | Medical Text: Admission Date: [**2152-3-10**] Discharge Date: [**2152-3-19**]
Date of Birth: [**2069-6-27**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
Lower GI bleed
Major Surgical or Invasive Procedure:
Right ileocectomy
History of Present Illness:
82F with a history of diverticulosis and lower GI bleeds with
last colonoscopy at [**Hospital1 2177**] in [**9-17**]. She presented to the emergency
room on [**2-/2073**] am with reports of bright red blood per rectum
since dinner the night prior. She reported feeling dizzy and
lightheaded at that time and called EMS, who brought her to the
emergency room. She denies any abdominal pain, chest pain,
fevers, or chills.
Past Medical History:
PMH: Diverticulosis with h/o multiple GI bleeds, Hypertension,
Hyperlipidemia, MI in [**2104**], gout, Polycythemia with chronic all
and elevated WBC count.
PSH: Hysterectomy for fibroids ([**2109**]), appendectomy as a child
Physical Exam:
On admission:
Temp 99.5 HR 95-100 BP 128/64 RR 18 O2 Sat 100%2L
Gen: AA&O x 3
HEENT: PERRL, EOMI b/l
Neck: supple
CV: RRR
Pulm: CTA b/l
Abd: +BS, soft, NT, ND, no rebound/gaurding
Rectal: dried blood around anus, clotted blood on rectal, no
BRBPR, no mass
Ext: No c/c/e
Pertinent Results:
On Admission:
[**2152-3-10**] 04:10AM PT-14.4* PTT-29.2 INR(PT)-1.3*
[**2152-3-10**] 04:10AM WBC-95.5* RBC-5.85* HGB-10.6* HCT-41.1
MCV-70* MCH-18.1* MCHC-25.7* RDW-17.2*
[**2152-3-10**] 04:10AM GLUCOSE-198* UREA N-54* CREAT-1.8* SODIUM-142
POTASSIUM-4.9 CHLORIDE-106 TOTAL CO2-23 ANION GAP-18
[**2152-3-10**] 05:56AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-MOD UROBILNGN-1 PH-5.0 LEUK-NEG
[**2152-3-10**] 08:22AM HCT-33.9*
[**2152-3-10**] 02:16PM HCT-25.7*
[**2152-3-16**] 08:41AM BLOOD Hct-31.4*
[**2152-3-17**] 07:57AM BLOOD Hct-31.0*
[**2152-3-18**] 06:50AM BLOOD Hct-32.5*
.
[**3-11**] Tagged RBC Scan:
INTERPRETATION: Following intravenous injection of autologous
red blood cells labeled with Tc-[**Age over 90 **]m, blood flow and dynamic
images of the abdomen for minutes were obtained. A left lateral
view of the pelvis was also obtained.
Blood flow images show normal tracer distribution.
Dynamic blood pool images show tracer activity in the ileocolic
artery distribution, suggesting active bleeding, first seen at
75 minutes with progressive accumulation of tracer in this
locale until 90 minutes.
IMPRESSION:
Positive GI bleeding study, with tracer accumulation in the
ileocolic artery distribution first seen at 75 minutes.
.
[**3-12**] Angiogram:
PROCEDURE AND FINDINGS: Informed consent was obtained and a
pre-procedure timeout performed. From a right femoral approach,
via a 5 French arterial sheath, the superior mesenteric artery
was selected with a C2 catheter and superior mesenteric
arteriograms were performed in AP and [**Doctor Last Name **] projections.
Subsequently, the C2 catheter was advanced over [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire
and the right colic branch selected. Magnification arteriography
was performed. The C2 catheter was then exchanged for a 5 French
[**Last Name (un) 3056**] catheter and the [**Female First Name (un) 899**] selected. [**Female First Name (un) 899**] arteriography was
then performed.
No point of active bleeding/contrast extravasation was
identified in either the SMA or [**Female First Name (un) 899**] territories. There was the
suggestion of prominent vascularity in the region of the upper
ascending colon at the hepatic flexure level, but this was felt
most likely to be due to underfilling of the colon with
secondary crowding of vessels in the wall of the colon.
Angiodysplasia, although not excluded, appears less likely.
The patient tolerated the procedure well without immediate
complications. Total of 175 cc of nonionic contrast was given.
IMPRESSION: No active bleeding site identified.
Equivocal hypervascularity near the hepatic flexure felt more
likely due to non- distended/collapsed colon. Focal inflammatory
changes or angiodysplasia are felt to be less likely. However,
correlation with colonoscopy is recommended.
.
OP NOTE:
PREOPERATIVE DIAGNOSIS: Lower gastrointestinal bleeding from
the distribution of the ileocolic vessels.
POSTOPERATIVE DIAGNOSIS: Lower gastrointestinal bleeding
from the distribution of the ileocolic vessels.
PROCEDURES: Open right ileocolectomy.
ASSISTANTS: [**Doctor Last Name **] and [**Doctor Last Name **]
ANESTHESIA: General.
INDICATIONS FOR SURGERY: The patient is an 82-year-old woman
who has had previous admissions for GI bleeding without a source
being identified. She had known diverticulosis. On [**3-11**] she
continued to drop her hematocrit gradually and a bleeding scan
was ordered. The scan was positive in the distribution of the
ileocolic vessels. It could not be clearly seen whether there
was distal ileal disease or right colon disease. The patient
underwent a follow-up arteriogram which was negative. However,
over the course the day she required transfusion of multiple
units for continued slow bleeding. She agreed to surgical
excision of the affected area as indicated by the bleeding scan.
OPERATIVE NOTE: The patient was taken to the operating room,
and after satisfactory induction of general endotracheal
anesthesia, she was prepped and draped in the usual fashion. She
had a previous hysterectomy incision that was well-healed. This
was a vertical incision. A midline laparotomy scar was carried
out through skin and subcutaneous tissue and fascia. The belly
was opened in the supraumbilical position to be in virgin
territory. The abdomen was opened and there few adhesions. The
right colon was mobile and easily brought up out of the gutter.
There was not a large amount of blood in the colon, but the
patient had had a bowel prep as a colonoscopy had been
anticipated. In the distribution of the ileocolic artery, there
were very large mesenteric lymph nodes traveling along the path
of the ileocolic artery. These were confined to this area and
not found diffusely throughout the bowel. There were no palpable
lesions in the right colon. There were findings of some
thickening of the small bowel wall again in the distribution of
the ileocolic artery. These were small limited areas. A
mesenteric lymph node was harvested for intraoperative frozen
section and this was unrevealing of carcinoma. The small bowel
was divided proximal to the most palpably abnormal section and
the abnormal lymph nodes and divided with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3224**] stapler.
Likewise the right colon was divided just proximal to the middle
colic vessels. The right colon was mobilized up out of the right
gutter in the usual manner. The duodenum was seen and
preserved. Using a LigaSure, the mesentery was sequentially
divided. Despite 2 applications of the LigaSure, there was not a
good seal in the vessels and larger vessels were clamped and
ligated. Hemostasis was assured. The specimen was sent to
pathology. The side-to-side functional end-to-end anastomosis
was created with staplers in the usual fashion. Crotch stitches
were placed. The TA staple line was inspected and oversewn as
appropriate. Hemostasis was assured. Sponge count was correct
and the abdomen was closed with running suture. A pain pump was
placed on the fascia and the skin was closed. The wounds were
cleaned and dressed and the patient was taken from the operating
room to the recovery room in stable condition. Estimated blood
loss was 20 ml, and sponge, needle and instrument counts were
reported to be correct x2.
Brief Hospital Course:
Ms. [**Known lastname 102456**] was admitted to the TSICU for serial hematocrits
and hemodynamic monitoring. Her hematocrit started at 41 and
quickly fell to 25. Of note, her WBC count at admission was 95.
However the patient reports a history of leukocytosis/undefined
myeloproliferative disorder for which she is followed by Dr.
[**First Name (STitle) **] at [**Hospital1 2177**] with a chronically elevated WBC count. Given her
cardiac history and active bleeding she was transfused to
maintain a hematocrit above 30. She was kept NPO. A tagged red
blood scan was done on [**3-11**] which showed a slow bleed in the RLQ
at 75 minutes. As this was felt to be fairly nonspecific and
she continued to have blood bowel movements with drops in her
hematocrit, an angiogram was done on [**3-12**]. The angiogram however
did not show an active bleed. At this point she had recieved 11
units of blood. Overnight on [**3-12**] she again had a bloody bowel
movement and dropped her hematocrit. In consultation with the
gastroenterologists, we planned for a colonoscopy on [**3-13**] in
hopes of identifying the location of the bleed. She was prepped
with golytely. In the am of [**3-13**] her hematocrit had dropped to
22 and at this point she had required a total of 14 units of
blood. The decision was made to proceed directly to the
operating room. She underwent an ileocectomy as there was a
question of an inflammatory mass in the RLQ and the positive
tagged scan in the RLQ. She tolerated the procedure well with
minimal blood loss. For details please see the operative
report.
Post-operatively she did well. Her blood counts remained stable
at 31. She was transferred out of the intensive care unit on
postoperative day #1. She was controlled on a dilaudid PCA and
was started on sips on POD#1. She was noted to have runs of
PSVT which continued up to discharge, but she was asymptomatic
and her electrolytes were normal. She was continued on a
perioperative betablocker, lopressor 12.5 TID. Heme/onc was
consulted for the leukocytosis and felt no further workup was
needed. They recommended follow-up with her outpatient
hematologist. The patient was given a copy of the hematology
consult to take with her to the appointment. This she be
arranged at the rehab facility. On POD#2 her hematocrit
remained stable and she was started on subcutaneous heparin for
DVt prophylaxis. She was started on a clear liquid diet.
Physical therapy was consulted and recommended that rehab
post-discharge for the patient as she needed significant
assistance with ambulation. On POD3 she was having some nausea
and was kept on a clear liquid diet. She had a large bloody
bowel movement but her hematocrit remained stable at 31. This
was likely residual blood. A KUB was done as she continued to
have nausea which was unremarkable. By POD5 the nausea had
resolved and she was tolerating a regular diet.
She will be discharged to rehab on POD6. As the patient was
unsure of her home medication doses she will be discharged on
Lopressor 12.5 TID. Her daughter will bring her home
medications to the rehab facility where they can be restarted as
approriate. She should see her PCP this week to review her
medications and doses. She should follow up with her
hematologist as well. Finally she should follow-up with Dr.
[**Last Name (STitle) 1120**] in [**1-12**] weeks after discharge. Her central venous catheter
was removed prior to discharge.
Medications on Admission:
Colchicine, simvastatin, cozaar, metoprolol, nifedipine,
hydrochlorothiazide, zestril
Discharge Medications:
1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day): hold for SBP < 100, HR < 50.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Lower GI bleed s/p R hemicolectomy
Discharge Condition:
Good
Discharge Instructions:
You were admitted with a lower GI bleed requiring 14 units of
blood. You underwent a Right ileocectomy. Your blood counts
were stable afterwards. You were discharged to a [**Hospital1 1501**].
Call your doctor for chest pain, shortness of breath, worsening
pain at your incision not controlled by pain medication,
persistent n/v, fevers > 101, new bloody stools or other
symptoms concerning to you.
Restart your home medications when you are sure of the doses.
Your daughter will bring them to the rehab facility.
You should follow up with Dr. [**Last Name (STitle) 1120**] in 1 week to have your
staples removed. You should follow up with your hematologist,
Dr. [**First Name (STitle) **] at [**Hospital1 2177**] to review your elevated WBC count. You should
follow up with your PCP [**Name Initial (PRE) 176**] 1 week to review all of your
medications.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 1120**] in 1 week, call for an appointment.
([**Telephone/Fax (1) 3378**]
Follow up with Dr. [**First Name (STitle) **] in 1 week to review your WBC count.
Follow up with Dr. [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) **] (PCP) in 1 week.
Completed by:[**2152-3-19**]
ICD9 Codes: 5789, 9971, 4019, 412, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1087
} | Medical Text: Admission Date: [**2166-12-6**] Discharge Date: [**2166-12-11**]
Date of Birth: [**2119-10-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1646**]
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
47 yo M with history of seizure disorder and EtOH abuse brought
to ED by EMS after likely seizure at shelter. At time of
presentation to ED, EMTs reported FSBS was 87. On arrival,
patient reportedly appeared to be post-ictal and intoxicated.
Initial labs and tox in ED showed serum EtOH 433 as well as
therapeutic phenytoin and valproate. All other urine and serum
tox was negative. CT scan head was without acute findings, the
prelim read questioned foreign bodies, though on review with
radiology, the "foreign bodies" are actually calcified sebaceous
glands. Was guaiac negative in the ED. Serial lactates were
checked and were 2.3 -> 3.5 -> 3.5 -> 2.2 with time and
hydration. Patient was re-evaluated by the ED team at 0300 and
had a witnessed seizure. In setting of EtOH level dropping, the
ED team was concerned for withdrawal seizures and thus requested
ICU transfer. Prior to transfer to the ICU vitals were: T
afebrile, HR 118, BP 118/76, RR 22, O2Sat 100% NRB.
REVIEW OF SYSTEMS:
(+)ve: seizures, fatigue
(-)ve: fever, chills, night sweats, loss of appetite, chest
pain, palpitations, rhinorrhea, nasal congestion, cough, sputum
production, hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal
dyspnea, nausea, vomiting, diarrhea, constipation, hematochezia,
melena, dysuria, urinary frequency, urinary urgency, focal
numbness, focal weakness, myalgias, arthralgias
Past Medical History:
1) EtOH abuse
2) ? IVDU in past
3) Seizure disorder (NOS by patient)
Social History:
Patient lives in a shelter.
Tobacco: Denies current use
EtOH: Reports heavy drinking (~1 pint per day) 3-4 days per
week.
Illicits: ? history of IVDU given venous stigmata
Family History:
NC
Physical Exam:
VS: T 98.2, HR 105, BP 134/90, RR 9, O2Sat 92% RA
GEN: Pleasant, NAD, appears sedate
HEENT: PERRL, EOMI, no tounge wag, oral mucosa moist and
atraumatic, oropharynx benign
NECK: Supple, no [**Doctor First Name **]
PULM: CTAB
CARD: RR, nl S1, nl S2, no M/R/G
ABD: BS+, soft, NT, ND
EXT: no C/C/E
SKIN: no rashes
NEURO: Oriented only to self, recognizes hospital, though
thought he was at [**Hospital1 2177**]
PSYCH: Mood and affect appropriate given level of sedation
Pertinent Results:
Admission Labs:
[**2166-12-6**] 03:50PM WBC-3.3*# RBC-4.58* HGB-12.4* HCT-38.5*
MCV-84# MCH-27.0# MCHC-32.1 RDW-15.1
[**2166-12-6**] 03:50PM ASA-NEG ETHANOL-433* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2166-12-6**] 03:50PM PHENYTOIN-15.8 VALPROATE-19*
[**2166-12-6**] 03:50PM LIPASE-58
[**2166-12-6**] 03:50PM ALT(SGPT)-76* AST(SGOT)-253* ALK PHOS-68 TOT
BILI-0.2
[**2166-12-6**] 03:50PM GLUCOSE-93 UREA N-11 CREAT-0.7 SODIUM-142
POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-28 ANION GAP-16
[**2166-12-6**] 03:53PM LACTATE-2.3*
[**2166-12-6**] 03:50PM PLT SMR-NORMAL PLT COUNT-199
Studies:
[**2166-12-6**] CT Head
1. No acute intracranial abnormality.
2. Moderate cerebellar and cerebral volume loss advanced for
patient's stated age.
[**2166-12-6**] Chest XRay: Bibasilar opacities likely atelectasis,
larger on the left side.
Brief Hospital Course:
47 yo M with history of seizure disorder and EtOH abuse brought
to ED by EMS after a seizure at his shelter.
#. Seizures: He had a seizure prior to presentation and multiple
witnessed seizures after admission. The timecourse was not felt
to be consistent with alcohol withdrawal seizures. Instead, it
was felt more likely that his seizures were contributed to by
alcohol ingestion but represented his underlying seizure
disorder. He was not entirely clear about his baseline seizure
frequency. He was continued on phenytoin and Depakote and was
given an extra dose of Depakote when he continued to have
seizures. His levels remained therapeutic. He had 4 seizures
after admission which were self-limited but he was given 2mg IV
Ativan at the time of seizure to help prevent others. He was
eventually started on standing Ativan 1mg po TID. He was
followed by the neurology service while in the hospital. He
underwent EEG and MRI which were essentially unremarkable. He
was discharge with an ativan taper and with his anti-epileptic
meds. We encouraged him to get reconnected with his neurology
clinic at [**Hospital1 2177**].
#. EtOH abuse: He reported that he occasionally attends AA
meetings, though expresses no strong desire to quit drinking at
this time. He was monitored on a CIWA scale but did not have
signs of withdrawal. He was given thiamine, folate, and
multivitamins, and was seen by social work while here. He was
counseled on avoiding triggers for seizures, includin alcohol
consumption.
Medications on Admission:
*per inspection of patient's pill box*
Divalproex sodium 500 mg QAM and 1000 mg QPM
Phenytoin sodium ER 300 mg QAM
Citalopram hydrobromide 20 mg daily
4 other medications that cannot be identified, though patient
reports taking vitamins
Discharge Medications:
1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QPM (once a day (in the
evening)): 1 tab qAM.
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO DAILY (Daily).
Disp:*90 Capsule(s)* Refills:*2*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): for 1 day, then half tablet twice a day for one day. then
stop.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: 345.10 SEIZURE, CONVULSIVE
Secondary Diagnosis: 291.81 DRUG WITHDRAWAL, ALCOHOL
Secondary Diagnosis: 311 DEPRESSION, NOS
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted with recurrent seizures. Please continue to
take your medications as prescribed. We would also strongly
encourage you to stop drinking alcohol as well. We have also
provided you with an ativan taper for the next few days.
Followup Instructions:
[**1-8**] at 9:15AM with Dr. [**Last Name (STitle) 39679**] at [**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **] health
group on [**Location (un) **] street.
ICD9 Codes: 2761, 2762, 2875, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1088
} | Medical Text: Admission Date: [**2104-8-12**] Discharge Date: [**2104-8-15**]
Date of Birth: [**2060-3-4**] Sex: M
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is a 44-year-old
male with a diagnosis of HIV/AIDs, (last CD4 323 and viral
load less than 50 in [**Month (only) 547**] of this year), who presented with
a right submandibular swelling and fever for several days.
He was transferred from [**Hospital6 6640**] with a
temperature of 103.5. He denied shortness of breath but he
had decreased ability to open his mouth, increased pain in
his right jaw with chewing and can only drink fluids.
REVIEW OF SYSTEMS: Positive for trismus. He denied recent
dental procedures and odynophagia.
Vital signs upon arrival at the [**Hospital1 18**] Emergency Department
revealed a temperature of 101.1, blood pressure 166/92, heart
rate 100, respirations 18, oxygen saturation 98% on room air.
He was seen immediately by Otolaryngology who performed a
fiberoptic examination showing airway edema. He was given
Clindamycin two doses, one at the outside hospital and one at
our Emergency Department and also 12 mg of Decadron given at
[**Hospital1 18**]. Per report, a CT from several days ago was negative
for an abscess. but did show edema and a 1.5 cm hypodensity.
CT of the neck at [**Hospital1 **] revealed a large enhancing right
submandibular lesion exerting mass affect on the airway. The
patient went immediately from the Emergency Department to the
OR for drainage.
PAST MEDICAL HISTORY:
1. HIV/AIDS diagnosed in [**2101-1-11**] with PCP
[**Name Initial (PRE) 1064**], CD4 count at diagnosis was 33. The patient is
currently on HAART. He has had no other opportunistic
infections .
2. Hypertension.
3. Hypercholesterolemia.
4. Elevated LFTs with question of NASH (nonalcoholic [**Location (un) 18317**]
hepatitis).
5. History of hepatitis A.
6. CMV IgG positive.
ADMISSION MEDICATIONS:
1. Stavudine 40 mg p.o. b.i.d.
2. Videx EC 400 mg q.d.
3. Kaletra three tablets twice a day.
4. Atenolol.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient is originally from [**Male First Name (un) 1056**],
single, a homosexual. Denied tobacco use. Occasionally
drinks alcohol. Denied IV drug use. Works in the accounting
department.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Per the ENT
consult, temperature 101.1, heart rate 100, blood pressure
130 systolic, respirations 24, 99% on room air. General:
The patient was in no acute distress. The patient had a
normal voice with no stridor. Neck: He had a firm mass in
the right submandibular area extending inferiorly and went
just across midline. A bulge was seen at the right
pharyngeal wall and his oropharynx. He had 2.5 cm trismus.
On examination to the Medical Intensive Care Unit, the
patient was on mechanical ventilation, SIMV plus pressure
support 750 times 10, pressure support of 5, PEEP 5 at 60%
FI02. Vital signs: Temperature 100.1 axillary, blood
pressure 124/57, heart rate 106, respirations 16, saturating
100%. General: He was sedated and diaphoretic, intubated.
HEENT: Large bandage wrapped around his head with a drainage
tube coming out of his mouth. Heart: Sounds were normal,
regular rate and rhythm, no murmurs, rubs, or gallops.
Lungs: Clear anteriorly and laterally. Abdomen: Obese,
soft, normal bowel sounds, nontender. Extremities: No
edema, 2+ pedal pulses, and diaphoretic.
HOSPITAL COURSE: 1. SUBMANDIBULAR ABSCESS: As noted above,
the patient was taken immediately to the Operating Room and
had incision and drainage of his abscess by the
Oromaxillofacial surgeon. He had about 12-16 cc of puss
drained from the area. He also had extraction of teeth
number 32, 3, and 5. There were no complications in the
Operating Room. He was brought to the Medical Intensive Care
Unit for further monitoring. The puss drained from his
abscess eventually grew out Streptococcus milleri. The
patient was empirically started, however, on Zosyn 4.5 grams
IV q. eight hours. This was continued for four days at which
point he was changed to p.o. Augmentin for antibiotic
coverage. The patient initially had a low-grade temperature
but remained afebrile past his first hospital day. His white
blood cell count also continued to trend downwards and was
7.8 on the date of discharge.
In the Operating Room, after the incision and drainage of the
abscess, four Penrose drains were placed and one JP drain was
placed and these were all discontinued on the day of
discharge.
2. AIRWAY CONTROL: The patient was found to have swelling
in his airway on the fiberoptic examination and was started
on dexamethasone 12 mg q. eight hours which was continued for
24 hours, at which point he was successfully extubated and a
repeat fiberoptic examination showed significant decrease in
the amount of swelling and no further steroids were deemed
necessary.
3. HYPERGLYCEMIA: The patient had issues of hyperglycemia
in the first few days of his hospital stay but this was
thought probably to be secondary to the Decadron he was on.
He was covered with a regular insulin sliding scale and his
sugar did come down upon discontinuation of the steroids.
4. HIV/AIDS: The patient's HAART therapy was held for two
days only because he was not able to take p.o. medications as
soon as he was extubated. He was restarted on his Stavudine,
Videx EC, and Koletra.
5. HYPERTENSION: The patient was found to be hypertensive
with blood pressures up to the 160s. He was started on
Atenolol at a dose of 25 mg q.d. and his blood pressures were
much better controlled.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSIS: Submandibular abscess.
PROCEDURES: Incision and drainage of submandibular abscess
and teeth extraction.
DISCHARGE MEDICATIONS:
1. Augmentin 500 mg p.o. t.i.d. times ten days to complete a
14 day course of antibiotics.
2. Atenolol 25 mg p.o. q.d.
3. Stavudine 40 mg p.o. b.i.d.
4 Didanosine 400 mg p.o. q.d.
5. Lopinavir / Ritonavir three tablets b.i.d.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-697
Dictated By:[**Last Name (NamePattern4) 19744**]
MEDQUIST36
D: [**2104-8-22**] 03:45
T: [**2104-8-24**] 15:28
JOB#: [**Job Number 47429**]
ICD9 Codes: 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1089
} | Medical Text: Admission Date: [**2164-7-13**] Discharge Date: [**2164-7-16**]
Date of Birth: [**2089-3-5**] Sex: F
Service: MEDICINE
Allergies:
Atenolol / Diltiazem / Lisinopril / Verapamil
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
SOB, chest pain
Major Surgical or Invasive Procedure:
Cardiac catherization
History of Present Illness:
Ms. [**Known lastname 18582**] is a 75 [**Last Name (un) **] with HTN, hyperlipidemia, depression,
GERD, hypothyroidism and osetoporosis who was admitted today for
an elective cath. She had been complaining of one year of
fatigue and SOB.
.
She was taken to the cath lab where she had LAD with 40%
stenosis after the diagonal. The proximal D1 had a 90% stenosis
in which a BMS was placed. The pt had some CP on leaving the
cath lab which persisted and then worstened on [**Hospital Ward Name 121**] 3. Pt with
ST elevations in I, AVL and was sent for rpt cath
.
On repeat cath, she had restenosed the stent placed earlier in
the day so it was restented proximally and distally with 2 more
BMS's. Of note, she recieved a total of 465cc IV contrast.
.
On arrival in the ICU, she has no complaints initially but then
c/o mild headache.
.
On ROS, she denies any fevers, nausea, vomitting, pain, SOB,
lightheadedness or any other sx.
Past Medical History:
GERD
H Pylori [**2156**]
Lower GI bleed r/t diverticulitis
Polyps removed
Chronic headaches
Hypertension
Osteoporosis
Depression
Intermittent blurry vision-unclear etiology
Pneumonia
EP study [**2161**] d/t bradycardia
Eye surgery for growth
Hypothyroid
Pernicious anemia
Social History:
Retired [**Hospital1 18**] EKG tech. Widow. Lives alone. Has
5 daughters. Denies tobacco and ETOH.
Family History:
father died of an MI at age 52. Mother died at age [**Age over 90 **]
Physical Exam:
General: NAD
Heart: RRR, no m/r/g
Pulm: CTAB, no w/r/r
Ext: no edema
Neuro: grossly intact
Pertinent Results:
Admission labs:
[**2164-7-13**] 04:06PM BLOOD WBC-13.1* RBC-4.68 Hgb-13.1 Hct-38.8
MCV-83 MCH-28.0 MCHC-33.7 RDW-13.8 Plt Ct-308
[**2164-7-13**] 04:06PM BLOOD PT-15.4* PTT-47.6* INR(PT)-1.4*
[**2164-7-13**] 04:06PM BLOOD Glucose-165* UreaN-12 Creat-0.6 Na-137
K-3.4 Cl-99 HCO3-25 AnGap-16
[**2164-7-13**] 04:06PM BLOOD Calcium-8.3* Phos-4.9* Mg-1.7
[**2164-7-14**] 06:04AM BLOOD Triglyc-97 HDL-49 CHOL/HD-3.8 LDLcalc-120
.
Cardiac Enzymes:
[**2164-7-13**] 07:12PM BLOOD CK-MB-33* MB Indx-14.5*
[**2164-7-13**] 07:12PM BLOOD CK(CPK)-228*
[**2164-7-14**] 06:04AM BLOOD CK-MB-42* MB Indx-11.0*
[**2164-7-14**] 06:04AM BLOOD CK(CPK)-383*
[**2164-7-14**] 02:35PM BLOOD CK-MB-24* MB Indx-8.0* cTropnT-0.66*
[**2164-7-14**] 02:35PM BLOOD CK(CPK)-300*
[**2164-7-15**] 05:35AM BLOOD CK-MB-8 cTropnT-0.53*
[**2164-7-15**] 05:35AM BLOOD CK(CPK)-118
[**2164-7-16**] 06:05AM BLOOD CK-MB-3 cTropnT-0.72*
[**2164-7-16**] 06:05AM BLOOD CK(CPK)-49
.
Discharge labs:
[**2164-7-16**] 06:05AM BLOOD Glucose-97 UreaN-12 Creat-0.8 Na-140
K-4.9 Cl-102 HCO3-30 AnGap-13
[**2164-7-16**] 06:05AM BLOOD Calcium-9.3 Phos-4.3 Mg-2.1
.
[**2164-7-14**] Echo:
The left atrium is dilated. There is mild regional left
ventricular systolic dysfunction with mild hypokinesis of the
distal septal, anterior and apical hypokinesis. The remaining
segments contract normally (LVEF = 45%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. Mild (1+)
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Mild mitral and aortic regurgitation.
Compared with the prior study (images reviewed) of [**2164-7-13**],
the findings are similar.
.
[**2164-7-13**] Echo:
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is regional left ventricular systolic
dysfunction. There is no pericardial effusion.
IMPRESSION: No pericardial effusion identied.
.
[**2164-7-13**] 2nd Cath:
COMMENTS:
1- Limited selective coronary angiography of the LMCA sysrtem
showed
acute occlusion of the entire D1 system. This vessel underwent
PTCA and
stening with a 2.25x12 mm MiniVision BMS 2 hours prior. The
distal edge
dissection that appeared stable on serial angiography during the
bpruior
procedure (up to 10 minutes post stenting) is likely the culprit
of this
acute vessel closure.
2- The LMCA, LAD (known mid vessel lesion that was negative by
FFR
earlier), and LCX were unchanged.
3- Successful emergent PTCA and stenting of the D1 with two
additional
stents: A 2.0x8 mm distally overlapping and a 2.25x12 proximally
overlapping with the old (placed this AM) 2.25x12 mm MiniVision
BMS.
Final angiography showed TIMI 3 flow thrroughout the D1 system
without
vresidual stenosis, dissection or distal emboli.
4- Resting hemodynamic assessment showed stable hemodynamics
compared to
earlied RHC except for severe systemic arterial hypertension
(required
NTG gtt at doses as high as 200 mcg per min). The left- and
right-sided
filling pressures as well as teh cardiac output and cardiac
index were
all within normal limits.
5- Bedside echocardiography showed absence of pericardial
effusion
FINAL DIAGNOSIS:
1. Acute closure of the D1, two hours after PCI and stenting
2. [**Name (NI) 18583**] PTCA and stenting of the D1 with two additional
BMS (one
distal and the second proximal to the earlier placed BMS, all
overlapping).
3. CCU admission for observation
4. Continue Integrilin gtt for 18 hours
5. Plavix (75 mg po twice daily) for at least 1 week then 75 mg
daily
for a minimum of 3 months, longer if tolerated
6. ASA 325 mg po indefinitely
7. 2D echocardiogram
8. Global cardiovascular risk reduction strategies
.
[**2164-7-13**] 1st cath:
COMMENTS:
1- Limited selective coronary angiography of the LMCA sysrtem
showed
acute occlusion of the entire D1 system. This vessel underwent
PTCA and
stening with a 2.25x12 mm MiniVision BMS 2 hours prior. The
distal edge
dissection that appeared stable on serial angiography during the
bpruior
procedure (up to 10 minutes post stenting) is likely the culprit
of this
acute vessel closure.
2- The LMCA, LAD (known mid vessel lesion that was negative by
FFR
earlier), and LCX were unchanged.
3- Successful emergent PTCA and stenting of the D1 with two
additional
stents: A 2.0x8 mm distally overlapping and a 2.25x12 proximally
overlapping with the old (placed this AM) 2.25x12 mm MiniVision
BMS.
Final angiography showed TIMI 3 flow thrroughout the D1 system
without
vresidual stenosis, dissection or distal emboli.
4- Resting hemodynamic assessment showed stable hemodynamics
compared to
earlied RHC except for severe systemic arterial hypertension
(required
NTG gtt at doses as high as 200 mcg per min). The left- and
right-sided
filling pressures as well as teh cardiac output and cardiac
index were
all within normal limits.
5- Bedside echocardiography showed absence of pericardial
effusion
FINAL DIAGNOSIS:
1. Acute closure of the D1, two hours after PCI and stenting
2. [**Name (NI) 18583**] PTCA and stenting of the D1 with two additional
BMS (one
distal and the second proximal to the earlier placed BMS, all
overlapping).
3. CCU admission for observation
4. Continue Integrilin gtt for 18 hours
5. Plavix (75 mg po twice daily) for at least 1 week then 75 mg
daily
for a minimum of 3 months, longer if tolerated
6. ASA 325 mg po indefinitely
7. 2D echocardiogram
8. Global cardiovascular risk reduction strategies
Brief Hospital Course:
Ms. [**Known lastname 18582**] is a 75 [**Last Name (un) **] with HTN, hyperlipidemia, depression,
GERD, hypothyroidism and osetoporosis who was admitted today for
an elective cath, had BMS to 1st diag which thrombosed acutely
on the floor and had rpt stent x2
.
# CAD: Patient was chest pain free after 2nd catherization. She
was started on Aspirin 235, Plavix 75, and Pravastatin 40mg po
qday. Patient was hesitant to start new medications but was
counseled extensively that especially stopping Aspirin and
Plavix could lead to another MI. She was not started on a
beta-blocker given her history of complete heart block on
beta-blocker. She was not started on ACE-I or [**Last Name (un) **] [**3-6**] h/o
adverse events and patient refusal to start those medications.
Echo showed EF of 45% and regional systolic dysfunction c/w CAD.
She will follow up with Dr. [**Last Name (STitle) **].
.
# Rhythm- Patient was in sinus rhythm throughout
hospitalization.
.
# Osteoporosis- cont home Ca, vit D
Medications on Admission:
ASA 81mg daily
Calcium/ Vit D 600/400 [**Hospital1 **]
MVT daily
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: One (1) Tablet
PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
STEMI
.
Secondary Diagnosis:
GERD
Osteoperosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for a cardiac catherization. After the
catherization you had a heart attack and you had additional
stents placed in your coronary arteries. We have started you on
several medications that you must take every day otherwise you
could have another heart attack. Please follow up with your
cardiologist.
.
We have started you on the following medications:
1. Aspirin 325mg by mouth every day
2. Plavix 75mg by mouth every day
3. Pravastatin 40mg by mouth every day
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 7960**] Date/Time: [**2164-8-1**]
1:45pm
Completed by:[**2164-7-17**]
ICD9 Codes: 4019, 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1090
} | Medical Text: Admission Date: [**2160-4-2**] Discharge Date: [**2160-4-7**]
Date of Birth: [**2091-10-4**] Sex: F
Service: MEDICINE
Allergies:
Pseudoephedrine / Levofloxacin / Ampicillin
Attending:[**First Name3 (LF) 1620**]
Chief Complaint:
Bleeding after dental extractions
Major Surgical or Invasive Procedure:
NG tube placement and removal
History of Present Illness:
Ms [**Known lastname 4135**] is a 68 year old woman with alcoholic cirrhosis,
suspected HCC, hepato-pulmonary syndrome, presenting with
hemorrhage after molar extraction x 5 earlier today.
.
She underwent the extraction of 5 of her upper molars without
difficulty the day of admission, around 3 pm. There was no
premedication with fresh frozen plasma or vitamin K. Patient
returned home and husband found her around 8pm in bed with
"blood everywhere". Per report, patient has swallowed blood and
had some vomiting.
.
Patient denies feeling light headed or dizzy, no chest pain,
shortness of breath, reports feelig very tired. Last drink
during lunch time today, denies having a history of withdrawal
or seizures in the past.
In the emergency department, initial vitals: 99.5, BP 140/80, RR
16, O2 Sat 95% RA. Patient given 10mg Oral Vitamin K and
admitted for further management.
Past Medical History:
PAST MEDICAL HISTORY:
1. s/p R-basal ganglia hemorrhage ([**2154**]) with residual L-sided
hemiparesis
2. ETOH cirrhosis: first admission for mental status in fall
[**2156**], has had multiple episodes of encephalopathy since.
3. Hepatopulmonary syndrome with peristent hypoxemia at rest,
she
has been instructed to use her home oxygen at all times.
4. Hypothyroidism
5. Anxiety/Depression
6. Insomnia
.
Social History:
Lives with husband, long history of alcohol abuse, currently in
outpatient rehab program, drinking 3 drinks of 1 [**11-30**] oz hard
liquor.
Family History:
Family History:
Father: Died at 47 from MI
Mother: Died at 37 from cerebral hemorrhage
Brother: Died at 24 from heart bacterial infection
-no other siblings
Physical Exam:
VS: 99.4 130/70, HR 73, RR 16, O2 sat 94% 4L NC
GENERAL: Elderly woman, appears older than stated age
HEENT: (+) mild scleral icterus. Very poor dentition. MMM, no
cervical lymphadenopathy
CARDIAC: RR. Normal S1, S2. II/VI early systolic murmur heard at
LUSB.
LUNGS: CTA B, no rales.
ABDOMEN: NABS. Soft, NTND
EXTREMITIES: No c/c/e, 2+ dorsalis pedis/ posterior tibial
pulses.
NEURO: A&Ox3. Appropriate. Left hemibody weakness.
Pertinent Results:
Admission ECG: NSR at 92 BPM, small inferior Q waves, diffuse
precordial T wave flattening with inversions at V1 to V3,
unchanged from tracing of [**2159-12-13**].
[**2160-4-7**] 05:15AM BLOOD WBC-3.8* RBC-3.29* Hgb-11.6* Hct-34.7*
MCV-105* MCH-35.1* MCHC-33.4 RDW-23.5* Plt Ct-57*
[**2160-4-7**] 05:15AM BLOOD PT-22.4* PTT-40.7* INR(PT)-2.1*
[**2160-4-7**] 05:15AM BLOOD Glucose-150* UreaN-15 Creat-0.8 Na-141
K-3.0* Cl-107 HCO3-25 AnGap-12
[**2160-4-7**] 05:15AM BLOOD ALT-24 AST-94* AlkPhos-141* TotBili-4.6*
[**2160-4-7**] 05:15AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.4*
[**2160-4-2**] 01:20AM BLOOD WBC-3.9* RBC-3.08* Hgb-11.8* Hct-37.0
MCV-120* MCH-38.2* MCHC-31.7 RDW-17.9* Plt Ct-62*
[**2160-4-2**] 01:20AM BLOOD PT-24.2* PTT-40.2* INR(PT)-2.4*
[**2160-4-2**] 04:32AM BLOOD Glucose-135* UreaN-9 Creat-0.6 Na-142
K-3.9 Cl-113* HCO3-17* AnGap-16
[**2160-4-2**] 09:31PM BLOOD ALT-30 AST-123* LD(LDH)-400* CK(CPK)-567*
AlkPhos-125* TotBili-6.6*
[**2160-4-2**] 04:32AM BLOOD Calcium-7.8* Phos-2.7 Mg-1.3*
[**2160-4-2**] 09:31PM BLOOD CK-MB-64* MB Indx-11.3* cTropnT-0.95*
[**2160-4-3**] 04:26AM BLOOD CK-MB-93* MB Indx-11.0* cTropnT-1.99*
[**2160-4-3**] 08:06PM BLOOD cTropnT-1.74*
CXR [**4-2**]
Cardiomegaly is mild-to-moderate predominantly involving the
left ventricle.
The mediastinal position, contour and width are unremarkable.
There is
interval slight worsening of the right basilar opacity that has
been present
before but appears to be more obvious and might represent either
interval
aspiration or worsening of atelectasis. Left lower lobe opacity
is unchanged,
most likely representing either chronic scarring or area of
atelectasis.
CXR [**4-4**]
FINDINGS: In comparison with the study of [**4-3**], the bilateral
areas of
opacification are decreasing. This could reflect clearing of
aspiration or
reduction in pulmonary venous congestion. Enlargement of the
cardiac
silhouette persists. Nasogastric tube again extends well into
the stomach
ECHO:
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is mildly
depressed (LVEF= 40-50 %) secondary to inferior and posterior
wall hypokinesis. Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. The right ventricular cavity is
dilated with depressed free wall contractility. There are focal
calcifications in the aortic arch. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (valve area 1.2-1.9cm2).
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. Moderate [2+]
tricuspid regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
RUQ U/S w/ doppler
IMPRESSION:
1. Hepatofugal flow in the main portal vein is new since
[**2159-12-12**]. There is
no evidence of venous thrombosis.
2. Evaluation of the hepatic parenchyma is markedly limited for
assessment of
known hepatic lesions, which are better demonstrated on CT.
Brief Hospital Course:
68 year-old female with alcoholic cirrhosis, likely HCC,
presented with profuse post-procedure bleeding after elective
tooth extraction, course complicated by NSTEMI and pulmonary
edema. Hospital course was as follows.
On admission, patient was noted to have considerable
bleeding from her mouth. She was given vitamin K 10mg PO once
and admitted to the medicine [**Hospital1 **] for further management. She
was initially hemodynamically stable,. Her hematocrit dropped
from 37 to 22 in less than 24 hours, requiring transfer to MICU.
Prior to transfer, she received 2 units FFP given an INR of 2.9
(underlying liver disease). Dentistry was consulted and
recommended contacting oral surgery. Oral surgery could not be
reached in house through several attempts; the case was
discussed with oral surgery residents at [**Hospital1 2025**] who suggested
pressure and xerofrom dressing. [**4-2**] evening around 5pm, patient
developed sinus tachycardia to 130's, with low grade temp of
100.0. Patient was tremulous. HCT trend [**4-2**] 1:20 AM 37, 4:30 AM
33.8, 9AM 26.8, 4:30 PM 22.1. She got FFP as above, ordered for
2 units PRBC and cultured. She received clindamycin for
prophylaxis after tooth extraction. She was transferred to the
ICU for further management.
In the MICU, she was transfused 4 units PRBCs, FFP, and
mouth was packed with aminocaproic-acid soaked gauze, with good
hemostasis. She ruled in for NSTEMI with trop peak 1.99; started
ASA and metoprolol. After transfusions, she had mild-mod volume
overload, and she was gently diuresed. She was transferred back
to the medicine service for further management.
Remainder of hospital course was as follows.
1. NSTEMI: Peri-MI EF 35-40%, with mild-mod volume overload.
Troponin peaked at 1.99, as above. Patient was started on
aspirin 325mg daily. Plavix was not started given concern for
bleeding (mouth, esophageal varices). She was also started on a
low-dose cardioselective beta-blocker. She was evaluated by PT
and sent home with cardiac rehabilitation.
2. Alcoholic cirrhosis: RUQ ultrasound on [**2160-4-4**] showed reversal
of flow in portal vein, new since [**12-7**]. Concern for worsening
hepatic disease/cirrhosis vs. thrombosis. She was continued on
rifaxamin and beta-blocker, as above. She was also started on a
PPI. A CTA liver to further assess flow reversal was scheduled
as an outpatient.
3. Alcohol abuse: Actively using alcohol as outpatient. Patient
not interested in alcohol cessation at this time.
4. Hypothyroidism: Continued levothyroxine per outpatient
regimen.
5. Depression: SSRI temporarily held given interference with
platelet aggregation.
6. Hepatopulmonary syndrome: Patient with chronic hypoxemia. Due
to fluid overload, her oxygen requirement was increased after
transfer from the ICU. On discharge, she was with baseline O2
saturation on home oxygen requirement (2-3L).
Medications on Admission:
ESCITALOPRAM [LEXAPRO] - 5 mg Tablet - One Tablet by mouth daily
FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)
LEVOTHYROXINE [SYNTHROID] - 25 mcg Tablet - 1 Tablet(s) by mouth
daily
NADOLOL - 20 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily)
NYSTATIN [NYAMYC] - 100,000 unit/gram Powder - apply daily to
area
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth daily
OXYGEN - (Prescribed by Other Provider; not using at all) -
Dosage uncertain
POTASSIUM CHLORIDE [KLOR-CON M20] - 20 mEq Tab Sust.Rel.
Particle/Crystal - 1 Tab(s) by mouth daily
RIFAXIMIN [XIFAXAN] - 200 mg Tablet - 3 Tablet(s) by mouth two
times a day
MULTIVITAMIN [CENTRAL VITE] - Tablet - 1 Tablet(s) by mouth
DAILY (Daily)
Discharge Medications:
1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
2. Lexapro 5 mg Tablet Sig: One (1) Tablet PO once a day.
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
Disp:*15 Tablet(s)* Refills:*2*
10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Klor-Con M20 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One
(1) Tab Sust.Rel. Particle/Crystal PO once a day.
12. Outpatient Lab Work
Please check CBC in 1 week. Please fax results to Dr. [**Last Name (STitle) **]:
[**Telephone/Fax (1) 716**])
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Gingival hemorrhage
NSTEMI
Alcoholic cirrhosis with portal hypertension
Hepatopulmonary syndrome
Discharge Condition:
Hemodynamically stable. Chest pain-free.
Discharge Instructions:
You were admitted to [**Hospital1 69**] on
[**2160-4-2**] for bleeding from you mouth following multiple dental
extractions. You lost a considerable amount of blood, and
required a short stay in the ICU for management. You suffered a
heart attack and suffered a likely temporary reduction in your
heart function; given this and fluids that you required due to
blood loss, you experienced fluid build up in your lungs. This
improved prior to your discharge, and on discharge, your oxygen
requirement is at your baseline.
You also underwent a liver ultrasound which showed a reversal of
flow in one of the blood vessels which goes to the liver.
-You will need a CT-scan angiography of your liver to be done as
an outpatient
Your medication regimen has changed. Please review your
medication list closely.
Please call your physician or return to the emergency department
for bleeding, chest pain or pressure, shortness of breath, or
for any other symptoms which are concerning to you.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2160-7-18**] 12:00
**Please have your a CT-scan angiography performed of your
liver. Please call Dr. [**Last Name (STitle) 497**] or Dr. [**Last Name (STitle) **] to arrange this
study.
You have an appointment with your PCP [**Last Name (NamePattern4) **] [**4-15**] at 10am
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 719**]
Completed by:[**2160-4-10**]
ICD9 Codes: 2851, 2449, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1091
} | Medical Text: Admission Date: [**2200-4-18**] Discharge Date: [**2200-4-21**]
Service: MEDICINE
Allergies:
Sulfonamides / Macrodantin / Bactrim
Attending:[**First Name3 (LF) 317**]
Chief Complaint:
hypoxic respiratory distress
Major Surgical or Invasive Procedure:
BIPAP
History of Present Illness:
[**Age over 90 **]F with atrial fibrillation, severe tricuspid regurgitation,
moderate mitral regurgitation, and HTN, admitted to the MICU
from the ED with hypoxic respiratory distress. Ms. [**Known lastname 96416**] has
a long h/o chronic dyspnea, and has had extensive workup by
Cardiology and Pulmonary, including negative stress test, PFTs,
and CT chest. Her ambulatory sats have been normal. The etiology
has been felt to be most likely [**3-14**] a combination of diastolic
dysfunction, atrial fibrillation, and MR. However, she has
failed to improve on appropriate medical management of these
issues. Over the last 2 days, she has had symptoms similar to
past exacerbations. She states she has become intermittently
dyspneic with minimal exertion, worse in the morning. She has
had no associated chest pain, lightheadedness, diaphoresis,
palpitations, fever/chills, or cough. She has had no recent LE
edema, orthopnea, or PND. She states she has been compliant with
her medications. This afternoon, she was at her hairdresser and
had acutely worsening shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) **] she came into the
ED.
.
In the ED, her VS were T 96.8, HR 63, BP 150/70, RR 18, and
O2sat 100%RA. She was in no distress, but had scattered crackles
on lung exam. Her CXR showed no acute process. EKG showed
V-paced rhythm with no obvious abnormalities. Her BNP was mildly
elevated, as was her D-dimer. She was sent for CTA chest to r/o
PE. The CT showed no PE or other acute abnormality, however she
became acutely SOB and hypoxic to 85% on 6LNC upon returning.
She was 90% on NRB, and she was tried on nitro gtt, but became
hypotensive to 70s/40s. The nitro gtt was stopped and she
regained her BP. Her ABG on NRB was 7.51/26/55, and she was
started on BiPAP. She was subsequently given Lasix 40mg IV x 1
then 60mg x 1, to which she put out 1.25L. She was admitted to
the MICU for further management.
Past Medical History:
1. Chronic afib- s/p AVJ ablation ([**2-14**]) and PPM placement
([**4-13**])
2. Hypertension
3. hyperdynamic LV function in the absence of coronary disease
4. s/p breast reduction
5. History of post-herpetic neuralgia
Social History:
Walks with walker; lives alone at [**Hospital3 **]. Smoked for
one year [**73**] years ago; husband was a heavy smoker. Occasional
EtOH. She is an artist.
Family History:
Mother died of MI at 78
Father died of stroke at 84
Physical Exam:
PHYSICAL EXAM:
Vitals- T 96.6, HR 86, BP 108/80, RR 20, O2sat 96% 4LNC
General- very pleasant elderly woman in NAD, lying flat in bed
HEENT- NCAT, sclerae anicteric, dry MM
Neck- no JVD at 30 deg
Pulm- bibasilar crackles, good air movement
CV- RRR with 2/6 systolic murmur
Abd- +BS, soft, NT, ND
Extrem- no LE edema, DP pulses 2+ b/l
Pertinent Results:
[**2200-4-18**] 11:00PM GLUCOSE-141* UREA N-18 CREAT-0.7 SODIUM-133
POTASSIUM-4.1 CHLORIDE-95* TOTAL CO2-25 ANION GAP-17
[**2200-4-18**] 11:00PM CK(CPK)-71
[**2200-4-18**] 11:00PM CK-MB-NotDone
[**2200-4-18**] 11:00PM cTropnT-<0.01
[**2200-4-18**] 11:00PM MAGNESIUM-2.2
[**2200-4-18**] 09:11PM TYPE-ART PO2-55* PCO2-26* PH-7.51* TOTAL
CO2-21 BASE XS-0
[**2200-4-18**] 09:11PM HGB-15.8 calcHCT-47
[**2200-4-18**] 05:00PM GLUCOSE-112* UREA N-21* CREAT-0.7 SODIUM-135
POTASSIUM-3.5 CHLORIDE-95* TOTAL CO2-31 ANION GAP-13
[**2200-4-18**] 05:00PM estGFR-Using this
[**2200-4-18**] 05:00PM CK(CPK)-54
[**2200-4-18**] 05:00PM CK-MB-NotDone cTropnT-<0.01 proBNP-2143*
[**2200-4-18**] 05:00PM WBC-5.5 RBC-4.52 HGB-14.3 HCT-41.8 MCV-92
MCH-31.7 MCHC-34.3 RDW-15.3
[**2200-4-18**] 05:00PM NEUTS-73.8* LYMPHS-18.1 MONOS-7.0 EOS-0.6
BASOS-0.5
[**2200-4-18**] 05:00PM PLT COUNT-242
[**2200-4-18**] 05:00PM PT-28.3* PTT-32.7 INR(PT)-2.9*
[**2200-4-18**] 05:00PM D-DIMER-776*
.
Admission CXR
New convincing evidence of pulmonary edema in this radiograph.
The radiograph is of somewhat suboptimal quality
.
CTA Chest
1. No evidence of pulmonary embolism. Limited assessment of the
aorta demonstrates no aneurysmal dilatation.
2. Reflux of contrast into the inferior IVC likely secondary to
bolus rate, less likely right heart failure.
3. Stable CT appearance of 3-mm pulmonary nodules in the lingula
and left lower lobe from [**2198-11-3**].
.
Transesophageal echocardiogram
Conclusions:
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is 5-10 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and systolic function
(LVEF>55%). Regional left ventricular wall motion is normal.
There is no left ventricular outflow obstruction at rest or with
Valsalva. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. Trace aortic regurgitation
is seen. The mitral valve leaflets are moderately thickened.
Moderate (2+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion. Compared with the prior report (images
unavailable for review) of [**2198-11-5**], the findings are similar.
Brief Hospital Course:
This is a [**Age over 90 **]F with AF, TR/MR, and HTN, admitted with hypoxic
respiratory distress.
.
MICU Course: On admission to the MICU she was satting 100% on
BiPAP in NAD. She was weaned to 4LNC immediately and was
subsequently titrated down to RA again. She received IV lasix
and had good urine output to it. She is was then transferred
out to the floor. She denies chest pain, shortness of [**Age over 90 1440**],
lightheadedness, palpitation.
.
1. Hypoxic respiratory distress: SOB on presentation without
hypoxia. Decompensated after CT with hypoxia and respiratory
distress in setting of hypertension, likely [**3-14**] acute pulmonary
edema with IV contrast bolus. TTE is largely unchanged from [**2198**]
- shows mild-mod TR, mod MR. [**First Name (Titles) **] [**Last Name (Titles) 96417**] were flat, making
ACS unlikely.
She was transferred to the floor on room air, and her home dose
of lasix was restarted. Per Dr. [**Last Name (STitle) **], she should receive an
extra half dose for the next two days, and she should take this
extra dose prn shortness of [**Last Name (STitle) 1440**] or lower extremity edema.
.
2. Atrial fibrillation: s/p PPM placement and AVJ ablation. She
is followed by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] and Dr. [**Last Name (STitle) **] [**Name (STitle) 1911**] of
Cardiology. As above, she was continued Toprol XL for rate
control and coumadin.
.
3. HTN: On multiple meds as outpatient, reports compliance.
Continued Toprol XL, irbesartan, verapamil SR, HCTZ and lasix
.
4. FEN: Regular, heart-healthy/low-sodium diet
.
5. Ppx: PPI, coumadin
.
6. Code status: DNR/DNI, confirmed with patient
.
7. Communication: son, [**Name (NI) **] [**Name (NI) 96416**] ([**Telephone/Fax (1) 96418**],
([**Telephone/Fax (1) 96419**]
Medications on Admission:
Verapamil SR 120mg qd
Hydrochlorothiazide 25mg qd
Toprol-XL 37.5mg qd
Avapro 150 mg b.i.d.
Coumadin 2.5mg qhs
Lasix 10mg qd
Lipitor (unknown dose)
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Verapamil 120 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily).
5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Valsartan 160 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis:
Flash pulmonary edema
.
Secondary diagnosis:
Chronic afib- s/p AVJ ablation ([**2-14**]) and PPM placement ([**4-13**])
Hypertension
Hyperdynamic LV function in the absence of coronary disease
History of post-herpetic neuralgia
Discharge Condition:
Good
Discharge Instructions:
You were admitted for fluid in your lungs. You should resume
all of your home medications upon discharge.
.
Please take an extra half dose of lasix for the next two days,
or when you develop shortness of [**Month/Year (2) 1440**] or increased edema in
your lower legs.
.
Please call your doctor if you develop chest pain, shortness of
[**Month/Year (2) 1440**], fevers, chills, abdominal pain, nausea or vomiting.
Followup Instructions:
You have an appointment to follow up with your primary care
doctor, [**Location (un) **],[**Doctor First Name **] M. [**Telephone/Fax (1) 1713**]. On [**5-1**] at 1pm.
.
You have the following appointments already made:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2200-9-25**]
2:30
Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 902**]
Date/Time:[**2200-9-25**] 3:00
ICD9 Codes: 4240, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1092
} | Medical Text: Admission Date: [**2127-5-25**] Discharge Date: [**2127-6-18**]
Date of Birth: [**2098-2-4**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
MVC
Major Surgical or Invasive Procedure:
[**2127-5-25**] - sternotomy RSC interpos graft, bolt, ex-fix LLE and
LUE
[**2127-5-26**] - IVC filter & chest closure
[**2127-5-27**] - ORIF R+L femur
[**2127-5-28**] - ORIF R arm, left olecranon, closed rdxn ft frx
[**2127-6-6**] - trach
History of Present Illness:
This is a 29-year-old male who was involved in
a vehicle accident requiring extrication at the scene. He
had to be intubated at the field and subsequently transferred
here where he had a CT scan showing an upper mediastinal
hematoma and this was followed by CT with contrast showing a
right subclavian arterial pseudoaneurysm. He had been
relatively stable until all of a sudden he had copious
amounts of bloody drainage from his right pleural chest tube.
Suspecting that the bleeding was coming from this right
subclavian artery injury, he was taken to the operating room
emergently for exploration.
Past Medical History:
none
Social History:
Works at [**Company **]. Lives with roommate. Family supportive.
Brief Hospital Course:
Mr. [**Known lastname **] was found to have the following on exam and imaging:
cerebral edema
C7 TP frx
right subclavian artery avulsion
bilateral rib fractures
RP hematoma
bilateral femur fractures
left olecranon fracture
bilateral foot fractures
vertebral artery injury
As noted in the HPI, Mr. [**Known lastname **] was taken emergently to the
operating room on admission ([**2127-5-25**]) for a joint procedure
between cardiac surgery, vascular surgery, neurosurgery and
orthopedics where he had a median sternotomy to repair a right
subclavian artery transection with a 7mm dacron interposition
graft. Due to his cerebral edema, neurosurgery placed a bolt
monitor at this time. Orthopedics irrigated/debrided left open
elbow fracture, his left open femur fracture, put spanning
external fixators on his left elbow, left leg and right forearm,
then proceded to closed reduce his left olecranon, left femur
and right forearm.
He was taken to the TSICU post-operatively and returned to the
OR on [**2127-5-26**] for closure of his sternotomy and an IVC filter.
On [**2127-5-27**] he underwent ORIF of his right femoral neck fracture,
washout/debridement of his left supracondylar open frature,
removal of the left knee external fixator and ORIF of the left
distal femur with repair of the left quadriceps tendon tear.
On [**2127-5-28**] he returned to the OR with orthopedics once again and
underwent ORIF right both bone forearm fracture,
washout/debridement/ORIF of left olecranon fracture, removal of
his external fixators from both arms and closed reduction with
percutaneous pin fixation of his first and 2nd MTP dislocations
of the foot.
The remainder of his ICU course by systems:
Neuro: He was sedated with a combination of
fentanyl/midazolam/propofol while intubated. After trach on
[**2127-6-4**], his sedation was gradually weaned off. While there was
initially significant concern for TBI and cerebral edema, he
made quite a good recovery and was tracking, following commands
and responding appropriately to stimulus. He was started on
clonidine, ativan, oxycodone, and tylenol which achieved good
effect and eventually just transitioned to simply oxycodone and
tylenol.
CV: Initially on pressors and required blood transfusions (see
Heme). After the initial perioperative period however he was
hemodynamically stable without further issues throughout the
hospitalization. He was started and remained on aspirin for his
subclavian artery graft. This medication should be continued
indefinitely unless directed otherwise by his vascular surgery
team.
Resp: He was intubated on the scene and remained intubated
in-house. He was briefly extubated on [**5-30**] but didn't succeed,
thought to be due to his flail chest (bilateral rib fractures in
multiple locations) and was reintubated with plans for slow wean
from the vent to allow him to compensate for the chest trauma.
A tracheostomy was placed on [**2127-6-6**]. Of note, he was evaluated
for plating for the flail chest by the thoracic surgery team
however it was deemed as unlikely to help him given the relative
modest and distributed nature of his rib fractures.
He had bilateral chest tubes placed on admission, as described.
The chest tubes remained to suction [**2127-6-9**] when they were placed
to waterseal. It was decided to keep the chest tubes in until
after he was off of postive pressure ventilation. He was noted
to have a small left pneumothorax despite the appropriate
positioning and placement of the left chest tube. This chest
tube was treated with TPA but with minimal effect. Due to the
small size of the left pneumothorax and its unchanging character
on CXR, it was deemed unnecessary to work up further with
additional manipulation/further invasive chest tube placement
and was simply observed.
He was transitioned off the vent and tolerated a full day of
trach collar on [**2127-6-11**]. Also on [**2127-6-11**] he had a repeat CT Chest
which demonstrated resolution of the left pneumothorax (except
for a small pocked next to the tube in between fissures at the
base of the lung) but a very small right pneumothorax. Both
pneumothoraces were very small and asymptomatic. The left chest
tube was removed on [**2127-6-11**] and the right chest tube was removed
on [**2127-6-12**].
As of [**2127-6-15**] he had tolerated more than 48 hours of being off
of the ventilator.
GI: He was NPO initially, then started on tube feeds via an
NGT/dobhoff which he tolerated well. There was some initial
concern over high residuals from the NGT and he was placed on
reglan 10 four times daily. He was placed on a bowel regimen of
colace and senna and some milk of magnesia and soon thereafter
had a bowel regimen. His residuals were thereafter minimal.
After a PMV evaluation and being on trach collar he was cleared
to swallow and able to tolerate a soft diet. He was also
started on TID nutritional shakes. The NGT was removed, reglan
was dc'd.
Nutrition: He had a passy-muir valve placed on [**2127-6-11**] which he
tolerated well and passed a bedside swallow evaluation. His
diet was advanced to thin liquids and ground/pureed solids. He
did well with this and can advance as tolerated. He was also
receiving replete with fiber tubefeeds which were stopped after
he tolerated diet.
GU: He had a foley catheter placed initially. He initially
faced ATN with a rising creatinine that gradually resolved with
hydration throughout his hospital course -- it was 1.2 as of
[**2127-6-12**]. Foley was replaced with a condom catheter and had no
issues in this regard.
Heme: Placed on SQH throughout hospitalization and had an IVC
filter placed on [**2127-5-26**]. Also on aspirin for graft. Hct
stable at time of discharge from ICU, no active issues.
ID: Did recieve intra and periop antibiotics and received a
course of broad spectrum antibiotics early in the course of his
hospitalization (vanc/zosyn, then vanc/cipro/flagyl for periop
as well as to treat a suspected VAP). Though he had an elevated
WBC count, he was afebrile for the most part. All antibiotics
were discontinued on [**2127-6-6**]. On [**2127-6-10**] he did spike a fever and
subsequently bronchoscopy was done with BAL. All cultures were
negative or no growth to date.
TLD: Right PICC([**5-29**]-), trach ([**6-6**]-),
- d/c'd T/L/D: right femoral a line, left fem groin line ([**5-29**]),
right fem aline ([**6-1**]), PIV, L CT ([**Date range (1) 111887**]), R CT ([**Date range (1) 111888**]),
NGT ([**Date range (1) 3047**])
On [**2127-6-15**] the patient was doing sufficiently well to be
transferred to the floor. His pain was controlled, he was
tolerating a regular diet, and he was working with physical
therapy. Psychiatry was consulted for evaluation of his
depressed mood. There was initially a concern for suicidal
ideation, however after attending level review of the case and
discussion with the patient it was felt that he had only a
remote history of suicidal ideation and that there was no
criteria for psychiatric admission. He was discharged to
rehabilitation in good condition on [**2127-6-17**].
Medications on Admission:
none
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Trauma (Motor Vehicle Accident)
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Will require ongoing physical therapy to regain mobility.
Discharge Instructions:
You were admitted to the hospital after your high speed motor
vehicle crash with the following injuries:
1. Cerebral Edema
2. Cervical Spine #7 transverse process fracture
3. Right Subclavian Artery avulsion
4. Bilateral Rib Fractures
5. Retroperitoneal hematoma
6. Bilateral Femur Fractures
7. Left Olecranon Fractures
8. Bilateral foot fractures
9. Vertebral Artery injury
You will be discharged to an inpatient rehabilitation facility
where you will work on regaining your strength and mobility
after your extended hospitalization.
Please keep a list of your medications with you and bring them
to all your healthcare appointments.
Followup Instructions:
Please call Dr. [**Last Name (STitle) **] (Orthopedics) to make an appointment
to be seen in 4 weeks. His office number is ([**Telephone/Fax (1) 3147**].
Please call Dr. [**Last Name (STitle) **] (Neurosurgery) to make an appointment to
be seen in 4 weeks. His office number is ([**Telephone/Fax (1) 88**]. You
will need to have a CT scan of your head without contrast done
prior to your visit. Dr.[**Name (NI) 9034**] office can assist you with
arranging that.
Please call Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] (Vascular Surgery) for a follow up
appointment to be seen in 4 weeks. His office number is ([**Telephone/Fax (1) 1804**].
Please call the trauma surgery clinic to make an appointment to
be seen in 2 weeks. The phone number is ([**Telephone/Fax (1) 111889**].
Completed by:[**2127-6-17**]
ICD9 Codes: 5845, 2851, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1093
} | Medical Text: Admission Date: [**2178-2-20**] Discharge Date: [**2178-3-4**]
Date of Birth: [**2129-6-1**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Transfer from outside hospital with left basal ganglia
hemorrhage
Major Surgical or Invasive Procedure:
s/p intubation and mechanical ventilation
History of Present Illness:
48W with history of longstanding uncontrolled hypertension,
asthma, EtOH use and intermittent headaches who was transferred
from OSH after she was found to have a left basal ganglia
hemorrhage on head CT. History provided by patient's boyfriend,
daughter and sister.
Patient was seen by her boyfriend in her usual state of health
this morning between 5:30-6am. She showered and then went
downstairs to make lunch for the day. He went outside for a
smoke and came back in the house to find her on the floor of the
kitchen leaning against the cabinets. She was talking out of
the side of her mouth and her right arm was weak. He helped up
to the couch and tried to keep her awake as she became
increasingly somnolent. He then called 911 and the paramedics
brought her to the [**Hospital1 18**] ED.
Upon arrival in ED, VS 97.8 BP:222/133 HR:93-97 R:16 100%
O2Sats. Nsurg consulted. No surgical intervention indicated at
this time. Neurology was subsequently consulted for further
care and management. Patient given PRN IV hydralazine for BP
control and admitted to NeuroICU.
ROS: Her boyfriend reports that she has been increasingly
stressed at work, working long hours. For the past 2 months,
she has been complaining of intermittent headaches often worse
just prior to her periods. This past week she had a HA daily.
Otherwise, no known fevers/chills or recent illnesses.
Past Medical History:
- Uncontrolled hypertension x20 years (per boyfriend, they are
on a tight budget and so avoid seeing doctors)
- Asthma
- Intermittent HAs
No known surgeries
Social History:
She works as a dietician at a Nursing Home and lives in
[**Hospital1 487**], MA with her boyfriend. [**Name (NI) **] daughter and sister live
nearby. No tobacco however her boyfriend smokes. [**Name2 (NI) **] rum and
milk. No drugs.
Family History:
Father had a descending aortic dissection and mother had a
pulmonary embolus.
Physical Exam:
T: 97.8 BP: 171/111 HR:90s R 16 O2Sats 100%
Gen: Lying in stretcher, intubated on propofol drip
HEENT: moist oral mucosa, anicteric
Neck: hard C-collar
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Sedated on propofol drip. Not following commands.
Cranial Nerves:
Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Eyes midline without nystagmus. Unable to perform
OCM to assess eye movements. No apparent facial movement
asymmetry.
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor. Spontaneously moving left side. No spontaneous
movement on the right.
Sensation: Withdraws on the left side and trace flexion of right
arm only with noxious stimuli.
Reflexes:
+2 brisk and symmetric throughout. Toes right upgoing and left
downgoing.
Coordination, gait and romberg: deferred.
Pertinent Results:
Serum ASA, EtOH, Acetmnphn, Benzo, Barb, Tricyc Negative
Urine Barbs, Opiates, Cocaine, Amphet, Mthdne Negative
Urine Benzos Pos
140 109 14 106 AGap=12
-----------------
3.8 19 0.6
Ca: 8.2 Mg: 1.5 P: 2.5
PT: 13.6 PTT: 26.3 INR: 1.2
11.5 >13.8< 265
41.3
N:73.4 L:20.7 M:3.0 E:1.8 Bas:1.1
MCV 92 Ferritn: Pnd
ALT: 40 AP: 94 Tbili: 0.8 Alb: 3.5
AST: 43 [**Doctor First Name **]: 33
CK: 145 MB: Pnd Trop-T: Pnd
UA contaminated
Imaging:
CXR: no acute cardiopulmonary process
Brain MRI/MRA/MRV: Large, left basal ganglial hematoma, with
mild surrounding edema and compression on the frontal [**Doctor Last Name 534**] of
the left lateral ventricle. No midline shift. No obvious
vascular lesions noted on the MRA/MRV. However, limited
assessment as lesions could be masked by the large hematoma. To
consider further evaluation after resolution of the hematoma. No
evidence of venous sinus thrombosis.
Brief Hospital Course:
48 year old woman with uncontrolled HTN presents with headache
and right sided weakness. Initially taken to an OSH hospital
where a CT head showed a left basal ganglia hemorrhage,
prompting transfer to [**Hospital1 **]. Intubated and sedated prior to arrival
here. On initial examination, was sedated, did not follow any
commands. Pupils symmetrical, reactive. Right facial weakness;
no withdrawl to noxious stimuli on right arm. Feeble withdrawl
of right leg. Moves left arm and leg spontaneously. CT showed a
left basal ganglia/IC hemorrhage. MRI/A did not show any
vascular malformation. MRV normal. This was most likely a
hypertensive bleed given location and her history of
uncontrolled hypertension.
1. Neuro: She was intially admitted to the neuro ICU, but did
well and was extubated on [**2-21**]. Repeat CT done at that time
showed that the bleed was stable. Once off sedation, it was
clear that her mental status was essentially intact, except for
some paraphasias and dysarthria. She was titrated on captopril
to maintain blood pressure less than 160 in the acute setting.
She did well and was transferred out of the ICU to the Stroke
service. Her exam has slowly improved, and she has regained
nearly full strength in her legs, though she continues to be
esentially plegic in her right arm.
2. Cardiovascular: She was ruled out for MI. Cholesterol
profile was excellent, with Chol 147, TG 334, HDL 58, LDL 22.
Hypertension was controlled with captopril. She was changed to
lisinopril for easier dosing once she had reached a stable dose.
3. Pulm: s/p Intubation for altered mental status. Was extubated
on [**2178-2-21**] and has had no further pulmonary issues.
4. ID: [**2-20**] U/A negative, repeat [**2-24**] dirty but grossly positive
associated with foley so started on Ciprofloxacin x 7 days.
Urine culture was positive for pansensitive E.coli and she
completed her 7 day course.
5. FEN: passed swallow evaluation, though was placed on soft
foods. She was started on thiamine/folate/MVI supplementation.
She is also s/p gap and nongap acidosis likely multifactorial
including ketoacidosis (in urine) [**1-30**] alcoholism and IVF. Gap
had normalized by [**2-25**].
She was also maintained on pneumoboots for DVT prophylaxis, as
well as a proton pump inhibitor and bowel medications.
At the time of discharge, her exam had improved. She is awake,
alert and attentive. She still makes occasional paraphasic
errors and still has dysarthria. She has a right facial droop, a
dense right arm plegia, and mild right leg weakness. She also
has decreased, though not absent, sensation on the right to all
modalities. Tone is increased on the right, requiring a
multipodus boot, with increased reflexes and upgoing toe.
Medications on Admission:
- Prilosec
- "Old inhalers" for asthma
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain or fever.
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours) as needed for wheezing.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. Lisinopril 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Left basal ganglia hemorrhage complicated by dysphagia for
regular solids
Hypertension
Urinary [**Location (un) **] infection
s/p Intubation
Discharge Condition:
Improved, with almost full strength in right leg, though with
nearly complete paralysis of right arm and signficant weakness
of right face. She also continues with right hemisensory
deficit, dysarthria and mild aphasia as well.
Discharge Instructions:
Take all medications as prescribed.
Keep all follow-up appointments.
Call your doctor or return to the ED if you develop fever, new
weakness or numbness, difficulty seeing or speaking.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
ICD9 Codes: 431, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1094
} | Medical Text: Unit No: [**Numeric Identifier 64690**]
Admission Date: [**2146-11-2**]
Discharge Date: [**2146-12-14**]
Date of Birth: [**2146-11-2**]
Sex: F
Service: NB
DISCHARGE DIAGNOSES:
1. Premature female, twin number 2, 32 weeks gestation.
2. Status post respiratory distress syndrome.
3. Status post apnea and bradycardia of prematurity.
4. Patent foramen ovale with mild left pulmonary artery
stenosis.
5. Status post Serratia-Marcescens' eye infection.
6. Status post immature feeding.
7. Status post mild RDS
HISTORY: Nadya is the former 1600 gram product of a 32 week
gestation, born to a 35 year-old, Gravida II, Para 0, now I
living II female whose pregnancy was complicated by preterm
labor at 27 weeks, requiring admission to [**Hospital1 346**] and treatment with tocolysis and
betamethasone. She was readmitted on the evening of delivery
with spontaneous rupture of membranes. There were no risk
factors for sepsis except for prematurity and premature
rupture of membranes.
PRENATAL SCREEN: Prenatal screens revealed her to be A
positive. Group B strep status was unknown. Remaining screens
were non contributory.
Infant was delivered by Cesarean section. Nadya was born
with Apgars of 7 and 8. She was given blow-by oxygen and
brought to the Neonatal Intensive Care Unit at [**Hospital3 **]
Hospital.
PHYSICAL EXAMINATION: On admission, she weighed 1600 grams;
her length was 42.5 cm and her head circumference was 30.5 cm
(all appropriate for gestational age).
PROBLEMS DURING HOSPITAL STAY:
1. Respiratory: Infant was initially placed on C-Pap on
[**11-2**], the date of birth and remained on C-Pap until [**11-4**]
when she went to room air. She has remained in room air
throughout her hospital course; however, she had
episodes of apnea and bradycardia, insufficient to
require treatment with caffeine. She remained in
hospital until she was free of any episodes of apnea or
bradycardia for at least 5 days prior to discharge.
2. Infectious disease: She had an initial blood culture,
CBC which was benign with a white count of 9.7;
hematocrit of 48.9; platelet count of 245; 9 neutrophils,
0 bands, 78 lymphs. She was started on Ampicillin and
Gentamycin and at 48 hours with negative cultures, her
antibiotics were discontinued.She was treated with
Gentamycin eye ointment from [**2061-11-18**] for serratia eye
infection.
3. Cardiac: Infant remained stable throughout her hospital
course with normal blood pressures. However, she did
have an intermittent murmur for which an echocardiogram
was obtained on [**2146-11-21**]. The results indicate that she
has a patent foramen ovale and mild left pulmonary artery
stenosis with turbulent flow. There were no other
anomalies noted. If this intermittant murmur
is heard in several months, she should then have a
referral to [**Hospital1 **] Cardiology. The murmur has
not been heard for several weeks.
4. Ophthalmology: Infant was noted to have eye drainage ou.
She was initially started on Erythromycin for which she
was non responsive and on [**11-17**], serratia marcescens'
grew. She was treated for 10 days with good result. At
times, she has some clear eye drainage which has been
recultured and it is negative for gram stain and negative
for organisms.
5. Fluids, electrolytes and nutrition: The infant is
currently feeding ad lib demand of mother's milk.
She is breast feeding at least twice a day and her current
weight is 2.760 kg.
6. Immunizations: Patient had her hepatitis B immune
vaccine on [**11-24**].
6. Hearing Screening on [**12-12**] was normal
Patient will be discharged home with her parents. The day
post discharge, she will have a visiting nurse come to the
home. Within 5 days of discharge, she will have a follow-up
appointment at [**Hospital1 **] [**Hospital1 8**] Center with Dr.
[**First Name8 (NamePattern2) 32280**] [**Last Name (NamePattern1) 41658**]. Early intervention referral made.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 37691**], MD
Dictated By:[**Last Name (NamePattern1) 56049**]
MEDQUIST36
D: [**2146-12-9**] 09:28:49
T: [**2146-12-9**] 09:45:25
Job#: [**Job Number 64691**]
ICD9 Codes: 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1095
} | Medical Text: Admission Date: [**2184-1-20**] Discharge Date: [**2184-2-3**]
Date of Birth: [**2113-8-15**] Sex: M
Service: MEDICINE
Allergies:
Bactrim DS / Lipitor / Atenolol / Beta-Blockers (Beta-Adrenergic
Blocking Agts)
Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
Neurogenic claudication
Major Surgical or Invasive Procedure:
L4/L5 decompressive laminectomies with instrumented fusion
History of Present Illness:
In brief, patient is a 70 yo M w PMH of CAD(CABG ((LIMA-obtuse
marginal branch, SVG-LAD and known occluded SVG-RCA)in [**2170**], PCI
in [**2181**]), PVD, unprovoked PE, negative LENIs in [**2183-4-4**], who
was admitted to the ortho spine service for laminectomy. He had
successful L4-L5 laminectomy on [**2184-1-20**]. On [**2183-1-22**] he
developed chest/shoulder pain, tachycardia, EKG changes and
troponin elevation consistent with [**Date Range 7792**]. His EKG showed STD
in I, II, aVL, AVF, V2-V5 as well as STE in AVR. His troponin
was elevated at 0.12, Ck MB 11. He was also tachycardic to the
120s. His EKG changes improved with better rate control. He also
had fevers on [**2184-1-21**] and [**2184-1-22**]. Given concern for possible
recurrent PE, STAT echo was done at bedside this morning and did
not show right ventricular dysfunction or strain. Chest x-ray
showed multifocal pneumonia, so he was started on antibiotics
for HCAP coverage. He underwent cardiac catheterization on
[**2183-1-22**] which showed occlusion of the severely diseased LMCA
that supplied a diffusely diseased OM1 that measured previously
0.5 mm and a small (0.75 mm) diagonal system.
.
At 03:30 am on [**2183-1-23**] he flipped into atrial fibrillation with
rapid ventricular response (heart rate 130s to 140s), with rate
related ST-depressions. Patient reported some palpitations, but
no new chest pain. He also desaturated to the high 80s and
oxygen requirement increased. He was transitioned from 4L NC to
face tent with 35% Oxygen. He was administered 5mg IV
metoprolol with improvement of heart rate to the 110s, but also
a drop in SBP to the 80s. SBP trended back up to the low 100s
in about 15 minutes. He was given 500cc NS over 60 minutes and
transferred to the CCU for further management of Afib with RVR.
He previously had one episode of atrial fibrillation following
his CABG.
.
On arrival in the CCU he denies any chest pain, palpitations
subjective dyspnea except for an inability to take deep breaths,
no cough. He was AAOx3 and mentating well. Rate control was
attempted with diltiazem 5 mg IV. His HR went down to 100-110s,
and BP was down to 80s/60s, with MAPs in low 60s.
Past Medical History:
PMH: CAD w/ MI, mild chronic stable angina, hypercholesterol,
abdominal hernia, PAD
PSH: CABG [**54**], [**2181-5-2**] R [**Name (NI) 1793**] PTA/stent
Social History:
Lives with wife. [**Name (NI) **] teaches finance in [**University/College 5130**] [**Location (un) **].
Family History:
noncontributory
Physical Exam:
Admission Physical Exam:
AVSS
Well appearing, NAD, comfortable
BUE: SILT C5-T1 dermatomal distributions
BUE: [**5-8**] [**Doctor First Name **]/Tri/Bic/WE/WF/FF/IO
BUE: tone normal, negative [**Doctor Last Name 937**], 2+ symmetric DTR
bic/bra/tri
All fingers WWP, brisk capillary refill, 2+ distal pulses
BLE: SILT L1-S1 dermatomal distributions
BLE: [**5-8**] IP/Qu/HS/TA/GS/[**Last Name (un) 938**]/FHL/Per
BLE: tone normal, no clonus, toes downgoing, 2+ DTR knee/ankle
All toes WWP, brisk capillary refill, 2+ distal pulses
spinal wound is c/d/i
Discharge Physical Exam:
Vitals: Tmax: 97.9 T current: 97.9 HR: 80-87 RR: 16 BP:
105-115/65-66 O2 sat 100% on RA.
I/O:
24hr: [**Telephone/Fax (1) 18904**]
8Hr: 100/575
WEight: 76.8 (77.4)
.
Physical Exam:
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. sl dry MM
NECK: Supple with JVP of 9 cm.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: CTABL.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 1+ pitting edema at the ankles, No femoral bruits.
PULSES:
Right: DP 1+ PT 2+
Left: DP 1+ PT 2+
Pertinent Results:
TTE [**2184-1-22**]
The left atrium is mildly dilated. There is mild regional left
ventricular systolic dysfunction with mid- and distal septal
hypokinesis. The remaining segments contract normally (LVEF =
45%). Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened.
Moderate (2+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Mild aortic regurgitation. Moderate mitral
regurgitation. Mild pulmonary hypertension.
.
Cardiac cath showed [**2184-1-22**]
Cardiac Catheterisation [**2184-1-22**]
.
Hemodynamic Measurements (mmHg)
Baseline
Site Sys [**Last Name (un) 6043**] Mean HR
AO 105 60 72 102
Findings
ESTIMATED blood loss: <100 cc
Hemodynamics (see above):
Left ventriculography: mitral regurgitation; LVEF %;
Coronary angiography: right dominant
LMCA: Ostially occluded
LAD: Occluded mid vessel. Heavily calcified. Fills via SVG
graft and has mild disease.
LCX: Occluded mid vessel. Distal Cx and OM2 vessel fills via
the LIMA and has minimal disease. The rPL and rPDA system fill
via collaterals from the AV groove Cx.
RCA: Occluded proximally and distally fills via collaterals
from
the LCA via the LIMA graft and SVG to LAD graft
SVG-RCA: Known occluded
SVG to LAD: Widely patent. 20-30% proximal ISR
LIMA-OM2: Widely patent.
Assessment & Recommendations
1.Secondary prevention CAD
2.Infarction appears to be occlusion of the severely diseased
LMCA that supplied a diffusely diseased OM1 that measured
previously 0.5 mm and a small (0.75 mm) diagonal system.
3.Medical management for [**Last Name (un) 7792**].
4.No need to continue heparin and would not manage with
clopidogrel given recent spine surgery.
5.ASA po QD.
.
ETT: [**2184-1-7**]
INTERPRETATION: 69 yo man s/p CABG in [**2154**] and stent to LAD in
[**2170**]
was referred to evaluate an atypical chest discomfort. The
patient was administered 0.142 mg/kg/min of Persantine over 4
minutes. No chest, back, neck or arm discomforts were reported.
No significant ST segment changes were noted. The rhythm was
sinus with rare isolated APDs and VPDs noted. The hemodynamic
response to the Persantine infusion was appropriate.
Post-infusion, the patient was administered 125 mg Aminophylline
IV.
.
IMPRESSION: No anginal symptoms or ischemic ST segment changes.
Nuclear report sent separately.
.
CARDIAC CATH: [**2181**]
1. Successful PTCA and stenting of the SVG-LAD anastomosis
stenosis and distal 50% stenosis with a 2.25x20mm Taxus Atom
stent that was
postdilated to 2.5mm in the mid and proximal portion. Final
angiography revealed no residual stenosis, no angiographically
apparent dissection and TIMI III flow.
2. Successful deployment of angioseal vascular closure device.
FINAL DIAGNOSIS:
1. Patent SVG-LAD stents.
2. Successful PCI to SVG-LAD.
3. Successful deployment of angioseal closure device.
.
CXR [**2184-1-22**]
FINDINGS: As compared to the previous radiograph, there is
evidence of a
newly appeared parenchymal opacity at both the right lung base
and in the left lung, notably in the perihilar areas in the
retrocardiac space. The
distribution suggests pneumonia rather than pulmonary edema,
notably given the absence of pleural effusions and the absence
of other findings indicative of fluid overload. Borderline size
of the cardiac silhouette. Status post CABG. No hilar or
mediastinal changes.
.
CTA chest [**2184-1-23**]
FINDINGS: Sternal wires and post CABG changes are present. Mild
calcification of the coronary arteries is stable. The heart is
normal in shape and size. The right ventricle is not enlarged.
The interentricular septum is normal is shape and contour. There
is no pericardial effusion. The aorta unremarkable without
aneurysm or dissection. The pulmonary arteries are patent to the
subsegmental level without evidence of pulmonary embolism. There
is no axillary, hilar or mediastinal lymphadenopathy. Moderate
bilateral pleural effusions are present, including an
intrafissural component of effusion on the left. Small
homogeneous symmetric consolidations are present in the
dependent regions, which is most consistent with atelectasis.
Evaluation of the lung parenchyma is somewhat limited due to
extensive respiratory motion. Despite these limitations, there
are nonspecific scattered ground-glass opacities which likely
represent atelectasis and a small component of mild pulmonary
edema. There is no definite pneumonia. There is an increase in
size of the lymphatic tissues in the right hilum in the inferior
aspect.
There are degenerative changes of the spine without concerning
lytic or
sclerotic bone lesions. The osseous structures are otherwise
unremarkable.
IMPRESSION:
1. No pulmonary embolism.
2. Moderate bilateral pleural effusions.
3. Bilateral atelectasis.
4. Mild pulmonary edema.
Brief Hospital Course:
70 yo M with PMH significant for CAD s/p CABG and PCI, PVD and
h/o [**Hospital **] transferred to CCU on POD#3 [**2184-1-22**] s/p L4-L5
laminectomy, with [**Month/Day/Year 7792**].
.
#L4/L5 laminectomy: Patient was admitted to the [**Hospital1 18**] Spine
Surgery Service and taken to the Operating Room for the above
procedure. Refer to the dictated operative note for further
details. The surgery was without complication and the patient
was transferred to the PACU in a stable condition. Pnemoboots
were used for postoperative DVT prophylaxis. ASA 81 mg was
resumed as well on POD 3 as dictated preoperatively by his
cardiologist. Intravenous antibiotics were continued for 24hrs
postop per standard protocol. Initial postop pain was controlled
with a PCA. Diet was advanced as tolerated. The patient was
transitioned to oral pain medication when tolerating PO diet.
Foley was removed on POD#2. Physical therapy was consulted for
mobilization OOB to ambulate. Pt experienced an [**Hospital1 7792**] on
[**2184-1-22**] in postop setting and was transferred to the CCU - see
[**Date Range 7792**] below.
.
#[**Date Range 7792**]/ACS - pt s/p [**Date Range 7792**] [**2184-1-22**] in postop setting. Cardiac
cath at that time showed infarction appeared to be occlusion of
the severely diseased LMCA that supplied a diffusely diseased
OM1 that measured previously 0.5 mm and a small (0.75 mm)
diagonal system. Medical management for [**Month/Day/Year 7792**] was pursued. CP
resolved until [**1-28**] when pt had midnight episode of chest
tightness - he described this as similar to previous episodes at
home relieved with nitro although those episodes on exertion and
this time lying in bed. no radiation of pain. K had just been
repleted (was at 3.8) ECG showed NSR at 100 (had been in 80s
earlier in the night - on tele sped up slowly, in sinus) new 1mm
depression in lead I, avF with 2mm dep in lead II. V1 with 1mm
St elevation, V3-V5 with 3mm depression, V6 with 2mm dep. Within
10 minutes pain improved, stated tightness was gone prior to
recieving any medications. HR had gone down to 80s
spontaneously. Repeat ECG showed resolution of changes mentioned
above but pt now with inverted T waves V1 V2 V3, NSR at rate 80.
V4 and V5 with 2mm depressions V6 with only 1mm dep now. BP
maintained at low 100s/60s throughout, O2 sat 96 on 2L nc. Pt
had a similar episode the following night prompted by urinating
in a urinal by lying down. Again pronounced ECG depressions in
same leads (anterolateral and inferior) which resolved within 10
minutes, this time pt was administered IV metoprolol with po for
longer-lasting effect. These anginal episodes recurred the
following 2 nights as well with rapid resolution of ECG changes.
Pt endorsed significant component of anxiety during and prior to
both events. Although in sinus tach each time, his HR had been
creeping up from 70s up to 100 at which point he experienced the
chest pain. Most likely [**2-5**] demand ischemia in territory of
diseased RCA supplied by collateral circulation. Long acting
nitro was uptitrated with good effect. Isosorbide dinitrate was
started, which was exchanged for nitro patch prior to discharge.
Patient also started on Renolazine. Cardiac catheterization
images revisited and it was felt that pt did not have any
visible occlusions to intervene on, in which case CABG was also
not an option.
- recurrent episodes of nocturnal stable angina managed by
uptitration of antianginals: nitro patch and Ranolazine.
# Atrial Fibrillation with RVR: Patient has one prior documented
history of AFib shortly after CABG, none since. On [**2184-1-23**] pt
went into Afib with HR in 110s, SBP 90s-100s, 3 hours later back
into sinus tack, then an hour later with RVR 140-150s, dilt gtt
started. Dropped pressures on metoprolol, pressures slightly
better on diltiazem. This pattern of flipping in and out of Afib
with RVR continued for the next few days. Apart from [**Name (NI) 7792**], pt
also had fevers, leukocytosis, and CXR findings concerning for
?pneumonia on transfer to the CCU. It was felt that infection
and tachycardia with demand was likely triggering aFib. Most
likely pt had dilation of [**Doctor Last Name 1754**] in setting of MR [**First Name (Titles) 6643**] [**Last Name (Titles) 93010**]d Afib. Initially rate was controlled with dilt drip and
pt was anticoagulated with heparin gtt (no bolus - this was
approved by orthopedics in post-op setting) and was initiated in
setting of [**Last Name (Titles) 7792**]. PT was monitored on telemetry, and did not
require electrical cardioversion as he was never unstable.
[**2184-1-26**] pt started on metoprolol and loaded with digoxin and
given daily doses until [**2184-2-1**]. After adequate diuresis and
resolution of decompensated heart failure, patient spontaneously
converted to sinus rhythm and digoxin was discontinued. Given
high CHADS score, patient was continued on anticoagulation for
PAF with heparin gtt transitioned to warfarin. On day of
discharge, INR was 2.0
- initiation of metoprolol to 75mg [**Hospital1 **] for rate control
- initiation of warfarin for anticoagulation
# CAD: Patient has known CAD, s/p CABG and occluded SVG-RCA.
Given tachycardia, troponin was checked and found to be
elevated, ruled in for [**Hospital1 7792**]. s/p Echo which showed no new wall
motion abnormalities, EF 45% at baseline, s/p cardiac
catheterisation which showed OM1 lesion. No stents placed, plan
was to continue medical management. Continued on aspirin 325,
initially heparin gtt, plavix was held as pt was in post-op
setting. Metoprolol initially not tolerated by the pt but was
eventually able to wean from dilt gtt and metoprolol was
started. Continued rosuvastatin and glucose control.
- optimize medical management for CAD: ASA 325mg, initiation of
bblocker, statin
- if renal function stabilzes, please consider initiation of
ACEI
#fevers/leukocytosis: On transfer to CCU pt had fevers,
leukocytosis>16, CXR findings suggestive of multifocal
pneumonia. C/f HCAP and started treatment with
vancomycin/cefepime/levofloxacin. Blood and sputum cx showed no
growth. Antibiotics continued for 7d HCAP treatment course.
There was also c/f PE; pt with history of unprovoked PE in [**Month (only) 547**]
[**2183**], no hypercoagulability workup done at the time.
Fever/leukocytosis and tachycardia along with recent immobility
s/p spinal surgery, high risk for PE. CXR changes however
thought to be more consistent with pneumonia.
Pt was started on empiric heparin gtt for [**Year (4 digits) 7792**] which also
addressed possibility of PE.
# Hct drop: Hct drop to nadir 23.4 from 32.1 on [**2184-1-22**], pt is
s/p laminectomy. Ortho was following and examined the spine
without concerns. Pt did not have overt bleeding/swelling or
pain. Initially hct monitored QID in setting of beginning
heparin gtt. Stools were guiaic negative. Pt received 1u pRBCs.
Patient reported his last colonoscopy 10 years ago, due for a
followup colonoscopy in [**Month (only) 956**], of note his mother died of
colon CA at age 63.
- recommend outpatient colonoscopy in [**Month (only) 956**]
# CHF: Patient has no known history of CHF. Echo done at bedside
showing preserved EF but mitral regurg worsened. Pt was
significantly fluid overloaded on transfer to the CCU and was
diuresed aggressively on lasix gtt transitioned to boluses.
# Hypotension: Concern for cardiogenic shock vs. PE with
hemodynamic instability vs. septic shock from multifocal
pneumonia (as below). Pt had no evidence of right ventricular
strain on echo, so massive PE with hemodynamic instability felt
unlikely. HCAP coverage was continued to cover possible septic
state from multifocal pna. Most likely hypotension was [**2-5**]
cardiogenic shock as pt with recent [**Month/Day (2) 7792**] now with increased
mitral valve regurgitation. Pt also developed Afib which
exacerbated hypotension. BP improved with control of Afib and
aggressive diuresis.
#hyperkalemia - central venous line was placed to deliver larger
quantities of potassium. Hyperkalemia resolved with aggressive
diuresis.
#abdominal distension - pt was noted to lack bowel sounds and
was with distended abdomen after laminectomy. KUB showed ileus
but no evidence of obstruction and exam was otherwise benign. At
this time levoquin was DCd (see fever/leukocytosis above, C/f
HCAP) and flagyl was initiated, with good response. Pt
eventually tolerated liquids and diet was advanced without
issue.
#Emesis - pt developed several episodes of watery, nonbloody
nonbilious emesis. concurrently his heart rate would drop into
the 60s. This was felt to represent a vasovagal episode and
these episodes self-terminated.
#singultus - pt was given thorazine for hiccups and became
extremely somnolent with difficulty finding words. This
medication was discontinued, hiccups resolved on their own.
#anxiety - pt had considerable component of anxiety and this was
felt to precipitate his episodes of chest pain somewhat. Pt was
treated with ativan prn with good effect.
TRANSITIONS OF CARE:
- continue medical management of CAD/ angina with uptitration of
nitrates as needed. Currently on nitro patch and ranolazine.
Also on ASA, bblocker and statin
- continue anticoagulation with coumadin for paroxysmal afib
- consider initiation of ACEI given significant CHF once renal
function has stabilized
- f/u with [**Last Name (un) **] as needed for laminectomy
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 1
puff tid prn
HYDROCODONE-ACETAMINOPHEN - 5 mg-500 mg Tablet - 1 Tablet(s) by
mouth [**Hospital1 **] prn
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - Place one tablet
under tongue for chest pain, repeat every 5 minutes times 2 prn
Lipitor
TRIAMCINOLONE ACETONIDE - 0.1 % Cream - apply topically to legs
once every 1-2 weeks as needed
Lovenox
OMEPRAZOLE MAGNESIUM [PRILOSEC OTC] - (OTC) - 20 mg Tablet,
Delayed Release (E.C.) - 0.5 (One half) Tablet(s) by mouth daily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. nitroglycerin 0.2 mg/hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal QHS (once a day (at bedtime)).
Disp:*30 Patch 24 hr(s)* Refills:*2*
5. ranolazine 500 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO BID (2 times a day).
Disp:*60 Tablet Extended Release 12 hr(s)* Refills:*2*
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
7. warfarin 2 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM: alternate with 7mg (3.5 tablets) .
Disp:*180 Tablet(s)* Refills:*2*
8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety/insomnia.
Disp:*15 Tablet(s)* Refills:*0*
9. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
Three (3) Tablet Extended Release 24 hr PO Q 12H (Every 12
Hours).
Disp:*180 Tablet Extended Release 24 hr(s)* Refills:*2*
10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
11. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as directed as needed for chest pain.
Disp:*25 tablets* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Lumbar spinal stenosis at L4-L5 with grade I spondylolisthesis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) 1141**] [**Last Name (NamePattern1) 4983**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3736**]
Date/Time:[**2184-2-3**] 10:00
ICD9 Codes: 486, 5849, 4240, 2767, 2768, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1096
} | Medical Text: Admission Date: [**2124-8-24**] Discharge Date: [**2124-9-5**]
Date of Birth: [**2049-3-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Byetta / Hydrocodone
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2124-8-28**] - Redo Sternotomy, CABGx1 (Vein graft->Posterior
descending artery), Interposition of Vein graft->Right coronary
artery), Aortic Valve Replacement (21mm CE Magna Pericardial
Valve).
History of Present Illness:
75 year old female s/p CABG five years ago who is now
complaining of progressive exertional dyspnea with associated
angina. A cardiac catheterization revealed distal right coronary
artery disease. An echo revealed severe aortic stenosis. She is
now referred for surgical management.
Past Medical History:
CABG x2, AS, DM, diverticulosis, esophageal stricture in remote
past, polypectomy, hysterectomy, appy, bladder suspension,
hyperlipidemia, HTN, Osteoarthritis
Social History:
Retired. Denies smoking or alcohol use.
Family History:
Brother and sister with CAD prior to age of 55.
Physical Exam:
67 102/52 4'[**27**]" 155lbs
GEN: WDWN in NAD
SKIN: Warm, dry, no clubbing or cyanosis.
HEENT: PERRL, Anicteric sclera, OP Benign
NECK: Supple, no JVD, FROM.
LUNGS: CTA bilaterally, mild kyphosis. Well healed sternotomy.
HEART: RRR, II/VI SEM
ABD: Soft, ND/NT/NABS
EXT:warm, well perfused, no bruits, no varicosities
NEURO: No focal deficits.
Pertinent Results:
[**2124-8-24**] 07:00PM WBC-5.2 RBC-3.36* HGB-11.9* HCT-33.8*
MCV-101* MCH-35.5* MCHC-35.3* RDW-13.0
[**2124-8-24**] 07:00PM ALT(SGPT)-35 AST(SGOT)-37 LD(LDH)-257* ALK
PHOS-55 AMYLASE-92 TOT BILI-0.3
[**2124-8-24**] 09:26PM URINE RBC-17* WBC-250* BACTERIA-MANY
YEAST-NONE EPI-2
[**2124-8-24**] 09:26PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
[**2124-8-26**] CTA
1) Unremarkable CT appearance of the sternotomy. No evidence of
dehiscence, focal fluid collection, or significant inflammatory
changes. Minimal retrosternal soft tissue, largely obscurred by
streak artifact from the adjacent surgical clips, of uncertain
clinical significance.
2) Prominent aortic valve calcification.
3) 2-mm lingular nodule; if patient has a history of smoking or
other lung
cancer risk factors, this could be reassessed in one year's
time, otherwise no follow up recommended, [**First Name8 (NamePattern2) **] [**Last Name (un) 8773**] Society
guidelines.
4) A few scattered calcified pleural plaques, the sequela of
remote asbestos exposure, with basilar subpleural reticulation,
greater at the right base, suggestive of possible early fibrotic
changes. This could be further assessed by dedicated CT which
includes prone and high-resolution images as clinically
indicated.
[**Known lastname **],[**Known firstname 10900**] L [**Medical Record Number 79308**] F 75 [**2049-3-9**]
Radiology Report CHEST (PA & LAT) Study Date of [**2124-9-3**] 10:30
AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2124-9-3**] SCHED
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 79309**]
Reason: s/p cabg discharge xray
[**Hospital 93**] MEDICAL CONDITION:
75 year old woman with
REASON FOR THIS EXAMINATION:
s/p cabg discharge xray
Final Report
HISTORY: CABG.
Two radiographs of the chest demonstrate the patient to be
status post CABG.
There is a left-sided PICC line with its tip in the right
atrium, unchanged
from [**2124-8-31**]. Increased perihilar airspace opacities and small
bilateral
pleural effusions are present. Right basilar atelectasis may be
slightly
improved. Trachea is midline. No pneumothorax detected.
IMPRESSION:
Mild CHF.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6892**]
Approved: MON [**2124-9-4**] 10:37 AM
Imaging Lab
[**2124-8-28**] ECHO
PRE-BYPASS: No spontaneous echo contrast or thrombus is seen in
the body of the left atrium or left atrial appendage. No
spontaneous echo contrast is seen in the body of the right
atrium or right atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size is normal. with borderline normal free
wall function. There are simple atheroma in the aortic root.
There are simple atheroma in the ascending aorta. There are
simple atheroma in the descending thoracic aorta. There are
three aortic valve leaflets. The aortic valve leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis (area <0.8cm2). Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no
pericardial effusion.
[**2124-8-31**] CXR
In comparison with the study of [**8-30**], there is little change in
this patient following cardiac surgery. Basilar atelectatic
changes,
especially on the right, are again seen. Relatively lower lung
volumes. Mild blunting of the costophrenic angles and
enlargement of the cardiac silhouette persists.
[**2124-9-4**] 05:21AM BLOOD WBC-7.2 RBC-3.33* Hgb-10.4* Hct-31.0*
MCV-93 MCH-31.3 MCHC-33.6 RDW-16.5* Plt Ct-177
[**2124-9-4**] 05:21AM BLOOD Glucose-105 UreaN-12 Creat-0.7 Na-138
K-4.1 Cl-102 HCO3-30 AnGap-10
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted to the [**Hospital1 18**] via transfer form [**Hospital 5279**]
Hospital on [**2124-8-24**] for surgical management of her aortic valve
and coronary artery disease. She was worked-up by the cardiac
surgical service in the usual preoperative manner. A CTA
revealed prominent aortic valve calcification, a 2-mm lingular
nodule; if patient has a history of smoking or other lung cancer
risk factors, this could be reassessed in one year's time,
otherwise no follow up recommended, [**First Name8 (NamePattern2) **] [**Last Name (un) 8773**] Society
guidelines and a few scattered calcified pleural plaques, the
sequela of remote asbestos exposure, with basilar subpleural
reticulation, greater at the right base,
suggestive of possible early fibrotic changes. Ciprofloxacin was
started for a urinary tract infection. On [**2124-8-28**], Mrs. [**Known lastname **]
was taken to the operating room where she underwent a redo
sternotomy, coronary artery bypass grafting to one vessel,
interposition of the saphenous vein graft to the right coronary
artery and an aortic valve replacement using a 21mm magna
pericardial valve. Please see operative note for details.
Postoperatively she was transferred to the intensive care unit
for monitoring. Amiodarone was started for A Fib.On
postoperative day one, Mrs. [**Known lastname **] awoke neurologically intact
and was extubated. As she was thrombocytopenic, a HIT was sent
which was negative. A serotonin assay was then sent which is
pending. On postoperative day two, she was transferred to the
step down unit for further recovery. She was gently diuresed
towards her preoperative weight.Chest tubes and pacing wires
removed per protocol. The physical therapy service was consulted
for assistance with her postoperative strength and mobility. She
had several episodes of hypotension which responded to fluid and
albumin. As she had a slightly enlarged cardiac silouette on
chest x-ray, an echo was obtained. She continued to make good
progress and was cleared for discharge to rehab on POD #8. Pt.
is to make all followup appts. as per discharge instructions.
Medications on Admission:
aggrenox 25/100", baclofen 2 tabs", Toprol XL 25', Detrol LA 4',
Vitamin A, Zetia 10', Acyclovir 200', Meclizine PRN, Protonix
40', Nexium 40', Actos 15', Levotabs 15 mcg', Trazadone 50 hs
prn, Cozaar 50"
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. Tramadol 50 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
Disp:*45 Tablet(s)* Refills:*0*
3. Acyclovir 200 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Tolterodine 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
6. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): 200 mg [**Hospital1 **] through [**9-5**]; then start 200 mg daily ongoing
on [**9-6**].
Disp:*60 Tablet(s)* Refills:*1*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 weeks.
Disp:*7 Tablet(s)* Refills:*1*
12. Baclofen 10 mg Tablet Sig: 1-2 Tablets PO every twelve (12)
hours.
13. Meclizine 12.5 mg Tablet Sig: One (1) Tablet PO once for one
doses: prior to transfer.
14. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. Aggrenox 200-25 mg Cap, Multiphasic Release 12 hr Sig: One
(1) Cap, Multiphasic Release 12 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name 79310**]healthcare center
Discharge Diagnosis:
CAD/AS s/p Redo CABG/AVR(Tissue)
postop A Fib
Hyperlipidemia
HTN
PUD
Diabetes
Osteoarthritis
Diverticulosis
Esophageal stricture
Sciatica
Colonic polyps
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 914**] in 2 weeks. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) 39975**] in 6 weeks. ([**Telephone/Fax (1) 78432**]
Follow-up with Dr. [**Last Name (STitle) 34488**] in [**4-4**] weeks. [**Telephone/Fax (1) 79311**]
Please call all providers for appointments.
Completed by:[**2124-9-5**]
ICD9 Codes: 9971, 2762, 5990, 4241, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1097
} | Medical Text: Admission Date: [**2157-6-21**] Discharge Date: [**2157-6-26**]
Date of Birth: [**2089-4-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Angina
Major Surgical or Invasive Procedure:
Aortic valve replacement 21mm tissue, coronary artery bypass
grafting times four (LIMA>LAD, SVG>PL, SVG>OM, SVG>D1) [**6-22**]
History of Present Illness:
68yoM with increasing exertional angina. Angina is described as
chest pressure which he experiences daily. Brought on by walking
200-400 feet, releived
with rest.
Past Medical History:
Hypertension
Hyperlipidemia
Diabetes Mellitus
Chronic Obstructive Pulmonary Disease
Anxiety
Depression
Social History:
Lives with wife. Computer [**Name2 (NI) 112043**] at GE-[**Location (un) **]
40 pack-year quit [**2136**], ETOH quit 1 year ago
Family History:
Non-contributory
Physical Exam:
Discharge Exam
VS:T: 98.4 HR: 90-100 SR BP: 120-130/70 Sats: 95% RA Wt:
156 lbs
General: 68 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: RRR normal S1,S2 no murmur
Resp: decreased breath sounds otherwise clear
GI: abdomen soft, non-tender, non-distended
Extr: warm right tr edema, left 2+ edema
Incision: sternal and LLE clean dry intact no erythema, no
sternal click
Neuro: awake,alert oriented
Pertinent Results:
[**2157-6-26**] WBC-6.9 RBC-3.02* Hgb-9.3* Hct-27.4 Plt Ct-117*
[**2157-6-25**] WBC-5.9 RBC-2.88* Hgb-8.8* Hct-25.6 Plt Ct-98*
[**2157-6-23**] WBC-6.3 RBC-2.93* Hgb-8.8* Hct-25.3 Plt Ct-71*
[**2157-6-21**] WBC-8.1 RBC-2.31*# Hgb-6.6*# Hct-19.8*Plt Ct-178#
[**2157-6-26**] Glucose-151* UreaN-33* Creat-1.2 Na-135 K-4.4 Cl-99
HCO3-28
[**2157-6-21**] UreaN-18 Creat-0.8 Na-144 K-4.0 Cl-113* HCO3-22
AnGap-13
[**2157-6-21**] MRSA SCREEN (Final [**2157-6-24**]): No MRSA isolated.
CXR:
[**2157-6-25**]; The small left apical pneumothorax is unchanged.
Heart size and mediastinum are unchanged but there is interval
improvement of bibasal aeration with still present atelectasis
and small amount of pleural fluid.
Echocardiogram
[**2157-6-21**]: RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Normal regional LV systolic function. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Focal calcifications in
ascending aorta. Simple atheroma in descending aorta.
AORTIC VALVE: Moderate AS (area 1.0-1.2cm2) Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular calcification. [**Male First Name (un) **] of the mitral chordae (normal
variant). No resting LVOT gradient. Eccentric MR jet. Moderate
(2+) MR. [**Name13 (STitle) 15110**] to the eccentric MR jet, its severity may be
underestimated (Coanda effect).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
Conclusions
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the descending thoracic aorta. There is moderate aortic valve
stenosis (valve area 1.2cm2). Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Two jets,
one being an eccentric, posteriorly directed jet of Moderate
(2+) mitral regurgitation is seen. Due to the eccentric nature
of the regurgitant jet, its severity may be significantly
underestimated (Coanda effect). Dr. [**Last Name (STitle) **] was notified in
person of the results.
POSTBYPASS
Biventricular systolic function is preserved. There is a well
seated, well functioning bioprosthesis in the aortic position.
No AI is visualized. The MR now appears to be decreased. Mild to
moderate ([**12-6**]+) with the eccentic jet appearing to be decreased.
The remaining study is unchanged from prebypass.
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2157-6-21**] where the patient underwent Coronary
artery bypass grafting LIMA to LAD, SVG PL, SVG to OM, SVG to D1
and Aortic Valve Replacement with [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Aortic Porcine Valve
21 mm. Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. Cefazolin was
used for surgical antibiotic prophylaxis. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically
stable on no inotropic or vasopressor support. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight. The patient was transferred to the
telemetry floor for further recovery. Chest tubes and pacing
wires were discontinued without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. Initially his blood pressure while doing
stairs was 88/50 asymptomatic with quick recovery, repeat while
walking in halls was consistently 120/70. By the time of
discharge on POD5 the patient was ambulating freely, the wound
was healing and pain was controlled with oral analgesics. The
patient was discharged to home in good condition with
appropriate follow up instructions.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient outside report.
1. Simvastatin 20 mg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. Lisinopril 5 mg PO DAILY
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Cyanocobalamin Dose is Unknown PO DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth once a day
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Simvastatin 20 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Oxycodone-Acetaminophen (5mg-325mg) [**12-6**] TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
every six (6) hours Disp #*60 Tablet Refills:*0
8. Metroprolol succinate 0.5 mg twice daily
8. Cyanocobalamin 50 mcg PO DAILY
9. Furosemide 40 mg PO DAILY Duration: 5 Days
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*5
Tablet Refills:*0
10. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary artery disease
Hypertension
Hyperlipidemia
Diabetes Mellitus Type 2
COPD
anxiety/depression
renal insufficiency (baseline creat 1.1)
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Shower daily including washing incisions gently with mild soap,
no baths or swimming, and look at your incisions
NO lotions, cream, powder, or ointments to incisions
Daily weights: keep a log please bring it with you to your
appointments.
Blood pressure: keep a daily log and bring it with you to your
appointments
No driving for approximately one month and while taking
narcotics
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**] [**2157-7-5**] at
10:00AM
in the [**Hospital **] Medical Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**2157-8-10**] 1:30PM in the [**Hospital **]
Medical Building [**Last Name (NamePattern1) **] [**Hospital Unit Name **]
Cardiologist Dr. [**Last Name (STitle) 72502**] [**2157-7-6**] at 11:15
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 112044**],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 78021**] in [**3-10**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2157-6-26**]
ICD9 Codes: 4111, 5180, 4241, 5859, 2724, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1098
} | Medical Text: Admission Date: [**2172-5-20**] Discharge Date: [**2172-5-27**]
Date of Birth: [**2104-7-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Abnormal stress test
Major Surgical or Invasive Procedure:
[**2172-5-22**] Coronary Artery Bypass Graft x 5 (Left internal mammary
artery to left anterior descending, Saphenous vein graft to
diagonal, saphenous vein graft to ramus, saphenous vein graft to
obtuse marginal, saphenous vein graft to posterior descending
artery)
History of Present Illness:
60 year old male who underwent cardiac evalutaion due to risk
factors. Had abnormal stress test and underwent cardiac cath.
Catherization revealed severe coronary disease and he was
transferred to [**Hospital3 **] for surgery.
Past Medical History:
Coronary Artery Disease with history of Myocardial infarction
Hypertension
Diabetes Mellitus
Hyperlipidemia
status post Appendectomy
status post Tonsillectomy
Social History:
Retired custodian. Tobacco history of 2 packs year history as
teenager. No alcohol in last 25 years.
Lives with significant other
Family History:
Non-contributory
Physical Exam:
Vitals: 48 16 148/76
General: No acute distress
Skin: Warm, dry and intact
HEENT: Unremarkable
Neck: Supple, full range of motion
Chest: Lungs clear bilaterally
Heart: Irregular rhythm with 1/6 systolic murmur
Abd: Soft, non-tender, non-distended, +bowel sounds
Ext: Warm, well-perfused, -edema
Neuro: Grossly intact
Pertinent Results:
[**2172-5-26**] 05:55AM BLOOD WBC-5.8 RBC-3.08* Hgb-9.4* Hct-28.5*
MCV-93 MCH-30.6 MCHC-33.0 RDW-14.5 Plt Ct-135*
[**2172-5-20**] 08:23PM BLOOD WBC-5.7 RBC-3.72* Hgb-11.5* Hct-33.5*
MCV-90 MCH-30.8 MCHC-34.2 RDW-14.6 Plt Ct-154
[**2172-5-26**] 05:55AM BLOOD Plt Ct-135*
[**2172-5-20**] 08:23PM BLOOD PT-12.8 PTT-27.1 INR(PT)-1.1
[**2172-5-20**] 08:23PM BLOOD Plt Ct-154
[**2172-5-26**] 05:55AM BLOOD Glucose-157* UreaN-15 Creat-1.0 Na-142
K-4.5 Cl-105 HCO3-28 AnGap-14
[**2172-5-20**] 08:23PM BLOOD Glucose-250* UreaN-13 Creat-1.0 Na-141
K-4.1 Cl-107 HCO3-27 AnGap-11
[**2172-5-20**] 08:23PM BLOOD ALT-14 AST-17 LD(LDH)-133 CK(CPK)-42
AlkPhos-44 Amylase-19 TotBili-0.4
[**2172-5-20**] 08:23PM BLOOD Lipase-34
[**2172-5-27**] 06:35AM BLOOD Phos-3.6 Mg-2.1
[**2172-5-20**] 08:23PM BLOOD %HbA1c-7.7*
[**Known lastname **],[**Known firstname **] [**Medical Record Number 82479**] M 67 [**2104-7-7**]
Radiology Report CHEST (PA & LAT) Study Date of [**2172-5-26**] 3:07 PM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2172-5-26**] 3:07 PM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 82480**]
Reason: f/u atx, effusion
[**Hospital 93**] MEDICAL CONDITION:
67 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
f/u atx, effusion
Final Report
HISTORY: Status post CABG.
FINDINGS: In comparison with study of [**5-24**], the patient has
taken a much
better inspiration and the degree of basilar atelectasis is
decreased. There
is opacification posteriorly heading upward along the chest wall
consistent
with probable bilateral pleural effusion. Little change in the
appearance of
the mediastinal silhouette.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Approved: TUE [**2172-5-26**] 4:54 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 82481**]
(Complete) Done [**2172-5-22**] at 9:25:27 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2104-7-7**]
Age (years): 67 M Hgt (in): 68
BP (mm Hg): 123/67 Wgt (lb): 183
HR (bpm): 67 BSA (m2): 1.97 m2
Indication: Intraoperative TEE for CABG. Chest pain. Coronary
artery disease. Left ventricular function. Preoperative
assessment. Right ventricular function.
ICD-9 Codes: 786.05, 786.51, 440.0
Test Information
Date/Time: [**2172-5-22**] at 09:25 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1510**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW1-: Machine: aw1
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Ascending: 3.3 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 7 mm Hg < 20 mm Hg
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal regional LV
systolic function. Overall normal LVEF (>55%). No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Normal descending aorta
diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
Prebypass
1.No atrial septal defect is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses are normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
3.Right ventricular chamber size and free wall motion are
normal.
4.There are simple atheroma in the descending thoracic aorta.
5.The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen.
6.The mitral valve appears structurally normal with trivial
mitral regurgitation.
7.There is a trivial/physiologic pericardial effusion.
8. Dr [**Last Name (STitle) **] was notified in person of the results on
[**2172-5-22**] at 930am.
Post Bypass
1. Patient is in sinus rhythm and receiving an infusion of
phenylephrine.
2. Biventricular systolic function is unchanged.
3. Aorta intact post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2172-5-22**] 13:43
[**Known lastname **],[**Known firstname **] [**Medical Record Number 82479**] M 67 [**2104-7-7**]
Cardiology Report ECG Study Date of [**2172-5-22**] 3:32:52 PM
Sinus rhythm with bigeminal atrial premature beats. Compared to
the previous
tracing of [**2172-5-20**] atrial premature beats are not seen on the
current tracing.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] D.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
68 126 78 390/404 -2 -21 53
Brief Hospital Course:
As mentioned in the history of present illness, Mr. [**Known lastname 67118**]
was transferred from outside hospital to [**Hospital3 **] for
coronary artery bypass surgery. Upon admission he was
appropriately worked up prior to surgical intervention. On [**5-22**]
he was brought to the operating room where he underwent a
coronary artery bypass graft surgery. Please see operative
report for surgical details. He received vancomycin for
perioperative antibiotics because he was in the hospital greater
than twenty four hours. Following surgery he was transferred to
the CVICU for invasive monitoring. Within 24 hours he was weaned
from sedation, awoke neurologically intact and extubated. Chest
tubes and epicardial pacing wires were removed per protocol. On
post-operative day three he was transferred to the telemetry for
further care. He continued to improve while working with
physical therapy. On hospital day five he was discharged home
with VNA services.
Medications on Admission:
Aspirin 325mg daily, Atenolol 25mg daily, Avandamet 2/1000mg
[**Hospital1 **], Lisinopril 20mg daily, Simvastatin 20mg daily,
Nitroglycerin SL PRN
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
8. Rosiglitazone 2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
10. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Blood glucose monitor
Blood glucose strips
Lancets
Alcohol wipes
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Coronary Artery Disease s/p cornary artery bypass graft surgery
Hypertension
Diabetes Mellitus type 2
Hyperlipidemia
Myocardial infarction
status post Appendectomy
status post Tonsillectomy
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month, and while taking
narcotics
No lifting more than 10 pounds for 10 weeks from date of surgery
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Please monitor blood glucose two to three times a day until
sternal wound healed and if 200 or greater please follow up with
Dr [**Last Name (STitle) 12593**] [**Telephone/Fax (1) 82482**]
Please avoid concentrated sweets
Followup Instructions:
Please call to schedule appointments
Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) **] in [**3-17**] weeks
Dr. [**Last Name (STitle) 12593**] in 1 week [**Telephone/Fax (1) 82482**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2172-5-27**]
ICD9 Codes: 2724, 4019, 2875, 2859, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1099
} | Medical Text: Admission Date: [**2127-1-13**] Discharge Date: [**2127-1-16**]
Date of Birth: [**2070-1-31**] Sex: M
Service: MEDICINE
Allergies:
Iodine
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization s/p RCA cypher stent
History of Present Illness:
56yo M with GERD, smoker and pos alcohol p/w chest pain at 1:30
AM. This woke him up from sleep. He describes [**8-1**] sharp SSCP
that did not radiate. He c/o diaphoresis and dizziness, no
palpitation/nausea/SOB. He had no prior occurence. EMS called
1/2 hour later and was brought to cath lab at 3AM. VS on the
field BP 180/90 P117.
.
VS in ED BP 138/74 P80 R16 100%on NRB. EKG show IMI pattern. He
was started on lopressor, integrillin and heparin in ED. He
received benedryl, solumedrol and pepcid for dye allergy. Cypher
stent was placed in RCA. During procedure, patient was
bradycardic to 50s with long pausese and also hypotensive to
70s. He received atropine and started on dopamine drip with good
response. HD from PA cath show PCWP 24 for which he was given
20mg lasix. PA 47/25/33, CI 3.51, RA 20
.
Currently, patient c/o dry mouth and back pain from lying flat.
Otherwise denies chest pain, SOB, palpitation, dizziness, GI
symptoms, headahce, fever, chills.
Past Medical History:
splenomegaly from recent mononucleosis
Social History:
2ppd for 35 years, 2 vodka/whiskey per night, no drugs, works as
engineer at Xerox
Family History:
grandfather died of CAD at 76
Physical Exam:
T97.2 P90 BP110/65 R 16 95% on 4L
Gen- well appearing obese gentleman, no distress
HEENT- small but reactive pupils, anicteric, dry mucus membrane,
neck supple, cannot appreciate JVD in supine position
CV- regular, no rubs/murmur/gallop, no carotid bruit
RESP- clear bilaterally on anterior exam, no distress
ABDOMEN- obese, soft, nontender, nondistended, hard to assess
hepatosplenomegaly
EXT- right groin no hematoma, no bruit, DP dopplerable
bilaterally, PT 2+ bilaterally
NEURO- A+O x3, CN II-XII intact
.
Pertinent Results:
Hgb A1c 6.1
CK peak 2633
Na 139, K 3.9, Cl 104, bicarb 24, BUN 16, Cr 1.0
.
[**1-13**] EKG: Sinus rhythm. Inferolateral ST segment elevation with
reciprocal depressions in leads I and aVL, consider acute
inferolateral myocardial infarction.
.
[**1-13**] Cath report (prelim):
Successful thrombectomy, PTCA, and stenting of the proximal and
mid RCA was performed with a 3.0x33 mm Cypher stent which was
postdilated with a 3.5mm NC balloon. Final angiography revealed
0% residual stenosis, no dissection, and TIMI 3 flow. (see PTCA
comments)
.
[**2127-1-14**] Echo:
Left Ventricle - Ejection Fraction: 45% to 50% (nl >=55%)
Conclusions:
The left atrium is elongated. There is mild symmetric left
ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with mild hypokinesis of the
basal to mid inferior and inferolateral walls. The remaining
segments contract normally. Right ventricular chamber size and
free wall motion are normal. The aortic arch is mildly dilated.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Mild regional systolic dysfunction consistent with
coronary artery disease. Mild symmetric left ventricular
hypertrophy. No structural valve disease.
Brief Hospital Course:
Mr [**Known lastname 2013**] is a 56 yo M who presented w/ CP and ECG w/ ST
elevations inferior leads and V4R consistent with RCA thrombus
and RV infarct. He was taken emergently to the cardiac
catheterization lab where thrombectomy was performed and a
Cypher stent was placed to RCA. His cath revealed disease-free
LMCA, LAD, L Cx, dominant RCA with L-R collagerals. He was
bradycardia in the lab requiring temp wire and hypotense
requiring dopamine. Hemodynamics were indicative of RV
involvement. This is a summary of hospital course by problem
list.
.
# CAD: Inferior MI s/p RCA cypher stent and thrombectomy [**1-13**].
He was admitted to the CCU on dopamine which was weaned off
within a day and he was started on metoprolol, lisinopril and
lipitor. He should continue aspirin for life, plavix x 12
months.
.
# Pump: [**Hospital1 **]-V failure by cath HD(high RV and LVEDP, high PCWP),
CXR show mild CHF but asymptomatic and on RA. Echo w/o RV
failure, mild-symmetric LVH with EF 45-55% (see results).
.
# rhythm: NSR
.
# Fever: Resolved. Asymptomatic; no infiltrate on CXR.
.
# alcohol abuse: Counselled on quiting, covered with CIWA scale.
.
# nicotine: Counselled about quiting. Would recommend that PCP
continue to encourage and provide assistance with nictoine
replacement and/or wellbutrin.
.
# [**First Name5 (NamePattern1) 698**] [**Last Name (NamePattern1) 71070**] - daughter/HCP - HOME 904-230
Medications on Admission:
NONE
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): take for 1 year to prevent stent thrombosis.
Disp:*90 Tablet(s)* Refills:*2*
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Lab work Sig: One (1) Once for 1 doses: Please have your
PCP test your blood work. You should have a CMB (esp potassium,
cr, BUN) because you were started on lisinopril. .
Disp:*1 * Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
STEMI
Discharge Condition:
good; AFVSS; chest-pain free
Discharge Instructions:
Please continue to take all medications as prescribed. You had
a heart attack and had a medicated stent placed in your right
coronary artery; it is crucial that you take plavix for one year
and aspirin for life to prevent occlusion of this stent. You
also need to quit smoking, this is crucial to prevent further
heart damage. You will need to follow up with cardiology here
at the appointment listed below.
.
If you have any recurrence of chest pain, shortness of breath,
jaw or arm pain you should go to the emergency department
immediately. If you are lightheaded or have dizziness, please
contact your PCP or cardiologist. If you have leg swelling
please seek medical attention.
Followup Instructions:
With Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12526**] at [**Hospital3 **] Medical center.
([**Telephone/Fax (1) 71071**])
Tuesday [**2-18**] at 9am; please arrive at 8:30 AM
fax [**Telephone/Fax (1) 71072**]
.
You need to make an appointment with your PCP to be seen within
7-10 days. Please have them check electrolytes (CMB).
ICD9 Codes: 4280, 4271 |
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