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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1100
} | Medical Text: Admission Date: [**2182-4-29**] Discharge Date: [**2182-5-1**]
Date of Birth: [**2118-11-2**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
SOB/Chest pain
Major Surgical or Invasive Procedure:
Central Venous Line placement
History of Present Illness:
History of Present Illness: 63M with cigar smoking history and
radiographically apparent diffuse metastatic disease (likely
highly aggressive Stage IV Lung CA) who came to the ED, was
intubated, and admitted to the unit for severe acidosis and
respiratory support. Patient was in his USOH until about 1 month
ago when he started experiencing SOB, weight loss (8lbs in 2
weeks), cough, gouty attacks in his toes, and right sided chest
pain. He was initially evaluated in clinic [**4-11**] with a CXR and
subsequent CT chest showing Left perihilar mass, mediastinal
LAD, right pulmonary nodules, and what appear to be diffuse
liver mets. He was seen by IP as an outpatient and had a
thoracentesis [**4-23**] with cytology still pending.
Over the last 2 days, his status has taken a turn for the worse.
Per wife, he has become jaundiced with increasing shortness of
breath. This morning he was apparently doing okay, by lunch time
he was only able to speak [**1-21**] words at a time due to shortness
of breath and by this evening he was unable to talk. His wife,
[**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 7243**], called the IP office regarding his
symptoms and was referred to the ED for further management.
.
In the ED, initial VS were: 30-40 rr, 70s O2. diaphoretic.
borderline hypotensive SBP 90s
-EKG with LBBB - unsure if new - meets sgarbosas criteria
-CK: 243 MB: 8 Trop-T: <0.01
-CTA Torso negative for PE but demonstrating the left perihilar
mass, with liver mets
-CT Head non-con negative
-Labs: WBC of 58.9 with 90% neutrophils, INR 3.3
-Chem 7: K 6.8, Bicarb 7, Bun/Cr 102/2.5
-Lactate 14.1 -> 14.9
-pH 6.84/58/411 -> 7.09/38/148
-ALT: 586 AP: 2875 Tbili: 11.4 Alb: 3.2 AST: 1300 LDH: 5685
-Phos 10.7, Mg 4.3, Ca 9.4, Uric acid 21.1
-UA: Many Bacteria, 8 whites, 1 epi
-Serum Tox: Negative
.
Given:
-3 amps of bicarb
-calcium, insulin, dextrose
-albuterol nebs
-now on bicarb drip - 150 per hour
-5L NS
-zosyn and vancomycin for concern of cholangitis
-Renal contact[**Name (NI) **] regarding concern for tumor lysis syndrome
-Intubated, vents - 500, rate 15 --> rate increased 27
-Not started on pressors, no CVL placed, MAP around 65 -->
slowly downtrending
two 18s and 20g
2 u FFP ordered
on metformin
Wife - full code
Admitted to MICU for further management
.
On arrival to the MICU, patient's VS: 97.0, 110, 103/61, 27,
100% FiO2 50%. Intubated and sedated and unable to give further
history.
.
Past Medical History:
History:
-Gout
-Allergic Rhinitis
-Obesity
Social History:
Social History: Lives with his significant other. [**Name (NI) 1403**] in the
Medical Collection Business. Hasn't had any exposures to
asbestos or other metals. Smokes [**11-4**] cigars a year, has done
that for
the past 30 years, Drinks 12-15 drinks a week (beer), no known
drug use
Family History:
Family History: Grandfather has chronic bronchitis
Physical Exam:
ADMISSION PHYSICAL EXAM:
97.0, 110, 103/61, 27, 100% FiO2 50%
General: Sedated, intubated
HEENT: Icteric sclerae
Neck: Supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation anteriorly
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: Foley in place
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
DISCHARGE PHYSICAL EXAM: Expired
Pertinent Results:
ADMISSION LABS:
.
[**2182-4-29**] 06:45PM BLOOD WBC-58.9*# RBC-5.45 Hgb-15.4 Hct-50.6
MCV-93 MCH-28.3 MCHC-30.5* RDW-13.9 Plt Ct-81*#
[**2182-4-29**] 06:45PM BLOOD Neuts-80* Bands-9* Lymphs-2* Monos-3
Eos-4 Baso-0 Atyps-0 Metas-0 Myelos-2* NRBC-3*
[**2182-4-29**] 06:45PM BLOOD Hypochr-3+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-1+
[**2182-4-29**] 11:15PM BLOOD Hypochr-2+ Anisocy-NORMAL Poiklo-2+
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Burr-2+
Stipple-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 4486**]
Fragmen-OCCASIONAL
[**2182-4-29**] 06:45PM BLOOD PT-33.6* PTT-47.9* INR(PT)-3.3*
[**2182-4-29**] 06:45PM BLOOD Plt Smr-LOW Plt Ct-81*#
[**2182-4-29**] 06:45PM BLOOD Fibrino-179*
[**2182-4-29**] 11:15PM BLOOD Fibrino-84*#
[**2182-4-29**] 11:15PM BLOOD FDP-80-160*
[**2182-4-29**] 06:45PM BLOOD Glucose-62* UreaN-102* Creat-2.5*# Na-137
K-6.8* Cl-91* HCO3-7* AnGap-46*
[**2182-4-29**] 11:15PM BLOOD Glucose-154* UreaN-81* Creat-1.8* Na-141
K-4.9 Cl-113* HCO3-11* AnGap-22*
[**2182-4-29**] 06:45PM BLOOD ALT-586* AST-1300* LD(LDH)-5685*
CK(CPK)-243 AlkPhos-2875* TotBili-11.4*
[**2182-4-29**] 11:15PM BLOOD ALT-513* AST-1584* LD(LDH)-5100*
CK(CPK)-172 AlkPhos-1551* TotBili-6.8*
[**2182-4-29**] 06:45PM BLOOD Lipase-26
[**2182-4-29**] 06:45PM BLOOD Albumin-3.2* Calcium-9.4 Phos-10.7*
Mg-4.3* UricAcd-21.1*
[**2182-4-29**] 11:15PM BLOOD Calcium-6.6* Phos-8.6*# Mg-2.8*
[**2182-4-29**] 11:15PM BLOOD CEA-131*
[**2182-4-29**] 06:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2182-4-29**] 08:32PM BLOOD Type-ART pO2-411* pCO2-58* pH-6.84*
calTCO2-11* Base XS--26 Intubat-INTUBATED
[**2182-4-29**] 06:51PM BLOOD K-6.6*
[**2182-4-29**] 08:32PM BLOOD Glucose-113* Lactate-14.3* Na-134 K-5.6*
Cl-105
[**2182-4-29**] 08:32PM BLOOD Hgb-11.7* calcHCT-35
[**2182-4-29**] 11:31PM BLOOD freeCa-0.79*
[**2182-4-29**] 07:30PM URINE Color-DkAmb Appear-Cloudy Sp [**Last Name (un) **]-1.016
[**2182-4-29**] 07:30PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-MOD Urobiln-NEG pH-5.0 Leuks-NEG
[**2182-4-29**] 07:30PM URINE RBC-5* WBC-8* Bacteri-MANY Yeast-NONE
Epi-1
[**2182-4-29**] 07:30PM URINE CastHy-48*
[**2182-4-29**] 07:30PM URINE Gr Hold-HOLD
[**2182-4-29**] 07:30PM URINE Hours-RANDOM
.
Final Labs:
.
[**2182-5-1**] 04:00AM BLOOD WBC-32.4* RBC-3.56* Hgb-10.0* Hct-31.0*
MCV-87 MCH-28.1 MCHC-32.4 RDW-14.6 Plt Ct-64*
[**2182-5-1**] 04:00AM BLOOD Neuts-61 Bands-5 Lymphs-19 Monos-5 Eos-9*
Baso-0 Atyps-0 Metas-1* Myelos-0 NRBC-12*
[**2182-5-1**] 04:00AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-1+ Tear
Dr[**Last Name (STitle) 833**] [**Name (STitle) 4486**]
[**2182-5-1**] 12:50PM BLOOD PT-55.4* PTT-55.7* INR(PT)-5.5*
[**2182-5-1**] 08:22AM BLOOD FDP-40-80*
[**2182-5-1**] 12:50PM BLOOD Glucose-206* UreaN-100* Creat-4.8* Na-139
K-6.5* Cl-89* HCO3-26 AnGap-31*
[**2182-5-1**] 12:50PM BLOOD ALT-1419* AST-6173* LD(LDH)-[**Numeric Identifier 7244**]*
AlkPhos-2185* TotBili-12.1*
[**2182-5-1**] 04:00AM BLOOD Lipase-702*
[**2182-5-1**] 12:50PM BLOOD Albumin-1.7* Calcium-8.0* Phos-8.1*
Mg-2.9* UricAcd-4.3
[**2182-5-1**] 12:55PM BLOOD Type-ART Temp-37.7 Rates-/20 Tidal V-500
PEEP-10 FiO2-100 pO2-109* pCO2-41 pH-7.47* calTCO2-31* Base XS-5
AADO2-553 REQ O2-93 -ASSIST/CON Intubat-INTUBATED
[**2182-5-1**] 12:55PM BLOOD Lactate-11.3*
.
MICRO/PATH:
Blood Culture x 2 sets [**2182-4-29**]: NGTD
Urine Culture [**2182-4-29**]: NO GROWTH
MRSA SCREEN [**2182-4-29**]: Pending
.
IMAGING/STUDIES:
.
CT Head Non-Con [**2182-4-29**]:
IMPRESSION: No acute intracranial process. No space occupying
lesion
identified. If clinical concern for intracranial mass is high,
MRI is more
sensitive for detecting metatatic disease; non-contrast CT has
limited
sensitivity but there is no evidence for mass effect or edema.
.
CT Torso with IV Contrast [**2182-4-29**]:
IMPRESSION:
1. No acute aortic pathology or pulmonary embolism.
2. Short term interval progression of the large left hilar mass
with
progression of mediastinal, right hilar and left axillary
lymphadenopathy. The pulmonary arteries are attenuated as
described above by hilar lymphadenopathy. Small left pleural
effusion has decreased in size. Right pulmonary nodules are
overall increased slightly in size despite the short interval.
3. Bilateral lung parenchymal opacities likely represent
atelectasis and post obstructive pneumonitis. Infection cannot
be excluded, though not necessarily present.
4. Increased size and heterogeneity of the liver since
[**2182-4-18**], compatible with diffuse metastatic disease including
rapid increase. Porta hepatic lymph nodes are enlarged and
increased in size. No other metastatic disease in the abdomen or
pelvis.
5. Diverticulosis without diverticulitis.
Brief Hospital Course:
Assessment and Plan: 63M with cigar smoking history and new
diagnosis of Stage IV adenocarcinoma of the lung who was
intubated admitted for respiratory distress found to have renal
failure, fulminant hepatic failure, DIC, and TLS.
.
# Stage IV Adenocarcinoma of the Lung: Patient had recent hx of
weight loss, SOB, voice hoarseness and a CT with left perihilar
mass with compression of adjacent pulmonary artery and bronchi,
bilateral lung nodules with LAD and what appears to be diffuse
liver metastases. On admission, no tissue diagnosis was
available but pleural fluid cytology from outpatient
thoracentesis returned as adenocarcinoma. His course was fairly
atypical given the general nature of this malignancy as he, over
a period of a week developed significant symptoms of chest pain
and SOB which progressed to multiorgan failure and expiration
despite aggressive intensive care.
.
# Respiratory Failure: Patient was intubated for respiratory
distress, tachypnea, and hypoxia likely related to his acidosis
compressive perihilar mass in the ED. He underwent a CTA chest
which was negative for pulmonary embolism or significant pleural
effusion. His ventilator settings were aggressively titrated for
management of his acidosis but as his condition continued to
deteriorate the focus of his care was transitioned to comfort
with weaning of his ventilator settings. He passed shortly
thereafter in no apparent distress.
.
# Acute Renal Failure, Hyperkalemia: Patient had a Cr of 2.5 on
admission up from unknown prior baseline and initial K of 6.8 in
the ED with prominent peaked t-waves on EKG as well as an
arterial pH of 6.84. His hyperkalemia was felt to be the result
of acidsosis causing extracellular shifts, renal failure causing
decreased excretion, and tumor lysis syndrome causing increased
production. His acidosis and hyperkalemia were initially
controllable with high dose continuous bicarbonate drip as well
as frequent administration of IV insulin and dextrose. On
meeting with his family, it was determined that if he were able
to make his own decisions he would likely not be in favor of
being put on dialysis for an irreversible condition. As his
condition deteriorated he became less responsive to medical
management of his hyperkalemia.
.
# Severe Lactic Acidosis: On admission his arterial pH was 6.84,
GAP of 38, and lacate of 14.9. His lactic acidosis was thought
to be multifactorial related to likely fairly sudden-onset renal
failure and fulminant hepatic failure with highly aggressive
malignancy and tumor lysis. He was maintained on aggressive
management his acidosis as described above but his condition
continued to worsen.
.
# Tumor Lysis Syndrome: On admission he had a Cr 2.5, Uric acid
21.1, K 6.8, Phos 10.7, Calcium 9.4, LDH 5600+. He had been
having issues with gouty attacks which were new for him and
likely the initial stages of his TLS. TLS is very atypical for a
solid malignancy so concern was raised for possible lymphoma
although review of his blood smear and final report on his
pleural fluid as positive for adenocarcinoma removed this
suspicion. He was treated aggressively as above in addition to
recieving a dose of rasburicase.
.
# Concern for Sepsis, Source Unknown: Patient was admitted with
a white count to 59K with 10% bands, tachycardia, tachypnea, and
borderline pressures in the ED that were fluid responsive.
Positive UA with negative urine cultures, pending blood
cultures, and possible obstructive liver enzyme profile
(although could be [**Last Name (un) 7245**] malignancy related). He was treated
with vanc/zosyn empirically during his hospitalization.
.
# Fulminant Liver Failure/DIC: Patient was admitted with Tbili
11.4, INR 3.3, ALT 500+, AST 1300, Alk phos 2800. Also with low
fibrinogen and thrombocytopenia. This was thought to be related
to bulk disruption of his hepatic parenchyma by massive tumor
infiltration and overall multiorgan failure from rapidly
progressive malignancy.
.
Despite the greatest efforts of the [**Hospital 228**] medical team and
staff, Mr. [**Known lastname **] had progressive multiorgan dysfunction without
options for oncological treatment from his terminal lung cancer.
He passed away in no apparent distress in the presence of his
loving significant other and sister.
Medications on Admission:
HYDROCODONE-ACETAMINOPHEN - 5 mg-500 mg Tablet - 1 Tablet(s) by
mouth every four (4) - six (6) hours as needed for pain
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
N/A
Discharge Condition:
N/A
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2182-5-2**]
ICD9 Codes: 0389, 5845, 2767, 4019, 2749, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1101
} | Medical Text: Admission Date: [**2159-8-14**] Discharge Date: [**2159-8-17**]
Date of Birth: [**2099-1-30**] Sex: M
Service: CARDTHOR
HISTORY OF PRESENT ILLNESS: This is a 60 year old man with a
past medical history significant for hyperlipidemia,
irritable bowel syndrome, benign prostatic hypertrophy,
fibromyalgia, status post Lyme Disease in [**2149**], and a past
surgical history for right knee surgery [**76**] years ago, a left
inguinal hernia repair 15 years ago and tonsillectomy in the
past.
This is a 60 year old man with a two year history of chest
discomfort and chest burning accompanied with shortness of
breath on exertion which has worsened over the past month,
which prompted the patient to see a Cardiologist. The
patient underwent a stress test at that time and a subsequent
cardiac catheterization which revealed one vessel coronary
artery disease. The patient underwent unsuccessful
intervention to the left anterior descending at that time and
was therefore referred for coronary artery bypass grafting.
The patient underwent coronary artery bypass grafting [**2159-8-14**]. It was an off pump procedure times one with the
left internal mammary artery to the left anterior descending.
The patient was transferred to the Cardiac Surgery Recovery
Unit in stable condition just on Propofol drip.
MEDICATIONS PRIOR TO ADMISSION:
1. Toprol XL 25 mg p.o. q. day.
2. Norvasc 5 mg p.o. q. day.
3. Zantac 150 mg p.o. twice a day.
4. Imodium twice a day.
5. Librax 10 mg p.o. twice a day.
ALLERGIES: The patient has a drug allergy to aspirin.
HOSPITAL COURSE: Postoperative day one, the patient with no
events over the last 24 hours. The patient was extubated
[**8-14**], around 6 o'clock p.m. Postoperative day one, the
patient remained afebrile with vital signs stable. Physical
examination was benign and the plan was to Fast Track him out
of the unit and on to the Floor that day. The patient was
transferred to the Floor on [**2159-8-16**], postoperative
day two.
The patient remained afebrile and vital signs were stable
with a sodium of 136, potassium of 3.7, BUN of 15, creatinine
1.0. Postoperative day three, no events over the last 24
hours with a low grade fever of 99.8 F., with a temperature
maximum of 101.4 F. Physical examination remained unchanged
and the plan was to check the white blood cell count and if
normal, the patient could be discharged home as long as he
remained afebrile throughout the day.
The patient's labs were white count of 9.7, hematocrit of 33,
sodium 141, potassium 3.3, BUN 17, creatinine 1.1 and a
glucose of 137. A current white count on discharge 8.1 down
from 9.7. The patient with a temperature of 99.8, in sinus
rhythm at 76. Physical examination was benign.
CONDITION AT DISCHARGE: The patient's condition at
discharge is stable.
DISCHARGE MEDICATIONS:
1. Plavix 75 mg p.o. q. day times three months.
2. Atorvastatin 20 mg p.o. q. day.
3. Aspirin 325 mg p.o. q. day.
4. Zantac 150 mg p.o. twice a day.
5. Lopressor 75 mg p.o. twice a day.
6. Lasix 20 mg p.o. twice a day for seven days.
7. Potassium chloride 20 mEq p.o. twice a day for seven
days.
8. Percocet one to two tablets p.o. q. four hours p.r.n.
pain.
9. Librax 10 mg p.o. twice a day.
10. Imodium 2 mg p.o. twice a day.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Fibromyalgia.
3. Hypercholesterolemia.
4. Benign prostatic hypertrophy.
5. Irritable bowel syndrome.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Doctor Last Name 2011**]
MEDQUIST36
D: [**2159-8-17**] 15:22
T: [**2159-8-24**] 17:33
JOB#: [**Job Number 14809**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1102
} | Medical Text: Unit No: [**Numeric Identifier 61261**]
Admission Date: [**2199-5-13**]
Discharge Date: [**2199-7-18**]
Date of Birth: [**2199-5-13**]
Sex: F
Service: NB
HISTORY:
[**Known lastname 1894**] [**Known lastname 61262**] was born at 29-4/7 weeks gestation by
spontaneous vaginal delivery. Mother is a 29-year-old Gravida
2, para 0, now 2 woman. The mother's prenatal screens were
blood type B+, antibody negative, rubella immune, RPR
nonreactive. Hepatitis surface antigen negative and group B
strep unknown. The pregnancy was uncomplicated until the day
of delivery when the mother presented with pre-term labor and
labor progressed despite tocolytic treatment. The mother did
receive antibiotics and one dose of betamethasone prior to
delivery. This infant emerged active with good respiratory
effort. Her Apgar's were 7 at one minute and 8 at five
minutes.
Her birthweight was 1000 grams. Her birth length 39 cm, her
birth head circumference 25.5 cm.
ADMISSION PHYSICAL EXAMINATION: Reveals a quiet, pale, pre-
term infant. Anterior fontanel open and flat. Large caput,
erythema noted on both upper eyelids, no bruising. Coarse
breath sounds. Mild intercostal and subcostal retractions.
Heart was regular rate and rhythm. Abdomen is soft,
nontender, nondistended. Slightly decreased perfusion of
extremities. Tone slightly decreased overall.
NICU COURSE BY SYSTEMS: Respiratory status: Infant was
intubated soon after admission the NICU. She received two
doses of Surfactant. She weaned to nasopharyngeal continuous
positive airway pressure on day of life #1. She weaned to
room air on day of life #4 and has remained there. She was
treated with caffeine for apnea of prematurity from day of
life #2 until day of life #23. Her last episode of apnea was
greater than one month prior to discharge. On examination her
respirations are comfortable. Lungs sound clear and equal.
Cardiovascular status: She has remained normotensive
throughout her NICU stay. She has had intermittent Grade 1/6
systolic ejection murmur at the left sternal border. She is
pink and well perfused. She had a normal EKG on [**2199-6-26**] and
on her x-ray she has a normal cardiothymic silhouette as well as
normal four extremity blood pressures. On exam at discharge
the patient has a heart with regular, rate and rhythm, no
murmurs. She is pink and well perfused.
Fluid, Electrolyte and Nutrition status: Enteral feeds were
begun on day of life #2 and advanced without difficulty to
full volume feeding. She was on maximum calorie enhanced
formula of 30 calories per ounce. At the time of discharge
she is eating NeoSure 28 calories per ounce made by
concentration on an ad lib schedule. Calorie concentration
has proven necessary to maintain consistent weight gain. At
the time of discharge her weight is 2560 grams, her length 45
cm and head circumference 31 cm.
Gastrointestinal status: [**Known lastname 1894**] was treated with
phototherapy for hyperbilirubinemia of premature from day of
life #1 until day of life #8. Her peak bilirubin occurred on
day of life #3 at total 7.8, direct 0.4.
Hematology: She has received no blood product transfusions
during her NICU stay. Her last hematocrit on [**2199-7-1**] was
27.5. She is receiving supplemental iron.
Infectious Disease status: She was started on ampicillin and
gentamicin at the time of admission for sepsis risk factors.
The antibiotics were discontinued after 48 hours and the
blood culture was negative and the infant was clinically
well. She has remained off antibiotics since that time.
Neurology: Head ultrasound done on [**2199-5-22**] and [**2199-6-18**] were both within normal limits.
Ophthalmology: Eyes were examined most recently on [**2199-6-24**] and revealing mature retinal vessels. No retinopathy was
detected during admission. A follow- up exam
is recommended in six months.
Psychosocial: Parents have been very involved in the infants
care throughout the NICU stay. The mother's last name is
[**Doctor Last Name 1689**].
The infant is discharged in good condition.
She is discharged home with her parents. Her twin sibling is
not yet ready for discharge.
Primary pediatric care will be provided by Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 4249**], [**Apartment Address(1) 61263**], [**Location (un) **], [**Numeric Identifier 60829**],
Telephone #[**Telephone/Fax (1) 61264**].
RECOMMENDATIONS:
Feedings: NeoSure 28 calories per ounce as needed to maintain
weight gain.
Medication: Ferrous Sulfate (25 mg per ml) 0.2 ml p.o. daily.
The infant has passed a car seat position screening test.
Last State Newborn screen was sent on [**2199-6-24**] and was
within normal limits.
She has received the following immunizations: Pediarix on
[**2199-7-11**]. HIB [**2199-7-11**] and pneumococcal [**2199-7-11**].
Recommended immunizations:
1. 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: Day
care during the RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities, or school age
siblings or 3. With chronic lung disease.
2. Influenza immunization is recommended annually in the Fall
for all infants once they reach six months of age. Before
this age, and for the first 24 months of the childs life
immunization against influenza is recommended for
household contacts and out of home caregivers.
FOLLOW UP:
1. Community Health Link early intervention program,
telephone #[**Telephone/Fax (1) 60831**].
2. Visiting nurse of the care group network, 1-[**Telephone/Fax (1) 12065**].
3. Infant follow-up program at [**Hospital3 **] [**Telephone/Fax (1) 60393**].
4. Ophthalmology, Dr.[**First Name9 (NamePattern2) 50073**] [**Name (STitle) **], [**Telephone/Fax (1) 61265**].
DISCHARGE DIAGNOSIS:
1. Status post prematurity 29-4/7 weeks gestation.
2. Twin #1
3. Status post respiratory distress syndrome.
4. Sepsis ruled out.
5. Status post apnea of prematurity.
6. Status post hyperbilirubinemia of prematurity.
7. Anemia of prematurity.
8. Heart murmur consistent with peripheral pulmonic stenosis.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**MD Number(2) 56682**]
Dictated By:[**Last Name (NamePattern4) 61266**]
MEDQUIST36
D: [**2199-7-17**] 17:47:16
T: [**2199-7-17**] 18:48:21
Job#: [**Job Number 61267**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1103
} | Medical Text: Admission Date: [**2142-3-20**] Discharge Date: [**2142-3-28**]
Service: [**Doctor Last Name 1181**] MEDICINE
Note: The patient was admitted to the [**Doctor Last Name **] Medicine
Service after being transferred from the MICU. For a
detailed course of the patient's stay in the MICU, please
refer to dictation summary from the MICU.
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
male with a history of coronary artery disease, congestive
heart failure, with an ejection fraction of 20%,
hypertension, atrial fibrillation, depression, and anxiety.
It should be noted that for atrial fibrillation, the patient
has not been on Coumadin, and there is a question of whether
this is chronic versus paroxysmal.
The patient's ejection fraction is 20% by echocardiogram done
at [**Hospital6 256**] last month.
The patient was admitted initially to the MICU with
respiratory distress and acute renal failure. The patient
was unable to answer questions, so all history was obtained
by the patient's primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5762**].
The patient lives is an assisted-living facility. He had
mildly elevated creatinine to 2.5 one week prior to
admission. This was felt to be secondary to Lasix for
congestive heart failure. There is little history for past
week, but the patient saw his primary care physician on the
day of admission, and was tachypneic and sent to the
Emergency Room for evaluation. Oxygen saturation could not
be obtained, but ABG revealed a paO2 of 112 on 100%
nonrebreather. The patient was also hypotensive with an SBP
in the 80s on presentation, but blood pressure increased to
120 on 1 L normal saline bolus.
Labs obtained that day found the patient to be hyperkalemic
at 6.3. Creatinine was 5.4. Electrocardiogram revealed new
ST depressions and T-wave inversions in V1-V3. The patient
was given Kayexalate and admitted to the MICU for further
care.
PAST MEDICAL HISTORY: 1. Coronary artery disease. Details
are unknown. 2. Congestive heart failure with an ejection
fraction of 20% by echocardiogram done at [**Hospital6 1760**] last month. 3.
Hypertension. 4. Atrial fibrillation, not known whether
chronic or paroxysmal. The patient was not on Coumadin. 5.
The patient has a history of anxiety and depression.
MEDICATIONS ON ADMISSION: Lisinopril 10 mg p.o. q.d., Lasix
40 mg p.o. b.i.d., Zyprexa 2.5 p.o. q.d., Depakote dose
unknown, Dexacen 1 mg p.o. b.i.d., Colace 100 mg p.o. b.i.d.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: He lives in an assisted-living facility.
Per her primary care physician, [**Name10 (NameIs) **] is severely deconditioned
and debilitated but refuses other living arrangements.
Daughter is active in his care.
PHYSICAL EXAMINATION: Vital signs: On admission pulse was
112, blood pressure 106/70 after fluid, oxygen saturation
100% on nonrebreather, respirations 28, temperature 97.8??????.
General: The patient was alert and in no acute distress.
HEENT: Within normal limits. Normocephalic, atraumatic.
Dry mucous membranes. Oropharynx clear. Neck: Supple. No
lymphadenopathy. Thyroid normal. No jugular venous
distention. Heart: Irregularly irregular. No murmurs,
clicks, or gallops. Lungs: Clear to auscultation
bilaterally. Abdomen: Soft, nontender, nondistended. No
hepatosplenomegaly palpated. Extremities: Lower extremities
with no clubbing, cyanosis, or edema. Skin: Without rashes.
Neurological: Grossly normal.
LABORATORY DATA: White count 14.1, hematocrit 40.1, platelet
count 200; INR 1.2; sodium 149, potassium 5.9, chloride 110,
bicarb 22, BUN 130, creatinine 5.4, glucose 104; depakote
level 36; ABG 7.38 pH; CK 581, MB 30, troponin 0.88.
HOSPITAL COURSE: In the unit the patient was treated with
vigorous intravenous fluids with improvement in renal failure
and blood pressure. His course was complicated by anemia
which was felt to be secondary to dilutional
.................. acidosis which was .................. and
felt to be secondary to dilutional acidosis.
The patient had atrial fibrillation in the unit, as well as
persistent fever. Chest x-ray revealed pneumonia felt to be
secondary to aspiration pneumonia. The patient was started
on Flagyl and Levofloxacin.
The patient was then transferred to the floor.
1. Pneumonia: Again this was felt to be secondary to
aspiration pneumonia. The patient's antibiotics were changed
from Levofloxacin and Flagyl to Levofloxacin and Clindamycin
to provide better coverage for gram-positive aerobes.
On the floor, the patient was initially stable on 2 L oxygen.
He had vigorous chest physical therapy that was delivered to
loosen up secretions, and he became stable on room air, with
oxygen saturations 95-96% on room air.
The patient's sputum culture was consistent with mixed
oropharyngeal flora, and no organism was isolated.
The patient was continued on Clindamycin and Levofloxacin and
was discharged with these medications.
In regards to his hospitalization on the floor, the patient
remained stable in room air.
2. Cardiovascular: Pump: The patient was initially off
afterload reducing agents such as ACE inhibitor; however,
Lisinopril was added at 2.5 mg p.o. q.d. once his creatinine
stabilized to his baseline of around 1.0-1.2. The patient
tolerated this quite well.
Rate control: The patient was considered for beta-blocker;
however, he was very sensitive to low-dose beta-blockers with
decrease in blood pressure, and hence these were
discontinued.
The patient throughout his hospitalization remained in atrial
fibrillation which was mostly very well rate controlled in
the 70-80s.
Beta-blockers and other nodal agents were not continued given
that the patient is very sensitive and would have low blood
pressures. He otherwise maintained good blood pressure
without problem.
Ischemia: There was no evidence of active ischemia. The
patient did have elevated CK, CKMB, and troponins; however,
these were felt to be secondary to demand ischemia in the
setting of renal insufficiency.
The patient did not actively complain of chest pain or have
any other symptoms that would indicate active ischemia.
Further management was deferred.
Atrial fibrillation: The patient has a history of atrial
fibrillation. This is unclear of whether this is chronic
versus paroxysmal. The patient was not on Coumadin on
admission, and Coumadin was not continued in-house.
The patient was mostly very well rate controlled with rate in
the 70s to 80s and had no evidence of acute embolic events
throughout his hospitalization.
Hypotension: Again this improved throughout his
hospitalization. The patient had no symptomatic hypotensive
episodes. His blood pressures were very well controlled on
ACE inhibitor at low dose.
3. Acute renal failure: By the time the patient was on the
floor, his renal failure had returned to baseline at
approximately 1.0-1.2 for his creatinine.
4. Congestive heart failure: The patient has a history of
congestive heart failure. His diuretics were stopped
entirely throughout his hospitalization. In fact, the
patient was aggressively fluid resuscitated on admission to
the MICU.
The patient was not maintained on diuretics at all, and his
only medications included Lisinopril 2.5 mg 1 p.o. q.d. for
afterload reduction.
The patient will not be discharged with a diuretic given that
he is currently stable on room air and is not in
decompensated heart failure, has no evidence of lower
extremity edema. His Lasix may need to be readded to his
regimen as an outpatient once he is discharged from the
hospital, as his volume status changes. His volume status
should be followed quite aggressively, and he should be
maintained on a low-sodium, puree, and thick liquid diet.
Additionally, his intake of fluids should not exceed 1500 cc
per day. The patient's urine output should also be followed.
5. FEN: Again acidosis was non-gap and felt to be secondary
to expansion. This resolved throughout his hospitalization.
The patient's hypernatremia again was felt secondary to fluid
resuscitation and free-water deficit. He was repleted with
D5 normal with resolution of his hypernatremia at discharge.
The patient's sodium of discharge was 143. Additionally,
hyperkalemia resolved with fluid resuscitation. The patient
had no electrocardiogram changes consistent with
hyperkalemia.
The patient while in-house had a video, as well as bedside
swallow study to evaluate his swallowing mechanism, given
that it was felt that his pneumonia was an aspiration event.
The patient passed his bedside swallow study; however, he
also had a video-swallow which he did not pass. The overall
recommendations from Speech and Swallow were that the patient
should be maintained NPO with consideration of PEG tube for
further tube feeding nutrition; however, the patient and his
daughter refused tube feed as an option and did not want PEG
tube or NG tube placed. It was explained to them that the
patient could have further aspiration events if he continued
on a p.o. diet; however, the daughter understood this as did
the patient. They were also explained that even with a PEG
tube, aspiration events cannot prevented given that the
patient can aspirate one's own secretions. Hence, the
daughter and patient both decided that the patient would
continue on a puree and thick liquid diet and that all eating
events would be monitored by staff.
The patient will be maintained on aspiration precautions and
that the head of his bed should be elevated. Both daughter
and the patient wanted to defer NG tube or PEG tube at this
time. They wanted to continue the patient on p.o. diet as
long as the patient could tolerate.
6. Heme: The patient throughout his hospitalization
received 1 U packed red blood cells. Again his drop in
hematocrit was felt to be secondary to dilution. After
transfusion of his 1 U packed red blood cells, hematocrit
remained stable between 30-31.9 at discharge.
7. Psychiatric: The patient was continued on
................... and Valproic Acid throughout his
hospitalization with no acute events.
8. Prophylaxis: The patient was maintained on subcue
Heparin and H2 blocker.
DISPOSITION: He will be discharged to a
rehabilitation/nursing home facility.
CONDITION ON DISCHARGE: Fair to stable. He is stable on
room air. He is maintained on antibiotics. He has been
afebrile for greater than three days. He has had no
witnessed aspiration events. Mental status is at baseline.
DISCHARGE MEDICATIONS: Aspirin 325 mg p.o. q.d., Bacitracin
Zinc ointment to be applied q.i.d. to the urethral meatus,
Albuterol nebs 1 q.6 hours as needed, Ipratropium nebs 1 q.6
hours as needed, Olanzapine 5 mg 0.5 mg 1 p.o. q.d.,
Lisinopril 5 mg 0.5 mg tab 1 p.o. q.d., Clindamycin 600 mg
p.o. q.8 hours for 7 days, Levofloxacin 500 mg 1 p.o. q.d.
For 7 days, Valproic Acid 250 mg/5 ml to be taken 5 ml p.o.
at bed time, .................. 40 mg/5 ml suspension to be
taken at 2.5 ml 1 p.o. q.d.
FOLLOW-UP: The patient is to set up follow-up with his
primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5762**] approximately one week after
he is discharged from his extended rehabilitation facility.
DISCHARGE LABS: White count 8.6, hematocrit 31.9, platelet
count 283; sodium 143, potassium 4.8, chloride 114, bicarb
21, BUN 21, creatinine 1.2, glucose 90, calcium 9.6,
magnesium 2.4, phos 2.7.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4263**]
Dictated By:[**Last Name (NamePattern1) 5843**]
MEDQUIST36
D: [**2142-3-28**] 09:12
T: [**2142-3-28**] 09:19
JOB#: [**Job Number 19235**]
cc:[**Last Name (NamePattern1) **]
ICD9 Codes: 5070, 5849, 2765, 4280, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1104
} | Medical Text: Admission Date: [**2116-8-30**] Discharge Date: [**2116-9-1**]
Date of Birth: [**2061-4-12**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies
Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
55F with PMH of IDDM presents after a day of feeling generally
unwell, and with nausea and vomiting, some chest pressure and
feeling of heart racing. Patient changed her insulin pump pod
prior to going to bed. Woke up around 6:30am feeling nauseated
with chest pressure. Her glucose was as 376 according to
insulin pump and remained elevated despite her increasing the
rate of insulin infusion on her insulin pump. She was concerned
that the pump may not have been working overnight. She states
that all symptoms feel identical to when she had DKA 10 years
ago. After waiting for a while, her blood sugar fell to 280, but
she still felt nauseated and unwell and her urine showed
ketones, so she presented tot he ED. She denies fevers, chills,
cough, rhinorrhea, sputum production, dyspnea, abdominal pain,
diarrhea, dysuria, rash. She did note however that she had [**3-20**]
non-loose bowel movements over the course of the day, which is
more frequent than usual for her.
.
In the ED, initial vs were: T97.6 HR111 BP138/66 RR20 O2sat 100%
RA
She had a K of 4.0 and an anion gap of 21, a normal CXR, EKG
with <1mm ST depressions that may have been rate dependent (no
priors for comparison), and a UA with 1000 glucose and ketones.
An ABG showed 7.3/31/85/16. Her lactate was 3.6. WBC14.5,
Plt241, Hct42.8 with differential: N:78.6 L:17.7 M:2.6 E:0.1
Bas:1.0. Patient was given 10 units insulin bolus, and 7 units
per hour insulin gtt, which was then turned down to 5 units per
hour when her blood sugar dropped to 193. She was started on NS
with 40meq of K+. VS on transfer were: 94, 115/48, 16, 100% on
RA.
.
When she arrived to the ICU, her vitals were: HR 93, BP 115/54,
RR 14, O2 sat 99 (RA). She felt much better, no longer
nauseated and no more chest pressure.
Past Medical History:
DM I (diagnosed
Fibromyalgia
Social History:
Works as a school nurse [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 2251**] [**Last Name (NamePattern1) **] School.
- Tobacco: none
- Alcohol: 5 glasses wine/week
- Illicits: none
Family History:
Mom died of CHF at 87; father died of old age, seven siblings
who are all healthy
Physical Exam:
Admission Physical Exam:
Vitals: HR 93, BP 115/54, RR 14, O2 sat 99 (RA).
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: +BS, soft, non-tender, non-distended, bowel sounds
present, Ext: warm, well-perfused, no edema
.
Discharge Physical Exam:
Pertinent Results:
Admission Labs:
Significant for K of 4.0 and an anion gap of 21. UA with 1000
glucose. ABG: 7.3/31/85/16. lactate 3.6. WBC14.5, Plt241,
Hct42.8 with differential: N:78.6 L:17.7 M:2.6 E:0.1 Bas:1.0.
.
[**2116-8-30**] 01:26PM WBC-14.5* RBC-4.58 HGB-14.6 HCT-42.8 MCV-94
MCH-31.9 MCHC-34.1 RDW-13.2
[**2116-8-30**] 01:26PM NEUTS-78.6* LYMPHS-17.7* MONOS-2.6 EOS-0.1
BASOS-1.0
[**2116-8-30**] 01:26PM PLT COUNT-241
[**2116-8-30**] 01:26PM cTropnT-<0.01
[**2116-8-30**] 01:26PM GLUCOSE-364* UREA N-22* CREAT-0.8 SODIUM-140
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-17* ANION GAP-25*
[**2116-8-30**] 01:33PM LACTATE-3.6*
[**2116-8-30**] 01:33PM PO2-85 PCO2-31* PH-7.30* TOTAL CO2-16* BASE
XS--9 COMMENTS-GREEN TOP
[**2116-8-30**] 02:53PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2116-8-30**] 02:53PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2116-8-30**] 02:53PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2116-8-30**] 02:53PM URINE GRANULAR-1*
.
Microbiology: no cultures sent
.
Imaging:
CXR ([**8-30**]): FINDINGS: PA and lateral chest radiographs were
obtained. The lungs are clear with no evidence of
consolidations, effusions, or pneumothoraces. The
cardiomediastinal silhouette is within normal limits.
.
Labs on discharge:
[**2116-9-1**] 05:15AM BLOOD Glucose-183* UreaN-7 Creat-0.6 Na-143
K-3.7 Cl-105 HCO3-27 AnGap-15
[**2116-9-1**] 05:15AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.7
.
ETT:
INTERPRETATION: 55 yo woman with h/o DM on insulin x 36 years
was
referred for evaluation of ST segment changes while tachycardic
in ED
being treated for diabetic ketoacidosis. The patient completed
11
minutes of a modified [**Doctor First Name **] protocol representing an average
exercise
tolerance for her age; ~ 9.2 METS. The exercise test was stopped
due to
fatigue. No chest, back, neck or arm discomforts were reported
by the
patient during the procedure. In the presence of nonspecific
baseline ST
segment changes, less than 0.5 mm of additional ST segment
depression
was noted inferiorly. The rhythm was sinus with no ectopy noted.
The
hemodynamic response to exercise was appropriate.
IMPRESSION: No anginal symptoms or objective ECG evidence of
myocardial
ischemia at a high cardiac demand and average exercise
tolerance.
Appropriate hemodynamic response to exercise.
Brief Hospital Course:
55F with PMH of IDDM with insulin pump presents with general
malaise and tachycardia, found to have DKA.
.
#DKA. At the time of presentation to the ICU, the patient's
glucose remained elevated at 364. She had metabolic acidosis
with anion gap of 21 when she presented to the ED, which on
arrival to the ICU had closed to 11. Although she had an
elevated WBC, she was afebrile and had a normal CXR and UA. Her
GI distress had resolved. Given her clinical resolution, there
was no evidence of infection and no further testing was done.
Her elevated WBC was suspected to be an inflammatory response to
the DKA iself. She was treated with hydration (D5W with KCl),
for a total of 4L of fluid. She was placed on an insulin drip
overnight. In the morning, her gap had closed and her
fingerstick blood glucose was normal. She was then transitioned
back to her insulin pump and started on a diabetic diet. By the
afternoon, her blood glucose was in good control, she was eating
well, and was entirely asymptomatic. She was transferred to the
floor for further observation and planned discharge the
following day. She did well on the medical floor, was seen by
the [**Last Name (un) **] consultation and was discharged on her pump in good
working condition. She was advised to only change cartridges in
the morning and then check finger sticks several hours later.
.
Her outpatient primary care physician and her diabetologist at
[**Last Name (un) **] were contact[**Name (NI) **] regarding her presentation and to ensure
follow-up to determine the etiology of her DKA. One obvious
cause could be a malfunction of the insulin pod that was changed
immediately before she retired for the night. However, she also
reports being under unusual stress over the preior four days.
The GI distress she reported (nausea and vomiting) may have been
a result of the DKA, but may have been causal. As she has only
one prior episode of DKA, that associated with the post-op
period, it may warrant further investigation.
.
# EKG changes: ST depression was noted in inferolateral leads
while tachycardic in the ED. These ST depressions disappeared
after her heart rate slowed down. This was suspicious for
demand ischemia while tachycardic. She complained of some chest
pain overnight on [**8-31**] and given this and her EKG changes, a ETT
was done, which was negative (see above for details).
.
#Fibromyalgia: Patient was diagnosed 2 years ago for general
aches and cramps. Her home regimen was continued.
Medications on Admission:
Humalog insulin per insulin pump (no long-acting insulin)
Prednisone 2 mg daily (slow taper, has been on for 2 years for
fibromyalgia)
Lyrica 50mg qhs
Lisinopril 5mg qhs
Discharge Medications:
1. prednisone 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. pregabalin 25 mg Capsule Sig: Two (2) Capsule PO QHS (once a
day (at bedtime)).
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. insulin pump syringe Miscellaneous
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic ketoacidosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with diabetic ketoacidosis, likely due to pump
malfunction. You were treated with insulin and IV fluids and
you improved. On admission, your heart rate was fast and you
had some minor changes to your EKG. You also noted some
intermittent chest pain. You underwent an exercise treadmill
test that was negative!
***
NO CHANGES WERE MADE TO YOUR HOME MEDICATIONS.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 5445**] N.
Address: [**Location (un) 32820**], [**Location (un) **],[**Numeric Identifier 32821**]
Phone: [**Telephone/Fax (1) 32822**]
Appointment: Thursday [**2116-9-10**] 10:15am
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1105
} | Medical Text: Admission Date: [**2152-3-28**] Discharge Date: [**2152-4-24**]
Date of Birth: [**2077-2-22**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**4-17**] CABG x 1, pericardial AVR
History of Present Illness:
75 F with PMH severe AS, DVT, HTN, hyperlipid, presented with
SOB to [**Hospital 1474**] Hospital on [**2152-3-22**] with CHF decompensation. The
patient has been hospitalized many times in the past several
weeks. She was at [**Hospital1 18**] for a cath in [**11-12**], in preparation for
AVR in [**4-13**]. At cath, pt was found to have RCA disease, moderate
OM, moderate LAD disease. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1290**] sent pt for venous
US of legs for vein mapping. Pt was found to have a DVT and was
started on coumadin. She has been on coumadin for 3 months now.
Followup venous US of legs at [**Hospital1 1474**] during this
hospitalization showed no DVTs. TTE at [**Hospital1 1474**] showed EF 40%,
with AV area 0.7 cm2, consistent with severe AS.
.
Pt was admitted to [**Hospital1 1474**] on [**3-22**] and discharged on [**3-24**], then
readmitted on [**3-27**] at 9 PM with hypoxic respiratory failure,
brought in by EMS. In the field, she was given lasix 80 IV x1
and morphine 12 mg x1, then lasix 80 IV x1 in ED. Initial SBP
was 140s, but decreased to 70s after intubation, and dopamine
was started for presumptive cardiogenic shock. Pt was found to
have an NSTEMI with CK 108, MB 4.5, Trop 2.9, Cr 1.2. Pt was
placed on Lovenox 80 mg x1 for DVT ppx. Pt was transferred to
[**Hospital1 18**] for possible IABP for cardiogenic shock management and CT
[**Doctor First Name **] for planned AVR. Pt arrived intubated: AC 500/14/5/80%, and
febrile to 103 rectal.
Past Medical History:
Severe AS
Hypothyroidism
HTN
Hyperlipidemia
DVT
Gout
Hemorrhoids
Migraines
Osteo
Cholecystectomy and hernia repair [**2145**]
Social History:
Married and lives independently with husband and daughter.
Active in her own care. Takes all her own medication, weighs and
records her weight daily. [**Hospital 2255**] [**Name (NI) 2256**] is coming to the
house now since d/c from [**Hospital 1474**] Hosp [**2151-10-19**]. Does not drink
alcohol, does not smoke cigarettes.
Family History:
Father died at age 45 of an MI.
Brother had a CVA and an MI in his 60's and died at the age of
66.
Physical Exam:
103 / 128/51 / 23 / 110 / 100% on 500/14+6/5/80%, PIP 27
Gen: Can nod and answer appropriately
HEENT: REJ line, cannot assess JVD, no LAD, OP clear
Lungs: Rales anteriorly bilaterally
Heart: 3/6 SEM radiating up
Abdomen: Soft, +BS, ND, NT
Neuro: [**5-12**] motor
Skin: No rashes
Pertinent Results:
Cath [**2151-11-18**]:
1. 2VD.
2. Severe aortic stenosis.
LMCA - wnl
RCA - diffusely diseased, multiple 60-70% lesions
LCX - Co-dominant, large filling defect in the mid AV groove at
one point of bifurcation with the OM1; OM1 with ostial 50%
LAD - non-obstructive 40-50% mid vessel
LV ventriculography was deferred given the known lesion on the
AV
valve and critical Aortic Stenosis.
Limited resting hemodynamics demonstrated normal right (RVEDP =
9 mm
Hg) and left (PCWP = 11 mm Hg) filling pressures. The LVEDP was
not
obtained due to known mobile mass on the aortic valve.
[**2152-3-24**] TTE:
EF 40%
1. Normal LV dimensions with mildly reduced LV systolic
function. The inferior and posterior walls appear hypokinetic.
2. RV size and systolic function wnl
3. Aortic valve is heavily calcified. Peak velocity across AV is
4.5 m/s. Mean gradient is 49, calculated AV area is 0.7 cm2
consistent with severe AS. Mild AR
4. Mild annular calcification with mild MR.
5. Other valves are normal with trace TR.
6. PASP 25-30
.
[**2152-4-24**] 08:45AM BLOOD Hct-33.6*
[**2152-4-22**] 09:45AM BLOOD Hct-29.8*
[**2152-4-20**] 05:53AM BLOOD WBC-10.8 RBC-2.86* Hgb-8.7* Hct-25.1*
MCV-88 MCH-30.3 MCHC-34.5 RDW-15.6* Plt Ct-125*
[**2152-4-24**] 08:45AM BLOOD K-4.3
[**2152-4-22**] 09:45AM BLOOD UreaN-20 Creat-1.2* K-4.3
[**2152-4-21**] 08:05AM BLOOD UreaN-23* Creat-1.3* K-4.2
[**2152-4-20**] 05:53AM BLOOD Glucose-94 UreaN-26* Creat-1.2* Na-139
K-4.0 Cl-103 HCO3-27 AnGap-13
Brief Hospital Course:
75 F with PMH severe AS, DVT, HTN, hyperlipid, presented with
SOB to [**Hospital 1474**] Hospital on [**2152-3-22**] with CHF decompensation,
admitted here with septic shock. She was treated in the cadiac
care unit until she was optimized for her AVR / CABG.
.
# Septic shock:
Pt was hypotensive and febrile to 103 on admission. Differential
included AV endocarditis, pneumonia, UTI, line infection,
hypothyroidism. CXR showed infiltrates which became more clear
with diuresis. Pt was covered with Vanco and Aztreonam for PCN
allergy. Levofloxacin was added on [**3-31**], since pt was still
having low grade fevers after 3 days, for double coverage of
gram negative organisms. Sputum culture grew out GPC. TTE and
TEE showed low likelihood of endocarditis, with severe AS, no
vegetation or mass seen on any valves. R femoral triple lumen
cath and REJ lines were changed to a RIJ swan. TSH was wnl. She
finished a course for HAP with vanco / levo / aztreonam, and
remained afebrile in the five days prior to her surgery.
.
Pt's beta blocker and [**Last Name (un) **] were held for hypotension to SBP 75-85
on admission. Pt was transferred on dopamine, and was changed to
levophed after 1 day to maintain MAP>65. Cortisol stimulation
test was wnl. Pt's fluid status was based in first few days on
swan readings. She was successfully weaned off of all pressure
support.
.
# Hypoxic respiratory failure:
Pt was transferred from OSH on AC vent, likely etiology due to
CHF exacerbation from pneumonia and severe AS. Pt was placed on
Vanc/Aztreonam, and Levofloxacin was added for double coverage
of gram negative organisms. She was extubated one week after
transfer, and required to go back on BiPAP three times after
extuabtion; this was in the setting of increased HR / BP while
anxious, with presumed acute pulmonary edema. She always
responded well to gentle diuresis, and was tolerant of BiPAP as
needed. She was weaned to room air prior to surgery.
.
# Cardiac status:
Pump:
TTE [**2152-3-24**] showed EF 50%, E:A 1.25, critical AS, possible 1 cm
mass on aortic valve. TTE and TEE were performed, showing severe
AS and no vegetation or mass seen on any valve. It is likely
that hypotension at OSH may have been from low CO from severe AS
and from medications given in the field, and that sepsis was an
underlying cause. She was preparing for AVR once her acute
issues were resolved.
She was taken to the OR on [**2152-4-17**] where she underwent a CABG x
1 (SVG->OM) and AVR (#23 pericardial). She was transferred to
the CSRU in critical but stable condition. She was extubated on
POD #1, and weaned from her drips and transferred to the floor
by POD #2. She had a short bout of atrial fibrillation post
operatively which resolved with amiodarone. She had no
complications and was discharge to rehab on POD#7.
Ischemia:
Pt had a troponin leak at [**Hospital 1474**] Hospital with a Trop 2.9.
Cath in [**11-12**] shows 2VD; LMCA - wnl; RCA - diffusely diseased,
multiple 60-70% lesions; LCX - Co-dominant, large filling defect
in the mid AV groove at one point of bifurcation with the OM1;
OM1 with ostial 50%; LAD - non-obstructive 40-50% mid vessel. Pt
was placed on ASA. Pt was not on a statin as an outpatient, and
was not placed on one inhouse. She evidently had a history of
myalgias which were attributed to statins, so they were
discontinued.
.
Rhythm:
Pt remained in NSR during most of CCU admission. Pt became sinus
tachycardic on dopamine, and was changed to levophed as a
pressor. She had an episode of atrial fibrillation, which was
new for her. She was rate controlled with IV amiodarone, and
converted to PO amiodarone; she was continued on a beta blocker
once off of pressors. She converted back to NSR, and remained
in that rhythm up until the time of surgery.
.
# Anemia:
Likely due to blood loss and anemia of chronic disease. Pt's Hct
continued to drift down slowly during admission. Pt's NGT was
guaiac+, and stool was guaiac- on admission. Hemolysis labs were
negative. Pt's Hct was supported with transfusions, since Hct
drop was slow, and was monitored until respiratory status was
stable. In preparation of surgery, she underwent an EGD and a
virtual colonoscopy to evaluate the anemia. The EGD revealed
mild gastritis without any active bleeding. The virtual
colonoscopy (done due to her tenuous hemodynamic status at the
time) revealed diverticulosis, no polyps, no active bleeding.
The etiology of her anemia was still unclear, but stable.
.
# History of DVT:
LENIs were found to be negative at OSH, and pt was given lovenox
60 x1 at OSH. Pt was maintained on Heparin sc TID inhouse.
.
FEN: Pt was given TF through OGT
Medications on Admission:
Admission Medications:
Benicar 40mg daily.
Lasix 80 mg q AM, 40 mg q PM.
Levothyroxine 50 mcg daily.
Toprol 25mg daily.
Norvasc 2.5 mg daily.
Calcitrol 0.25mcg daily.
ASA 81 mg daily.
TUMS 1 tablet [**Hospital1 **].
Allergies: PCN, no contrast or shellfish allergy
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400 mg QD x 1 week, then 200 WD. Tablet(s)
7. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
8. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
11. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
12. Tums 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Sepsis, pneumonia
Severe AS, HTN, hyperlipidemia, hypothyroidism, DVT
Discharge Condition:
Good.
Discharge Instructions:
Shower, no baths, no lotions, creams or powders to incisions.
Call with fever, redness or drainage from incisions or weight
gain more than 2 poundsin one day or five in one week.
No heavy lifting or driving.
[**Last Name (NamePattern4) 2138**]p Instructions:
1. Please follow up with your primary care physician, [**Last Name (NamePattern4) **].
[**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 6700**], [**Telephone/Fax (1) 3183**], within 1-2 weeks.
Dr. [**Last Name (Prefixes) **] 4 weeks
Completed by:[**2152-4-24**]
ICD9 Codes: 4280, 4241, 0389, 486, 5849, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1106
} | Medical Text: Admission Date: [**2149-8-10**] Discharge Date: [**2149-8-11**]
Date of Birth: [**2094-9-27**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Transfer after cardiac arrest
Major Surgical or Invasive Procedure:
Left Femoral Central Line
Cardioversion
Defibrillation
On transfer from OSH:
Intubation
Right Femoral Arterial Line
Right IJ temporary pacing wire
Left IJ central line/Swam Ganz catheter
foley Catheter
History of Present Illness:
Pt is a 54 F with h/o non-ischemic cardiomyopathy, diastolic CHF
with EF >55%, MR, severe pulm HTN thought [**2-21**] UIP/IPF on
steroids, DM2, HTN, PAF on coumadin, s/p renal Xplant in [**2143**] on
IS, who presents from [**Hospital 21970**] Hospital after asystolic arrest.
Per report, the patient presented to [**Hospital 1474**] hospital on
[**2149-8-2**] after feeling sudden onset of palpitations, chest pain,
and SOB. In the ED, she was treated for her CP but was found to
be in pulm edema and rapid afib. She was admitted to the ICU for
further care, where they aggressively rate controlled her and
diuresed her with lasix. Given her rapid afib, the patient was
started on sotalol on [**8-4**], where she converted to sinus rythm
on [**8-5**]. The patient remained stable until the afternoon of
transfer.
Per report, the patient subsequently went into asystolic arrest
at about 2:30PM on [**8-10**] requiring defibrillation, epi 1mg x4,
atropine 1mg x1, vasopressin 40units x1, lidocaine 100mg x1,
Amiodarone 150mg x1, bicarb, Ca returning her to sinus rythm.
There were no reported shocks. She was intubated during this
event and started on dopamine/neo for sbps in the 80s. In the
ICU, a PA line was placed demonstrating CVP 16, PAP 85/35 and
PCWP 40 with CO 1.4. A R fem A-line was placed, as was a temp
pacing wire for bradycardia. The patient was then switched to
nitro/levophed and given lasix 100mg IV x1. Bedside echo showed
EF 40%. ABG at the time of transfer was 7.35/31/60 on 100% Fi02
and PEEP 5. Due to family request, the patient was transferred
to [**Hospital1 18**] for further care.
On arrival to [**Hospital1 18**], the patient was intubated and sedated with
possible responsiveness. She arrived on nitro/levophed drip. She
was unable to provide history.
Also of note, the patient was recently admitted to [**Hospital1 18**] on
[**2149-6-12**] for increased abd girth and SOB thought [**2-21**] CHF
exacerbation. She was diuresed at that time with
lasix/metolazone. The patient also underwent R heart cath
confirming pulm hypertension(RVEDP = 20 mm Hg, mean PCWP 11 mm
Hg, pulmonary artery pressure 79/59 mm Hg). She underwent lung
biospy and evaluation by pulmonology showing likely UIP/IPF and
was started on high dose prednisone. She was also maintained on
cytoxan for her renal transplant.
ROS: Unable to obtain review of systems due to patient being
intubated/sedated.
Past Medical History:
Non-ischemic cardiomyopathy/CHF: Echo [**2149-6-13**]: EF >55%, 1+ MR,
severe pulm HTN, RV dilation c/w overload
- Pulmonary HTN: R heart cath on [**6-19**] with pulmonary artery
pressure 79/59 mm Hg.
- IPF/UIP--likely from aspiration pneumonitis-Patient has
documented room air saturation of 85%. Diagnosis is Interstitial
pulmonary fibrosis/UIP per thoracotomy and lung biospy
- Paroxysmal Afib with RVR with h/o conversion pauses to sinus.
On coumadin, recently started on sotalol
- ESRD secondary to chronic pyelonephritis, s/p cadaveric
kidney transplant on [**2143-11-12**]
- Diabetes Mellitus Type 2
- Hypertension
- Hyperlipidemia
- Anemia-multifactorial, ACD, ESRD on EPO, Baseline hct 28-35
h/o rhabdomyolysis
- Gout
- Hypothyroidism
Cardiac Risk Factors: + Diabetes, + Dyslipidemia, + Hypertension
Cardiac History: CABG: N/A
Percutaneous coronary intervention, in [**2140-10-21**]:
1. Resting hemodynamics demonstrate mildly elevated right heart
filling pressures. The mean RA pressure was 5mm Hg. The RV
systolic pressure was 42mm Hg. The mean wedge pressure was 12mm
Hg. The pulmonary arterial systolic pressure was 42mm Hg, with
an elevated PVR of 200 dynes-sec/cm2. LVEDP was 12mm Hg. The
cardiac index was 4.5 l/min/m2.
2. Coronary arteriography demontrates no siginifcant disease,
with mild luminal irregularities of the LAD.
3. Left ventriculography demonstrates moderate LV dysfunction
with
global hypokinesis. There was moderate (2+) mitral
regurgitation.
Pacemaker/ICD: N/A
Social History:
Pt. denies smoking, alcohol or illicit drug use. Pt. is
originally from [**Male First Name (un) 1056**], but moved to the US when she was
young and was raised here. She lives with her husband in
[**Name (NI) 1474**].
Family History:
There is history of renal failure and hypertension in the
family.
Physical Exam:
VS: Afebrile, BP 128/90 , HR , RR , O2 % on
Gen: Intubated, sedated female
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with left IJ swan in place. JVP to mandible.
CV: PMI displaced laterally. RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Diffuse
crackles.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No cyanosis/clubbing. Trace b/l edema. No femoral bruits.
Cold, dry extremities.
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
Ext: left UE fistula w/ bruit
Pertinent Results:
[**2149-8-10**] 08:37PM WBC-12.8*# RBC-3.48* HGB-11.8* HCT-37.0
MCV-106* MCH-34.0* MCHC-32.0 RDW-22.5*PLT COUNT-125*
CALCIUM-10.5* PHOSPHATE-6.6*# MAGNESIUM-2.7* GLUCOSE-129* UREA
N-107* CREAT-2.2* SODIUM-142 POTASSIUM-5.2* CHLORIDE-109* TOTAL
CO2-22 ANION GAP-16 LACTATE-2.6* TYPE-ART PO2-74* PCO2-45
PH-7.32* TOTAL CO2-24 BASE XS--3 freeCa-1.44*
[**2149-8-10**] 08:37PM CK-MB-35* cTropnT-1.40* CK(CPK)-209*
[**2149-8-10**] CXR: Swan-Ganz catheter remains distally positioned with
the tip projecting lateral to the right hilum, likely within a
segmental branch of the right middle or right lower lobe artery.
Other devices remain in standard position except for a right
PICC line, which crosses the midline to terminate at the
junction of the left brachiocephalic and left subclavian veins.
Bilateral combined alveolar and interstitial opacities are again
demonstrated. Alveolar opacities improved on the left but worse
on the right, likely due to rapidly shifting edema, although
superimposed secondary process in the right lung such as
hemorrhage or aspiration is also possible in the appropriate
setting. Small left pleural effusion is unchanged, but
small-to-moderate right pleural effusion has increased.
Position of the PICC line and Swan-Ganz catheter have been
communicated by telephone to Dr. [**Last Name (STitle) 20858**] by telephone on [**2149-8-10**]
[**2149-8-10**] CXR: Swan-Ganz catheter projects distal to the right
hilar contour, likely within a proximal segmental vessel of the
right middle or lower lobe. Right PICC line courses medially
within the left brachiocephalic vein with distal tip at the
junction of the left brachiocephalic vein and left subclavian
vein.
Endotracheal tube tip is not well demonstrated, but has been
better visualized on the subsequent radiograph performed 2215
(dictated under clip [**Clip Number (Radiology) 21971**]). Temporary pacing lead terminates
in right ventricle and nasogastric tube courses below the
diaphragm to terminate in the distal stomach near the junction
with the duodenum.
Cardiac silhouette is enlarged, and pulmonary vascularity is
engorged. Bilateral combined alveolar and interstitial pattern,
worse on the left than the right probably reflects pulmonary
edema. Small pleural effusions are present as well as
preexisting right-sided pleural thickening.
Position of lines and tubes was discussed by telephone on the
morning of [**2149-8-11**], with Dr. [**Last Name (STitle) 21972**].
[**2149-8-10**] ECG:Probable sinus rhythm with sinus arrhythmia and
extensive baseline artifact. Low voltage in the limb leads. ST-T
wave changes anterolaterally consistent with ischemia. Compared
with the prior tracing of [**2149-6-19**] anterolateral ST-T wave
changes are more prominent and QTc interval is shorter.
Brief Hospital Course:
54 F with non-ischemic cardiomyopathy, PAF, severe pulm HTN and
R heart failure, DM2, HTN, s/p renal xplant in [**2143**] presents
from OSH after episode of CP/SOB and cardiac arrest on day of
transfer to [**Hospital1 **]. She was coded with CPR, multiple doses of
epinephrine, atropine, CaCl, vasporession, bicarb, and dopamine
at the outside hopsital. Pressor support with levophed and nitro
on transfer.
Approximately one hour after arrival to the CCU at [**Hospital1 18**], the
patient went into PEA cardiac arrest. She recieved CPR, epi,
atropine, CaCl, vasopressin, and bicarb. Neosynephrine and
levophed were continued for pressor support. Patient had
episodes of maintaining blood pressure after epinephrine but
then would become hypotensive and return to PEA when placed on
ventilator. Patient developed pink, frothy sputum from ET tube.
IV lasix 300mg and bumex x2 failed to create urine output.
Swan showed significantly evelvated PA pressures, at times
higher than SBP. Beside echo with no evidence for tamponade.
CXR without sign of pneumothorax. Patient was not
hypo/hyperthermic. Labs drawn during the code without evidence
of hypo/hyperkalemia. Patient developed one episode of VFib and
was shocked and one episode of atrial fibrillation and she was
cardioverted. Both attempts failed to produce profusing rhythm.
Trial of inhaled NO to get pulm A pressures down failed
secondary to systolic hypotension. Trial of hemodialysis failed
with systolic hypotension. The code was called after 2 hours
and 15mins. Patient's family was at the hospital and notified.
Priest called at the request of the family.
Medications on Admission:
HOME MEDICATIONS:
Metoprolol 50 mg PO BID
Prednisone 60 mg PO DAILY
Pantoprazole 40 mg PO Q24H
Folic Acid 1 mg PO DAILY
Trimethoprim-Sulfamethoxazole 80-400 mg PO DAILY
Sevelamer 800 mg PO TID
Aspirin 325 mg PO DAILY
Levothyroxine 25 mcg PO DAILY
Cytoxan 50 mg PO Daily
Furosemide 80 mg PO BID
Insulin NPH 28units daily + sliding scale
Oxycodone 5 mg, 1-2 Tablets PO Q4-6H
Hydromorphone 2-4 mg PO Q3-4H
.
MEDICATIONS ON TRANSFER:
Cytoxan 50mg daily
Aspirin 325mg daily
Nitro 1 tab q5min prn
Tylenol 325-650mg q4-6 prn
Colace 100mg [**Hospital1 **]
RISS
Folic acid 1mg daily
Sevelamer 800mg TIW with meals
Prednisone 60mg daily
CaC03 1g daily
Vit D 800units daily
NPH 28units daily
Bactrim DS 0.5 daily
Levoxyl 50mcg daily
Neurontin 100mg HS
Sotalol 80mg daily
Imdur 60mg Daily
Esomeprazole 40mg [**Hospital1 **]
Morphine
Lasix 40mg daily
Famotidine 20mg daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Pulseless Electrical Activity Cardiac Arrest
Pulmonary Hypertension
Idiopathic Pulmonayr Hypertension
status post Ventricular Fibrilation arrest at outside hospital
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
ICD9 Codes: 4254, 4280, 4275, 4240, 4168, 2724, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1107
} | Medical Text: Admission Date: [**2134-9-20**] Discharge Date: [**2134-9-24**]
Date of Birth: [**2066-10-21**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Phenobarbital
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Cardiac Catheterization with Stent placement
History of Present Illness:
Ms. [**Known lastname 7518**] is a 67 year old woman with known CAD who
presented to [**Hospital3 10377**] Hospital on [**2134-9-14**] with
worsening shortness of breath x 2 days. At time of presentation,
her HR was 120, RR 30's, and BP 210/136. She had a CXR and
elevated BNP of 660, felt to be consistent with congestive heart
failure. She received Lasix 60 mg IV and was started on a
nitroglycerin drip as well as NIPPV.
Patient ruled in for an NSTEMI at OSH with troponin increase
from 0.12 to 3.4. Cardiac cath was receommended at this time,
but the patient refused. Patient agreed to a Myoview stress
test, which demonstrated an apical myocardial defect with an EF
of 28%. No c/o chest pain or dyspnea. Hospital course was
complicated by UTI for which she has been treated with
Levofloxacin since [**9-15**].
.
In cath lab, all vein grafts from her CABG were down. Patient's
left subclavian was occluded. LIMA was attempted to be reached
via right brachial then right radial approach. 2 stents were
deployed to right subclavian, proximal and distal. Catheter
perforated branch of left radial artery. Heparin was stopped.
While arm was being compressed, patient became bradycardic to
30's, BP unknown. CPR was initiated x 20 seconds. Atropine was
given and heart rate to 150's. Hand Surgery was consulted for
perforation of radial artery.
.
Pt was transfered to the floor on [**9-21**]. She underwent an
additional cardiac cath on [**9-22**] with placement of 5 stents.
Past Medical History:
1) CAD s/p 4-V CABG at [**Hospital1 18**] in [**2125**], with LIMA to the LAD, SVG
sequential to [**Last Name (LF) **], [**First Name3 (LF) **], SVG to PDA.
2) Hypertension
3) Hyperlipidemia
4) PVD
5) s/p right carotid endarterectomy [**10-10**]
6) s/p right carotid stent in [**6-/2134**]
7) TIAs due to r/t left carotid occlusion (Patient has known
occlusion of left internal carotid artery intracranially at the
level of the opthalmic artery, and she has had multiple TIAs
from this occlusion. Patient develops TIAs when her BP becomes
too low, and thus she requires SBPs ~130s to maintain perfusion.
Patient is on Florinef due to low BP causing TIA symptoms r/t
carotid
occlusion and CHF was felt to be related to the Florinef.)
8) [**3-12**] intracranial hemorrhage [**3-12**] while on asa, plavix and
coumadin (coumadin subsequently stopped)
9) Diabetes
10) Peripheral neuropathy
Social History:
Patient lives with her husband. She has a 40 pack-year smoking
history, and she quit in [**2125**]. Patient drinks alcohol
occasionally.
Family History:
Patient has five surviving children. Two of her sons have
diabetes. Brother died of CAD in his 50s. One of her sisters has
DM2. Father died in his mid-70s from alcoholic cirrhosis. Mother
was diabetic and died in her mid-50s.
Physical Exam:
VS: T 97.6, BP 144/72, HR 93, SpO2 97% on RA
Gen: WDWN elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple without JVD.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored in supine position, no accessory muscle use.
Trace basilar crackles. No wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: Ecchomyosis over Left wrist with palpable radial pulse from
mid forearm. Ulnar pulse present. Slight edema. Left hand warm
with 3 second capillary refill in all digits. No c/c/e. No
femoral hematomas. Stable Right femoral bruit present prior to
cath. warm extremities
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ Femoral 2+ DP 2+ PT nonattainable with doppler
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
[**2134-9-20**] 12:45PM HGB-11.5* calcHCT-35 O2 SAT-98
[**2134-9-20**] 06:17PM WBC-10.4 RBC-4.04* HGB-10.8* HCT-33.3*
MCV-83# MCH-26.7*# MCHC-32.3 RDW-13.9
[**2134-9-20**] 06:17PM BLOOD WBC-10.4 RBC-4.04* Hgb-10.8* Hct-33.3*
MCV-83# MCH-26.7*# MCHC-32.3 RDW-13.9 Plt Ct-231
[**2134-9-24**] 09:15AM BLOOD WBC-9.3 RBC-3.41* Hgb-9.2* Hct-28.4*
MCV-83 MCH-27.0 MCHC-32.4 RDW-13.9 Plt Ct-229
[**2134-9-23**] 06:15AM BLOOD PT-14.1* PTT-27.9 INR(PT)-1.2*
[**2134-9-23**] 06:15AM BLOOD Plt Ct-222
[**2134-9-24**] 09:15AM BLOOD Plt Ct-229
[**2134-9-20**] 06:17PM BLOOD PT-15.5* PTT-33.7 INR(PT)-1.4*
[**2134-9-20**] 06:17PM BLOOD Plt Ct-231
[**2134-9-24**] 09:15AM BLOOD Glucose-272* UreaN-18 Creat-0.8 Na-139
K-4.0 Cl-102 HCO3-29 AnGap-12
[**2134-9-20**] 06:17PM BLOOD Glucose-235* UreaN-27* Creat-0.9 Na-138
K-3.5 Cl-97 HCO3-33* AnGap-12
[**2134-9-20**] 10:38PM BLOOD CK(CPK)-18*
[**2134-9-21**] 05:44AM BLOOD CK(CPK)-26
[**2134-9-22**] 05:43PM BLOOD CK(CPK)-40
[**2134-9-23**] 06:15AM BLOOD CK(CPK)-219*
[**2134-9-23**] 03:52PM BLOOD CK(CPK)-175*
[**2134-9-20**] 10:38PM BLOOD CK-MB-NotDone cTropnT-0.18*
[**2134-9-21**] 05:44AM BLOOD CK-MB-3 cTropnT-0.26*
[**2134-9-22**] 05:43PM BLOOD CK-MB-NotDone
[**2134-9-23**] 06:15AM BLOOD CK-MB-26* MB Indx-11.9*
[**2134-9-23**] 03:52PM BLOOD CK-MB-17* MB Indx-9.7*
[**2134-9-23**] 06:15AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.9
[**2134-9-24**] 09:15AM BLOOD Mg-2.3
[**2134-9-20**] 12:45PM BLOOD Type-ART pO2-125* pCO2-46* pH-7.45
calTCO2-33* Base XS-7
.
[**9-21**] Urine cult no growth
.
[**9-20**] Cath:
1. Selective coronary angiography of this right dominant system
revealed severe diffuse coronary artery disease. The LMCA had
diffuse
calcification. The LAD was diffusely diseased, and was occluded
mid
segment. The LCx had severe diffuse disease with a 90% stenosis
of the
OM. The RCA was a dominant vessle with severe diffuse disease
througout.
2. Coronary angiography of the bypass grafts revealed an
occluded SVG to
D1 and an occluded SVG to RPDA. The LIMA to LAD graft was
patent.
3. The left subclavian artery was occluded proximal to the LIMA.
4. Resting hemodynamics were performed. The right sided filling
pressures were normal (Mean RA pressure was 5 mm Hg and RVEDP
was 7 mm
Hg). The pulmonary atery pressures were within the normal range,
measuring 30/9 mm Hg. The left sided pressures were normal, with
a mean
PCW pressure of 12 mm Hg. The systemic arterial pressures were
elevated
with a systolic pressure of 150-170mm Hg. The cardiac index was
calculated using FIck's principle with an assumed oxygen
consumption
index of 125 ml O2/min/m2, and was mildly decreased at 2.2
L/min/m2.
5. Left ventriculography revealed a depressed ejection fraction
of 36%.
There was no gradient across the aorta on pullback of the
catheter from
the left ventricular into the ascending aorta.
6. Successful PTA and stenting of the left subclavian artery
with two
overlapping stents. Final angiography revealed 0% residual
stenosis and
normal LIMA flow.
7. Arterial extravasation at the forearm without hand ischemia.
Normal
radial and ulnar pulses and no evidence of compartment syndrome.
FINAL DIAGNOSIS:
1. Diffuse three vessel coronary artery disease with occluded
SVG to D1,
occluded SVG to RPDA and patent LIMA to LAD
2. Left subclavian artery occlusion with PTA/stent x 2.
3. Systolic ventricular dysfunction with a depressed ejection
fraction
of 36%.
4. Successful stenting of the left subclavian artery with two
overlapping stents and normal LIMA flow.
.
Cardiac cath [**9-22**]:
COMMENTS:
1. Selective angiography of the left subclavian demonstrated
two widely
patent stents with normal flow throughout. Angiography of the
left
upper extremity demonstrated a an ulnar artery that filled the
left hand
and backfilled the proximal portion of the occluded radial
artery.
2. Selective angiography of the native coronary arteries
demonstrated
diffusely diseased three (3) vessel disease. The left anterior
descending artery was occluded proximally and was known to fill
by a
patent LIMA-LAD graft. The right coronary artery was diffusely
diseased
with a tight 95% proximal - ostial lesion. The left circumflex
demonstrated a diffusely diseased artery with a 99% lesion in
the second
obtuse marginal.
3. We did engage the saphenous vein grafts - the graft to the
RCA was
known to be occluded and the graft to the LCX was also known to
be
occluded proximally.
4. Successful PTCA and stenting of the 2nd obtuse marginal from
the
site of the SVG anastomosis to the bifurcation with the native
LCX
proximally with three overlapping Xience drug eluting stents
(2.5x12mm;
2.5x18mm; 2.5x18mm). Final angiography demonstrated no
angiographically
apparent dissection; no residual stenosis and TIMI III flow
throughout
the vessel (See PTCA comments).
5. Successful PTCA and stenting of the ostial-mid RCA with four
overlapping Xience drug eluting stents (2.5x18mm; 2.5x23mm;
2.5x23mm;
and 2.5x8mm). Final angiography demonstrated no
angiographically
apparent dissection, no residual stenosis and TIMI III flow
throughout
the vessel (See PTCA comments).
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Successful PTCA and stenting of the RCA with multiple drug
eluting
stents.
3. Successful PTCA and stenting of the LCX with multiple drug
eluting
stents.
4. Widely patent left subclavian stents. An occluded left
brachial-radial artery with a widely patent ulnar artery
supplying the
hand and backfilling the proximal portion of the radial artery.
.
Brief Hospital Course:
A+P [**2134-9-23**]: 67 y/o with CAD s/p CABG and PCI to subclavian,
PVD, CHF who presented to OSH with CHF exacerbation, NSTEMI.
Course complicated by left raidal artery perf, UTI, TIA symptoms
at SBP < 130. Triggered for TIA like symptoms in setting of SBP
of 90s
#. CAD: Patient is s/p CABG with severe multi-vessel disease.
Patient ruled in for NSTEMI at OSH and was transferred for
intervention. Trigger of CHF exacerbation was likely ischemic in
the setting of graft found down. CABG graft was revascularized
by angioplasty and stents x 2 to the proximal and distal
subclavian vein. Final resisual s/p stenting was 0% with normal
flow returned to [**Female First Name (un) 899**] and LBA. On [**9-22**] a total of 7 stents to
LCx and RCA were placed, see full report above.
After the [**9-22**] cath the patient had [**8-12**] Left should pain
without rad, N/V, mild right shoulder pain. Prior to CABG
presented with upper back pain. This pain is different, and
responded to vicodin and repositioning. No EKG changes.
The patient becamde orthostatic at times after cath, this
improved with fluid bolus. On the day of discharge the pt was
no longer orthostatic and able to ambulate without TIA symptoms
On discharge she was continued on Plavix 75 mg PO x 12 months,
ASA 325 mg daily, beta-blocker, high dose statin.
.
#. Pump: Acute on chronic systolic congestive heart failure:
Patient presented with CHF exacerbation and found to have
depressed ejection fraction in the setting of cardiac ischemia.
Symptoms improved after multiple cardiac cath interventions.
During cath EF measured at 36%. Patient may need echo as outpt
to access for functional status and change in EF. During
hosptialization the patient was continued on beta-blocker. The
patient is likely to benefit from addition of AceI; however, BP
will not tolerate at this time. With blood pressure's less than
130/90 patient is at risk of TIA symptoms and actually requires
Florinef to assure her BP is maintained near this range. The
patient did not require diuresis during this hospitalization.
On discharged she was continued on her beta blocker. ACE
inhibitor should be added to the outpt regimen if possible.
.
# Rhythm: During the first cardiac cath the catheter perforated
a branch of left radial artery. Heparin was stopped. While arm
was being compressed, patient became bradycardic to 30's, BP
unknown. CPR was initiated x 20 seconds. Atropine was given and
heart rate to 150's. This episode is likely secondary to vagal
episode, with return of perfusing rhythm after atropine. On
transfer to the floor she was closely monitored on telemetry.
The patient did not have any further bradycardia and remained in
NSR.
.
# Left radial artery performation: Resulted as a complication
to the first cardiac cath. Hand Surgery was consulted in house.
They stated no indication for extremity vascular reconstruction
at present given multiple comorbidities. The patient underwent
serial exams of left upper extremity to monitor for compartment
syndrome. In the days following catheterization the Left Radial
pulse returned, up to 1+, although it was felt strongest in the
mid forearm. She continued to have mild forearm swelling, but
FROM without evidence of compartment syndrome. She maintained a
ulnar pulse with normal capillary refill in all fingers. She
received warm compresses to forearm for comfort. Hand surgery
signed off saying she could f/u as an outpatient on an as needed
basis.
.
# h/o TIA: Patient has a history of TIAs due to r/t left
carotid occlusion (Patient has known occlusion of left internal
carotid artery intracranially at the level of the opthalmic
artery, and she has had multiple TIAs from this occlusion.
Patient develops TIAs when her BP becomes too low, and thus she
requires SBPs ~130s to maintain perfusion. Patient is on
Florinef due to low BP causing TIA symptoms r/t carotid. During
time on floor the patient triggered for TIA symptoms, R sided
facial weakness/droop and slurred speeh, in setting of SBP 90.
Resolved with trendelenburg and IVF bolus which improved the BP
to the 130s. Neurology saw the patient and suggested non-con
CT head and Carotid US, but decided against since episode same
as previously documented and Carotids patent on cath 2 days
prior to TIA. Continue to Maintain SBP>130, per outpatient
Neurology recs. Continue Florinef .2 qpm, to maintain BP. On day
of discharge patient was no longer orthostatic with SBP stable
in 130s to 140s. Pt was able to ambulate without large drop in
BP and was free of her TIA symptoms. As an outpatient the need
to continue florinef at .2 dosage should be discussed. The
patient previously became hypertensive to 170s on this dosage.
.
# UTI: Patient diagnosed at OSH with UTI, s/p 3 days of
levofloxacin prior to transfer. [**9-21**] UA showed large blood, 1000
glucose, leuk neg, nitrate neg and urine culture [**9-21**] showed no
growth. The patient was without symptoms of UTI and no further
treatment was given.
.
#. Diabetes: Treated with SSI, held glyburide in house.
Restarted glyburide on discharge.
.
#. FEN: DM, cardiac diet
.
#. PPx: pneumoboots, no heparin SQ [**3-6**] heparin "alergy" [**3-6**]
Intracranial hemmorage. Continued PPI per home regimen.
.
#. Code status: Full code, confirmed with patient and husband at
time of admission to CCU.
Medications on Admission:
Neurontin 200 mg TID
Asa 325 mg daily
Plavix 75 mg daily
40mg of nexium
Levaquin 500 mg (for UTI)
Lopressor 12.5 mg [**Hospital1 **]
1 inch of nitro paste
Glyburide 10 mg [**Hospital1 **]
Florinef 0.1 mg daily
Simvastatin 10 mg daily
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed): take one pill at onset of
chest pain, may repeat in five minutes for a total of 3 NTG.
Please call your doctor or go to the ED if you need to take this
medicine.
Disp:*1 bottle* Refills:*2*
5. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Fludrocortisone 0.1 mg Tablet Sig: Two (2) Tablet PO DAILY AT
8 P.M. ().
Disp:*60 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day.
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern MA
Discharge Diagnosis:
Primary Diagnoses:
NSTEMI
Acute on chronic systolic heart failure
TIA [**3-6**] left internal carotid stenosis and hypotension
orthostatic hypotension
peripheral vascular disease
Secondary Diagnoses:
Diabetes Mellitus
Discharge Condition:
good
Discharge Instructions:
You were transfered to [**Hospital1 18**] for management of your heart attack
(NSTEMI) and heart failure (CHF). You underwent 2 separate
catheterzations in which 2 stents were placed in an artery in
your left arm, and 7 additional stents were placed in the
arteries in your heart. These procedures were successful in
improving the blood flow through your heart. Your heart failure
improved with diuresis at the outside hospital.
You had injury to your left radial artery during one of the
cathiterzation. However it is improving and your pulse has
returned. You should follow up with Dr [**First Name (STitle) 10378**] for this and your
TIAs.
You had a episode of symptoms consistant with TIA following a
low blood pressure. If you experience a return of Right sided
weakness or slurred speech you should call your doctor or return
to the emergency room. You should discuss you florinef dose with
your PCP.
Medications:
1) Your Florinef was increased to 0.2mg daily to help maintain
your blood pressure.
2) Your simvastatin was increased to 80mg daily.
All other medicines are the same as prior to admission.
As you know it is very important for you to continue to take
your Plavix every day to prevent your heart stents from closing
which could cause another heart attack and even death.
Please follow up as below.
For arm or back pain take 2 extra strengh tylenol every [**5-9**]
hours. Call your PCP if the pain is severe.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight increases > 3
lbs.
Adhere to 2 gm sodium diet
Please call your doctor or return to the hospital if you
experience any concerning symptoms including chest pain, light
headedness, dizziness, persistance of your TIA symptoms or any
other new symptoms.
Followup Instructions:
You have a follow up appointment with The nurse [**First Name (Titles) 3525**] [**Last Name (Titles) 10379**]n at Dr[**Name (NI) 10380**] office [**2134-10-7**] at 11am ([**Telephone/Fax (1) 10381**])
You need to make an appointment with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for
cardiology follow up ([**Telephone/Fax (1) 3183**]) within two weeks of
discharge
You have an appointment with Dr [**First Name (STitle) 10378**] (vascular)([**Telephone/Fax (1) 10382**])
[**2134-10-12**] at 11:15am for follow up of your TIA and left radial
artery.
Completed by:[**2134-10-4**]
ICD9 Codes: 4280, 4439, 2724, 4019, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1108
} | Medical Text: Admission Date: [**2116-5-6**] Discharge Date: [**2116-5-12**]
Date of Birth: [**2043-8-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2116-5-8**] Redo Sternotomy, Redo Coronary Artery Bypass Grafting
with saphenous vein grafts to left anterior descending, obtuse
marginal, and right coronary arteries.
History of Present Illness:
Mr. [**Known lastname **] is a 72 year old male s/p CABG in [**2114**], graft failure
[**2115-4-11**] undergoing cypher(DES) stenting of LAD and LCx, and
three prior Vision (BMS) placed in mid and proximal LAD and one
to the proximal circumflex arteries. He recently presented to
[**Hospital6 **] with precordial chest "heaviness" [**9-20**],
on [**2116-5-5**]. He concomitantly had shortness of breath with chest
pain but denied nausea, vomiting, diaphoresis, and presyncope.
No radiation of pain. He was noted to have new 2mm ST
depressions v4-v6, TWI v3-v6. He received IV morphine, NTG x3,
and was started on weight based enoxaparin regimen. He was
already on Plavix. Pain was controlled to point where he was
chest pain free in ED. He ruled in for a NSTEMI. Initial neg
trop 0.04, that rose to 1.26, then 1.34. CK peak at OSH was 94.
He was stablized on medical therapy and was transferred to [**Hospital1 18**]
after diagnosis of NSTEMI so that he could be managed by his
primary cardiologist Dr. [**First Name (STitle) **]. On arrival to [**Hospital1 18**], patient
was chest pain free. Pt had ECG w/ new 1-2mm ST elevation in
V1-V2, and 2mm ST depression v4-v6, TWI v3-v6. 1mm ST depression
and TWI in I & avl are old. Pt was started on Heparin and
Integrillin on arrival to [**Hospital1 18**].
Past Medical History:
Coronary Artery Disease, History of CABG [**2114**]
(LIMA to LAD, SVG to RCA, sequential SVG to D1 and OM1)
Recent NSTEMI [**2116-4-11**]
Ischemic Cardiomyopathy/Chronic Systolic Heart Failure
Hypertension
Elevated Cholesterol
Type II Diabetes Mellitus
History of renal cancer status post left nephrectomy in [**2105**].
History of bilateral cataracts with repair.
Social History:
Patient is originally from [**Country 11150**], where he worked in
agriculture. He denies ever smoking, drinking etoh or using
illicit drugs. He came to the US in [**2094**], but returns frequently
to [**Country 11150**]. Last trip to [**2116-3-13**]. Pt lives with son and wife in
[**State 350**].
Family History:
Family history is significant for a brother with a CABG at the
age of 65. Parents died of old age.
Physical Exam:
PREOP EXAM:
VS - T 96.7, BP 109/49, HR 63, RR 16, 97% RA.
Gen: Indian male, No chest pain, resting comfortably.
HEENT: NCAT. PERRL, EOMI. Conjunctiva were pink, good dental
hygeine
Neck: Supple with JVP of 12 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: Crackles at the bases bilaterally. poor air movement. No
rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No edema. Nontender, 1+ weak DP/PT bilat.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+
Discharge
VS T98.4 HR 104ST BP 109/57 RR 18 O2sat 96% 2LNP
Gen NAD
Neuro Alert, orientedx3, non focal exam
Pulm CTA bilat
CV RRR-tachy, sternum stable, incision CDI
Abdm soft NT/+BS
Ext warm well perfused. 1+ pedal edema bilat
Pertinent Results:
[**2116-5-7**] Cardiac Cath:
1. Limited coronary angiography of this right dominant system
demonstrated severe three (3) vessel coronary artery disease.
The right
coronary artery was diffusely diseased with pressure damping
upon
engaging. The RCA had a 70% proximal lesion. The left main was
diffusely diseased with a 70% distal lesion. The left
circumflex
demonstrated 70% in-stent restenosis of the proximal stent. The
left
anterior descending artery was diffusely diseased with a tight
95%
proximal lesion along with serial 90% in-stent restenotic
lesions in the
proximally placed stent.
2. Arterial conduit angiography was deferred - LIMA-LAD known
atretic.
Venous conduit angiography was also deferred since both grafts
known to
be occluded.
3. LV ventriculography was deferred.
4. Limited resting hemodynamics demonstrated moderate central
aortic
(160/73mm Hg) hypertension.
[**2116-5-7**] Carotid Ultrasound:
Less than 40% internal carotid artery stenosis bilaterally.
Findings suggesting distal left vertebral artery occlusion.
[**2116-5-8**] Intraop TEE:
Pre-CPB: No spontaneous echo contrast is seen in the left atrial
appendage. Overall left ventricular systolic function is
severely depressed (LVEF= 20 - 25 %). There moderate global RV
hypokinesis. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are moderately
thickened. Mild to moderate ([**2-12**]+) mitral regurgitation is seen.
There is no pericardial effusion.
Post- CPB: The patient is on an infusion of Epinephrine. RV
systolic fxn is normal. LV systolic fxn is moderately globally
depressed. MR is 1+.
No AI. Aorta intact.
[**2116-5-6**] 06:10PM BLOOD WBC-6.8 RBC-4.27* Hgb-13.1* Hct-38.6*
MCV-90 MCH-30.7 MCHC-34.0 RDW-12.3 Plt Ct-126*
[**2116-5-6**] 06:10PM BLOOD PT-15.3* PTT-45.6* INR(PT)-1.3*
[**2116-5-6**] 06:10PM BLOOD Glucose-180* UreaN-19 Creat-1.3* Na-140
K-4.8 Cl-105 HCO3-27 AnGap-13
[**2116-5-6**] 06:10PM BLOOD ALT-19 AST-21 CK(CPK)-66 AlkPhos-58
[**2116-5-6**] 06:10PM BLOOD CK-MB-NotDone cTropnT-0.09*
[**2116-5-7**] 12:30AM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2116-5-7**] 04:00AM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2116-5-6**] 06:10PM BLOOD Albumin-3.4 Calcium-8.7 Phos-2.5* Mg-2.1
[**2116-5-7**] 11:50AM BLOOD %HbA1c-7.5*
[**2116-5-12**] 09:19AM BLOOD Hct-25.5*
[**2116-5-12**] 04:33AM BLOOD Plt Ct-109*
[**2116-5-11**] 03:36AM BLOOD PT-17.2* PTT-35.0 INR(PT)-1.6*
[**2116-5-12**] 04:33AM BLOOD Glucose-185* UreaN-29* Creat-1.5* Na-134
K-3.8 Cl-100 HCO3-29 AnGap-9
RADIOLOGY Preliminary Report
CHEST (PA & LAT) [**2116-5-12**] 2:02 PM
CHEST (PA & LAT)
Reason: ? effusion
[**Hospital 93**] MEDICAL CONDITION:
72 year old man with s/p cabg
REASON FOR THIS EXAMINATION:
? effusion
HISTORY: Status post CABG.
FINDINGS: In comparison with study of [**5-11**], the chest tubes have
been removed. No evidence of acute pneumothorax. Extensive
opacification at the left base is consistent with pleural fluid
and underlying atelectasis, though the possibility of
supervening pneumonia cannot be excluded.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
Brief Hospital Course:
Pt is a 72 y/o M w/ DM, HTN, s/p CABGx4V [**2114**], graft failure
[**4-17**],w/ multiple stents, most recent cath shows occluded SVGs
and LIMA-LAD arterial conduit, who is transferred to [**Hospital1 18**] from
OSH w/ NSTEMI,
Cardiac Cath: [**5-7**]
LMCA: Distal 70% lesion
LAD: Origin 95% lesion w/ serial 90% lesion ISRS in the previous
DES. The origin D1 has mild restenosis.
LCX: Non-Dominant vessel w/ 70% origin ISRS in the previous DES.
The OM1 origin is widely patent.
RCA: Dominant vessel with proximal 70% lesion at previous mild
lesion. There are r-l collaterals to the LAD and distal OM.
.
#Pump: Patients last echo [**10-18**] showed EF of 35-40%, with mild to
moderate regional left ventricular systolic dysfunction with
hypokinesis of the inferolateral and inferoseptal walls and
apex.
Cardiac Surgery
Pt brought to operating room for redo CABG on [**5-8**]. Please see
OR note for details, in summary patient had redo CABG x3 with
SVG>LCX, SVG>LAD, SVG>PDA, his bypass time was 109 minutes with
a crossclamp of 74 minutes. He did well in the immediate postop
period, was kept sedated throughout the night and was extubated
on POD #1. Additionally his swan was removed. His mediastinal
tubes were taken out POD #2. Cordis was replaced with a triple
lumen catheter due to difficulty with peripheral access. Pt was
transferred to the floor on POD #3. Once on the floor he had an
uneventful post operative course, his activity level was
advanced and medications adjusted. On POD4 it was decided he was
ready for discharge to rehabilitation at Palm [**Hospital 731**]
rehabilitation in [**Location (un) 15749**], MA
Medications on Admission:
-Aspirin 325 mg once daily
-Imdur 30 once daily
-Plavix 75 once daily
-Zocor 40 once daily
-Diovan 80 mg daily
-Toprol 150 mg daily
-Feosol 65 mg daily
-insulin per protocol
-Colace 100 mg daily
-senna 2 mg daily
-sublingual nitroglycerin 0.03 mg p.r.n.
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:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 10 days: then 20mg QD.
8. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 10 days: then 20mEq QD.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
15. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily):
75mg total.
16. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
17. Lantus 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous at bedtime.
18. Humalog 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous Q breakfast/lunch/dinner.
19. Insulin Regular Human 100 unit/mL Solution Sig: sliding
scale Injection QAC&HS.
Discharge Disposition:
Extended Care
Facility:
Palm [**Hospital 731**] Nursing Home
Discharge Diagnosis:
Coronary Artery Disease, History of CABG [**2114**] - s/p Redo
CABGx3(SVG-LAD,SVG-OM,SVG-RCA)[**5-8**]
Ischemic Cardiomyopathy/Chronic Systolic Heart Failure
Recent NSTEMI [**2116-4-11**]
Hypertension
Elevated Cholesterol
Type II Diabetes Mellitus
History of Renal Cancer, s/p Left Nephrectomy
Discharge Condition:
Good
Discharge Instructions:
1)Please shower daily. No baths. Pat dry incisions, do not rub.
2)Avoid creams and lotions to surgical incisions.
3)Call cardiac surgeon if there is concern for wound infection,
redness or drainage from wound.
4)No lifting more than 10 lbs for at least 10 weeks from
surgical date.
5)No driving for at least one month.
Followup Instructions:
Dr. [**Last Name (STitle) **] in [**5-16**] weeks, call for appt
Dr. [**First Name (STitle) **] in [**3-15**] weeks, call for appt
Dr. [**Known lastname **] in [**3-15**] weeks, call for appt
Completed by:[**2116-5-12**]
ICD9 Codes: 2859, 4280, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1109
} | Medical Text: Admission Date: [**2124-11-21**] Discharge Date: [**2124-11-28**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Fall down stairs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
87-year-old Greek-speaking male s/p unwitnessed fall down 10
stairs on Coumadin. +LOC of 2 minutes. Taken to OSH and found to
have C6 facet frature and large scalp laceration + frontal
fracture. Here at [**Hospital1 18**] found to have small SDH. Patient does
not recall the fall. Daughter states that he has lightheadedness
and syncope often and has had a thorough work-up at [**Hospital3 2568**]
including MRI/CT scan/cardiac tests.
Injuries: small SDH, Right frontal bone fracture (nondepressed),
C6 facet fracture, large scalp laceration, Right coracoid
process fracture
Past Medical History:
- CABG -[**2094**] on coumadin
- HTN
- rhinitis
- GERD
Social History:
Daughter involved in his care.
Married
Family History:
Non-contributory.
Physical Exam:
Upon presentation to [**Hospital1 18**]:
O: T: BP: 136/86 HR: 78 R:18 O2Sats:94%
Gen: WD/WN, comfortable, NAD.
HEENT: Large skin avulsion R frontal skull, currently being
sutured under sterile technique with plastics. Per plastics,
flap
went down to galia, and no skull was observed. Irrigated with
1l
NS. Pupils: [**2-14**] EOMs intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, knows she is in a hospital.
Year
[**2124**].
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, 2 to 1
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-17**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Pertinent Results:
CT head ([**2124-11-21**])
1. nondepressed skull fracture of R frontal bone extending to
middle cranial fossa with small extraaxial collection tracking
along it, measuring 6 mm at its thickest portion in the middle
cranial fossa.
2. R frontal scalp lac & subgaleal hematoma.
3. L frontal meningioma, 3.5 x 2.1 x 4.4 cm
CT c-spine ([**2124-11-21**])
1. fracture of R superior facet of C6
2. normal alignment and prevertebral soft tissues
CT torso ([**2124-11-21**])
1. no intrathoracic or intrabdominal injury
2. R coracoid process fracture
3. s/p midline sternotomy, enlarged R atrium
CT head ([**2124-11-22**])
Stable appearence of small extraaxial collection immediately
adjacent to a
right frontal bone fracture. Stable left frontal meningioma.
Right
frontal scalp lacerations and hematoma.
[**2124-11-21**] 02:30PM BLOOD cTropnT-<0.01
[**2124-11-21**] 02:30PM BLOOD PT-23.9* PTT-30.2 INR(PT)-2.3*
[**2124-11-22**] 01:37AM BLOOD PT-17.9* PTT-26.5 INR(PT)-1.6*
[**2124-11-21**] 02:30PM BLOOD WBC-7.4 RBC-3.39* Hgb-10.7* Hct-32.5*
MCV-96 MCH-31.5 MCHC-32.8 RDW-14.0 Plt Ct-201
[**2124-11-22**] 01:37AM BLOOD WBC-11.9*# RBC-2.78* Hgb-9.1* Hct-26.1*
MCV-94 MCH-32.6* MCHC-34.7 RDW-14.1 Plt Ct-136*
Brief Hospital Course:
He was admitted to the trauma ICU from the ED. His scalp wound
was closed by Plastics. Neurosurgery evaluated him and
recommended Dilantin load, C-collar, reversing his INR and
repeat head CT the following morning, which was done and stable.
His Coumadin was withheld.
On HD2 he was advanced to a regular diet and after evaluation by
neurosurgery was felt to be stable for transfer to the floor. He
remained on the Dilantin for 7 days and it was stopped.
Once transferred to the regular nursing unit and because of his
high risk for falls he was placed in a special low bed with mats
on floor beside his bed; chair and bed alarms were also
instituted. He did unfortunately sustain an unwitnessed fall out
of his low bed onto the mat. A repeat head CT scan was done
which showed no new intracranial injury; stable to minimally
decreased small extra-axial hemorrhage overlying the right
frontal lobe extending into the middle cranial fossa with an
associated non depressed skull fracture, right frontal subgaleal
hematoma unchanged, left frontal calcified meningioma was
stable. His mental status during his hospital stay has been
intermittently confused, he is oriented x1-2; his primary
language is Greek, although he does understand and speak some
English. The language barrier is likely contributing to some of
his disorientation as well.
His Coumadin was not restarted at time of discharge; given his
risk for falls and the subdural hemorrhage it should be
carefully determined by his primary providers as to resuming his
previous anticoagulation.
He was evaluated by Physical therapy and it was determined that
he would require rehab after his acute hospital stay. he was
screened for rehab by case management and discharged on hospital
day 8. He will follow up with Neurosurgery and Plastics as an
outpatient.
Medications on Admission:
fluticasone, lisinopril 10mg QD, furosemide 40mg QD
warfarin 2mg QD, Nadolol 40mg QD, Allopurinol 300mg PO,
Omeprazole 20mg PO
Discharge Medications:
1. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
9. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
Bear [**Doctor Last Name **] Nursing Center - [**Location (un) 2199**]
Discharge Diagnosis:
s/p Fall
C6 facet fracture
Scalp laceration
Nondepressed right frontal bone fracture
Subdural hematoma
Right coracoid process fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Your cervical collar must be worn at all times until follow up
with neurosurgeon in clinic.
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking if you are safe to do
so; no lifting, straining, or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel) prior to your injury and the medication was
stopped because of your bleeding brain injury, you should not
resume this medication until you follow up with your primary
care doctor.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you haven been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 548**] Neurosurgery in [**4-18**] weeks for a repeat
head and cervical spine CT scans. Call [**Telephone/Fax (1) 2992**] for an
appointment.
Follow up in [**1-15**] weeks in [**Hospital 3595**] clinic, call [**Telephone/Fax (1) 5343**] for
an appointment.
Completed by:[**2124-11-28**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1110
} | Medical Text: Admission Date: [**2102-5-15**] Discharge Date: [**2102-6-7**]
Date of Birth: [**2025-6-25**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins / amlodipine
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Headache and hypertension
Major Surgical or Invasive Procedure:
[**2102-5-15**] Right EVD placement
[**2102-5-16**] CEREBRAL ANGIOGRAM WITH COILING OF LEFT PCOMM
ANEURYSM
[**2102-5-30**] Right VP shunt placement
History of Present Illness:
This is a 76 year old female h/o SAH and coiling of PCA aneurysm
by Dr [**First Name4 (NamePattern1) **] [**2101-6-23**] with complete third nerve palsy. The
patient presented to [**Hospital6 204**] c/o headache and
was found to have a blood pressure of 220/120, vomiting and
aphasia. She was awake and able to follow commands. The
patient's mental status declined and she was intubated for
airway protection. The Head CT was obtained and it showed
diffuse subarachnoid hemorrhage with
intraventricular hemorrhage involving the lateral, third, and
fourth ventricles. The patient was transferred here for further
management and neurosurgical evaluation.
Past Medical History:
1. HTN
2. DM
3. Hypercholesterolemia
Social History:
Social Hx: Originally from [**Country **] and lives with daughter.
Does not work and no smoking or EtOH hx. Full code per
daughter/HCP, [**Name (NI) **] [**Telephone/Fax (1) 86893**].
Family History:
Parents hx unknown - no early deaths per
Physical Exam:
Hunt and [**Doctor Last Name 9381**]: grade V [**Doctor Last Name **]: grade 4 GCS:5T E:1 V:1T Motor:3
Gen:intubated non responsive
HEENT: Pupils: left pupil 4mm Non reactive, right pupil 3 mm
sluggish reaction
EOMs: unable to test
Neuro:
Mental status/Orientation:GCS:5T
Recall/Language: unable to test
Cranial Nerves:
I: Not tested
II: Pupils asymmetric. left pupil 4mm Non reactive, right pupil
3
mm sluggish reaction.
mm bilaterally. Visual fields-unable to test
III, IV, VI: Extraocular movements- unable to test
V, VII: Facial strength and sensation- unable to test
VIII: Hearing- unable to test
IX, X: Palatal elevation- unable to test
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius- unable to test
XII: Tongue midline-unable to test
Motor: posturing in upper extremities and flexes and withdraws
lower extremities minimally. Pronator drift- unable to test
Sensation:unable to test
Toes- mute
Coordination:unable to test
Discharge Exam:
EO to voice. [**Last Name (LF) 87009**], [**First Name3 (LF) **] say hello at times. MAE
spont/purposefully, follows commands at times to visual cues,
Non-English speaking. Incision C/D/I with sutures and staples.
Pertinent Results:
CT head [**5-15**]:
1. No significant change in the degree of subarachnoid
hemorrhage within the basal cisterns or quantity of
intraventricular hemorrhage.
2. Increased left parafalcine and unchanged bilateral tentorium
cerebelli
SDH.
3. Diffuse cerebral edema, especially in the brainstem, with
associated
herniation of the cerebellar tonsils.
4. Stable enlargement of the ventricles with new ventriculostomy
catheter as noted above.
Echo [**5-16**] - The left atrium is elongated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Head CTA [**2102-5-19**]:
IMPRESSION:
1. Status post recent placement of right transfrontal
ventriculostomy
catheter, in stable position; however, there has been a minimal
increase in the size of, particularly, the left lateral and
third ventricle, despite the decrease in the overall amount of
intraventricular blood.
2. Interval slight decrease in the amount of cerebral edema and
the left
parafalcine and tentorial subdural hematoma.
3. Status post coiling of left PCom aneurysms, limiting their
evaluation;
however, no new vascular stenosis, occlusion, or aneurysm larger
than 2 mm is identified.
4. Redemonstration of the relatively hypoplastic posterior
circulation;
allowing for this, there is no finding to specifically suggest
acute
vasospasm.
Head CTA [**2102-5-20**]:
IMPRESSION:
1. No new intracranial hemorrhage.
2. No specific evidence of acute vascular territorial
infarction.
3. Stable-to-slightly increased ventriculomegaly, despite the
presence of the recent right transfrontal EVD (which has been
clamped, according to the given history) with evidence of
interstitial edema, consistent with underlying hydrocephalus.
4. No change in the overall appearance of the cerebral vessels,
with no
finding to specifically suggest acute cerebral vasospasm
MRI Brain [**2102-5-20**]:
IMPRESSION:
Subarachnoid and intraventricular hemorrhage and
ventriculomegaly is
unchanged. Probable subacute ischemia in the left posterior
temporal/occipital lobe.
CTA Head [**2102-5-24**]:
IMPRESSION:
1. No definite evidence of vasospasm, flow-limiting stenosis,
occlusion, or aneurysm greater than 2 mm within the anterior or
posterior intracranial arterial circulations. N.B. The
assessment of the posterior circulation is somewhat limited by
the intrinsically small-caliber of these vessels, not
significantly changed over the series of studies.
2. No acute large vascular territorial infarction.
3. Decreased subarachnoid hemorrhage overlying the cerebral
hemispheres and resolved hemorrhage within the basal cisterns.
Decreased subdural hematoma overlying the left leaflet of the
tentorium cerebelli. Intraventricular hemorrhage is decreased in
the left occipital [**Doctor Last Name 534**] and unchanged in the right occipital
[**Doctor Last Name 534**].
4. Minimal decrease in size of the lateral ventricles with
unchanged size of the third ventricle.
LENIS BLE [**2102-5-25**]:
IMPRESSION:
No evidence of DVT in right or left lower extremity.
Head CT [**2102-5-27**]:
IMPRESSION:
1. No new focal hemorrhage.
2. Status post removal of a right frontal approach shunt
catheter with
persistent hydrocephalus. Allowing for differences in
measurements, there may be diffuse increased caliber of the
ventricular systems, suggestive of
increased obstruction.
In particular, note is made of new periventricular
hypoattenuation,
particularly about the frontal horns, suggestive of
transependymal CSF flow.
Head CT [**2102-5-28**]:
CONCLUSION: Stable appearance since previous CT.
Head CT [**2102-5-29**]:
IMPRESSION:
1. Hydrocephalus with transependymal flow of CSF; although not
changed from two most recent studies, this is clearly worse
since the studies of [**2102-5-20**] and [**2102-5-24**].
2. Stable intraventricular hemorrhage.
Head CT [**2102-5-31**]:
IMPRESSION:
Only mild decrease of ventricular size status post right frontal
approach VP shunt placement. The catheter tip lies within the
right frontal [**Doctor Last Name 534**] and is surrounded by hyperdense blood clot.
Unchanged hemorrhage in the occipital horns.
Head CT [**2102-6-2**]:
Decrease in ventricular size.
Head CT [**2102-6-4**]:
IMPRESSION:
1. Stable ventriculostomy tip position in the right frontal
lateral
ventricle. Progressively decreased ventricular size.
2. Improvement in intraventricular hemorrhage.
3. New left frontal subdural hygroma. Please correlate whether
there may be a possibility of overshunting.
Head CT [**2102-6-5**]:
IMPRESSION: Stable ventricular size with right frontal approach
ventriculostomy catheter. Grossly unchanged exam with slight
decrease in size of left frontal subdural hypodense collection.
Head CT [**2102-6-6**]:
Stable ventricular size with right frontal approach
ventriculostomy catheter. Stable left frontal hypodense
subdural collection.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to neurosurgery on [**2102-5-15**] for further
management. While in the [**Last Name (LF) **], [**First Name3 (LF) **] EVD was placed in routine
fashion. CT head demonstrated placement of EVD with stable
hydrocephalus and diffuse SAH. Discussed with family about poor
prognosis given his Diffuse SAH, extensor posturing and GCS of
5T on arrival. His code status was updated to only chemical
code only. On [**5-16**], he was taken for a cerebral angiogram and
coiling of PComm aneurysm. She tolerated procedure well without
complications. She was trasnferred back to ICU for further
management. Her EVD was increased to 15cmH2O. She was
extubated without incident on [**2102-5-17**]. Her neurological status
improved during her course. She started following commands and
moved all extremities purposefully. She had a speech and
swallow evaluation which she failed on [**5-18**] and [**5-19**].
An attempt was made to wean her EVD on [**5-19**] to [**5-20**]. Her EVD was
reopened on [**5-20**] when a CT showed a slight amount of enlargement
in her ventricles and she was found to be extremely lethargic on
exam. Her Dilantin level was also noticed to be 19 and [**Last Name (un) **] for
a number of doses.
On exam on [**5-20**] and [**5-21**] we found the patient lethargic and not
moving her right upper extremity. TCDS,CTA and an MRI were
prerformed to rule out vasospasm and stroke, all of which were
esentially negative and did not explain her lack of movement.
She spontaniously started moving her right arm the afternoon of
[**5-21**]. and on the morning of [**5-22**] she was much brighter and
brisker with her commands.
She continued to do well and a clamping trial was again pursued.
On [**2102-5-24**], she was transfused 1 unit PRBC for HCT 20.1 with a
repeat Hct of 22.8 and additional unit was given and hct was
27.8. Head CTA was repeated without sign of hydrocephalus or
vasospasm. CSF was sent from her EVD. Initial gram stain was
negative. She was kept in the ICU for monitoring, EVD remained
clamped. SBP was allowed to continue to autoregulate up to 200.
On [**2102-5-25**] her EVD was opened at 15cm to see if her neurologic
exam improved. LENS were done for screening. Her EVD did not put
out much CSF and no exam change was seen so her EVD was dropped
to 10cm.
On [**5-26**], no exam change was seen and the EVD did not put out any
output so her EVD was removed. She was transferred to the SDU
and her blood pressure was normalized.
Patient was seen to be a little bit more lethargic to family and
on exam. A STAT head CT was ordered to rule out hydrocephalus.
It showed increased ventricle size and transependymal CSF flow.
She remained in the SDU under close monitoring.
Serial imaging through [**5-29**] showed progressively increasing
ventricle size and increased lethargy. On [**5-30**] she went to the OR
for a VP shunt. Post-operatively, she was admitted to the Neuro
ICU as she was lethargic. On [**5-31**] AM she was more awake. She was
transferred to the floor.
On [**6-1**], she appeared more lethargic and continued to be
monitored. On [**6-1**] she had a CT Head which showed an interval
decrease in ventricular size. Her exam was much improved and
patient was more awake. A General Surgery consult was called for
a PEG and most likely will occur on Monday.
On [**6-3**], she removed her NG tube, was replaced, patient pulled
out again a second time. Applesauce was attempted without
difficulty so no further tube was placed. It was noted she had
decreased urinary output, bladder scan showed 275, her fluid
intake was increased.
On [**6-4**], she received Hydralazine for HTN. Her PO intake was
improving. Her exam was improving. She pulled her PICC out. A
repeat head CT showed a small R frontal hygroma.
On [**6-5**], patient c/o headaches and was hypertensive, a repeat CT
showed an increase in the R frontal hygroma.
On [**6-6**], a repeat Head CT was done which was stable. Calorie
counts continued.
On [**6-7**], her exam remained stable. She was offered a rehab bed
and was discharged.
Medications on Admission:
azithromycin 250mg, doxazosin 2mg daily, lasix 40mg daily,
glyburide 5mg daily, labetalol 200mg, lisinopril 20mg daily,
nifedical 30mg daily, proair prn, simvastatin 40mg daily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
6. oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q4H (every 4
hours) as needed for Pain.
7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. labetalol 100 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
9. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**12-25**]
Tablets PO Q4H (every 4 hours) as needed for headache.
10. insulin regular human 100 unit/mL Solution Sig: Sliding
Scale Injection Before meals: Refer to sliding scale.
11. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
16. docusate sodium 50 mg/5 mL Liquid Sig: 10mL PO TID (3 times
a day).
17. calcium carbonate 500 mg/5 mL (1,250 mg/5 mL) Suspension
Sig: One (1) PO QID (4 times a day).
18. lisinopril 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily) as
needed for HTN.
19. NPH insulin human recomb 100 unit/mL (3 mL) Insulin Pen Sig:
7 units Subcutaneous every twelve (12) hours.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] [**Hospital1 189**]
Discharge Diagnosis:
SAH
Hydrocephalus
Pcomm aneurysm
Hypertension
Hypotension
Bradycardia
Dysphagia
Left frontal hygroma
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples 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.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
Followup Instructions:
Follow-Up Appointment Instructions
?????? Please return to clinic on [**2102-6-15**] with a Head CT w/o
contrast. This appointment has been made for you:
* Head CT at 08:30 AM at the [**Hospital Ward Name 517**] Clinical Center
* Appointment with Dr [**First Name (STitle) **] at 09:45 AM at the [**Hospital **]
Medical
Office Building, [**Location (un) 470**], [**Hospital Unit Name 12193**]
??????Please call ([**Telephone/Fax (1) 2102**] to schedule an appointment with Dr.
[**First Name (STitle) **], to also be seen in 4 weeks.
??????You will need an MRI/MRA of the brain +/- ([**Doctor Last Name **] Protocol) at
that time.
Completed by:[**2102-6-7**]
ICD9 Codes: 431, 5849, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1111
} | Medical Text: Admission Date: [**2114-9-14**] Discharge Date: [**2114-9-21**]
Date of Birth: [**2063-4-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
transfer from [**Hospital1 18**] [**Location (un) 620**] for thrombocytopenia and
lymphadenopathy of unclear origen
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is 51 y/o M with history of hyperlipidemia who presented to
OSH on [**2114-9-13**] complaining of shortness of breath and
palpitations.
He refers that in [**Month (only) **] he started having increase urinary
frequency. No clear burnin on urination or decrease in the
caliber of the stream. After the [**9-1**], he started having
dry cough, night sweats, fevers and general malaise. No
pariticular pattern of his fevers. Low appetite as well. No
abdominal sympotms. He felt that it was a viral infection. After
3 weeks of this sympotms he developed more urinary sympotms,
burning on urination, bilateral frank pain. He felt that his
urinary symptoms had came back.
.
He went to see his PCP on [**9-1**]. he was started on
ciprofloxacine 500 daily for 10 days. He continue to have
persistent urinary symptoms, malaise and fatigue. he felt that
he coudl not doo as much work as he wanted. he was then refered
to the Urologist. He was seen on [**9-3**], (Dr [**Last Name (STitle) 24934**] who
felt that his prostate was enlarged and tender. His dose of
ciprofloxacine was increase to 500 [**Hospital1 **]. He also ordered a CT
Abdomen and checked labs. His CT revealed cystic strucuture in
the lower portion of left kidney and also numerous periaortic,
celiac and pelvic lymph node. Also enlarged prostate. Platelets
were noted to be [**Numeric Identifier 38500**]
.
Over the next week, he developed Right upper quadrant abdominal
pain, constant, and also over his right chest wall. He started
taking some Ibuprofen as per his report aroudn 600mg ~ q3h. A
week prior to admission he developed increasing shortness of
breath specially on exertion, extreme fatigue, palpitations,
nausea and vomit. Also increase in night sweats.
.
After talking to PCP coverage he was refered to the ED.
.
In OSH ED, VS T 98.6, Hr 113, Bp 94/75, RR 16 Sats 98% 2L. +
petechial lesion over extremities and abdomen. U/a had WBC 2 to
5. EKG with sinus tachycardia. CT Abdomen was done that showed
new pockets of ascitis, pelvic lymphadenopathy worse thatn
prior, cirrhotic liver, enlarged portoahepatis and portocaval
notes and heterogeneus prostate. A CTA was done that was
negative for PE - altough states that a suboptima IV bolus was
given-. Subpleural node 2.9 mm RML noted, 3mm focal opacity
along RM fisure. His labs were notable for WBC 5.6, HCT 41.6
Platelets of [**Numeric Identifier 961**], INR 1.0, PTT 25.8, elevated bili 2.63 Direct
1.66, and elevated transaminases ALT 225, AST 184, alk
phosphatase 165LDH 2163.normal Creatinine 1.0 Peripheral smear
was reviewed with no evidence of schistocytes.
.
Upon transfer to [**Hospital1 18**], the patient was evaluated by Hem/Onc who
reviewed smear - negative schistocytes. Platelet transfusion was
recomended with increase to 12. Bone marrow biopsy performed on
Friday showed findings consistent with neuroendocrine tumor.
Surgery was consulted for possible biopsy of lymph nodes but
felt it was unsafe to do it with thrombocytopenia.
.
On the evening of [**2114-9-17**], he developed acute respiratory
distress. He became more tachycardic, hypoxic, and tachypnic. He
was given Lasix 20 mg IV x 1 with good response. STAT CXR
revealed worsening B/L pleural effusions. CT chest concerning
for new opacities. He was started on Zosyn. ABG revealed hypoxia
and he was switched to a NRB and transferred to the MICU for
closer respiratory monitoring. In MICU he was treated with
morphine for SOB and continued on zosyn. Heme/onc recommended
initiating chemotherapy and due to his worsening respiratory
status with increased oxygen requirement he was transferred to
the [**Hospital Unit Name 153**] for close monitoring. He was placed on BiPAP for
increased SOB prior to transfer on [**9-19**].
.
On arrival to the [**Hospital Unit Name 153**] the patient was complaining of some mild
SOB, however reported that his breathing was better on BIPAP.
He denied CP, N/V, abdominal pain. He expressed that he was
anxious about his new diagnosis and the upcoming chemotherapy.
Past Medical History:
[**2114-9-14**] Bone Marrow biopsy
Social History:
Lives with wife and two dauthers. He is IT manager in a Bank.
Denied iv drug use. No smoking, Alcohol 3 glass of wine a week.
beer every three weeks.
No ocuppational exposures.
Family History:
Mother and Father with [**Name2 (NI) **] Cancer ~ age 50's.
Brother Melanoma. Brother [**Name (NI) **].
Physical Exam:
Vitals: T: 100.1 P:114 R: BP:113/83 SaO2:94%on RA
General: Awake, alert, NAD.
HEENT: NC/AT, PERRL, EOMI without nystagmus, mild icteric sclera
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Decrease breath soudns in the bases. No crackles.
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No edema 2+ radial, DP and PT pulses b/l.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: + petechia in lower extremitis and abdomen.
Neurologic: AxO times three. CN II-xII normal. DT reflexes
2+/4+.
Normal gait.
Pertinent Results:
CT Abdomen [**2114-9-13**]
PELVIS:
There is minimal interval enlargement of prominent
retroperitoneaL lymph nodes; a representative left parailiac
node measures 1.6 cm (image 59 series 2), previously measuring
11 mm. There is a 3.3 x 2.3 cm lymph node noted along the right
external iliac vessels. In addition, there is a stable 1.8 cm
lymph node along the left pelvic side wall. An additional
represenatative enlarged measures 2.9 x 2.9 cm left common iliac
lymph node. A 1.2 cm node is seen within the perirectal fat.
The prostate gland is slightly heterogeneous. Rectal fat right
of
midline. The bony structures are grossly unremarkable.
IMPRESSION:
1. NEW POCKETS OF ASCITES OF UNCERTAIN ETIOLOGY.
2. PELVIC LYMPHADENOPATHY CONCERNING FOR AN UNDERLYING
MALIGNANCY,
SPECIFICALLY [**Month (only) **] REFLECT UNDERLYING LYMPHOMA.
3. LIKELY CIRRHOTIC LIVER.
4. ENLARGED PORTAHEPATIS AND PORTOCAVAL NODES [**Month (only) **] BE
INFLAMMATORY
IN NATURE.
5. HETEROGENEOUS PROSTATE GLAND [**Month (only) **] REFLECT A HISTORY OF
PROSTATITIS.
.
CT PE [**2114-7-14**]: negative for PE
.
TTE [**2114-9-17**]
Small left ventricular cavity with hyperdynamic function,
tachycardia, moderate outflow tract gradient and systolic
anterior motion of the mitral valve leaflet in the absence of
left ventricular hypertrophy (suggestive of intravascular volume
depletion with high catecholamine state). No intracardiac shunt
identified.
.
CT Chest [**2114-9-17**]
No pulmonary embolism.
Diffuse tree-in-[**Male First Name (un) 239**] opacities predominating within the lower
lobes
bilaterally representing an acute infectious process.
Multiple hypoattenuating lesions diffusely throughout the liver
of varying sizes. While most of the opacities in the lung are
tree-in-[**Male First Name (un) 239**], some are morenodular and repeat chest CT may be
indicated if further abdominal workup reveals underlying
malignancy to rule out lung metastases.
.
CXR [**2114-9-19**]:
No new focal consolidations are identified with increased
obscuration of the right hemidiaphragm likely related to
underlying atelectasis. There is persistent left lower lobe
linear atelectasis and low lung volumes. The cardiomediastinal
silhouette, contours and pleural surfaces are unchanged.
.
Single organ US (liver) [**2114-9-20**]: CONCLUSION: Small amount of
ascites.
Brief Hospital Course:
Assessment and Plan: The patient is a 51 y/o M who was
transferred from OSH with thrombocytopenia, newly dx cirrotic
liver, and worsening lymphadenopathy. Preliminary BM biopsy
showed evidence of neuroendocrine tumor, complicated by
respiratory distress. The patient was transferred to the [**Hospital Unit Name 153**]
for initiation of chemotherapy, s/p intubation on [**9-20**] for
worsening respiratory distress.
ICU course by problem is as follows:
.
# Neuroendocrine tumor: Preliminary BM biopsy was consistent
with neuroendocrine tumor, not lymphoma. The patient had
diffuse LAD and hepatic nodules concerning for metastatic
disease. Chemotherapy was initiated on [**2114-9-20**]; however, due to
the patient's rapid clinical decline chemotherapy was felt to be
unlikely to produce an effect. These findings were discussed
with the family during a family meeting.
.
# New onset liver failure/ lactic acidosis: felt to be secondary
to metastatic disease. There was no plan for biopsy given low
platelets; however MR of the abdomen showed several diffuse
nodules in liver with necrosis - infectious vs lymphoma, less
likely HCC. Transaminitis continued to rise during the hospital
course. On [**2114-9-20**] there was a dramatic rise in lactate
secondary to liver failure with a steady increase throughout the
day from 7 to >18.
.
# Thrombocytopenia/ Anemia: Most likely [**3-2**] cancer. Preliminary
BM biopsy showed infiltrating carcinoma of bone marrow
consistent with neuroendocrine tumor. Hct progressively
declined, as below, but there was no clinical evidence of active
bleeding. An autoimmune process was also considered given that
platelets did not bump appropriately to transfusion.
.
# Anemia: The patient was at risk of bleeding given
thrombocytopenia, but did not show any active signs of bleeding.
Hct steadily declined from baseline 43 at OSH with values slowly
trending down into the mid-20s. B12 and folate were normal.
Hemolysis labs negative. Anemia was also thought to be related
to malignancy and BM process.
.
# SOB/tachypnea/hypoxia: Etiology was not entirely clear, but
most likely related to worsening acidemia and/or lymphangitic
spread of his tumor. CTA was negative for PE. CT chest with
opacities and concern for possible infectious process, and the
patient was broadly covered with vancomycin and zosyn for
possible PNA. Echo with bubble study negative for shunt. No
clinical evidence of volume overload currently with flat JVP.
Anemia may have also been contributing. During the ICU course
the patient was intubated on AC for increased work of breathing
and increasing O2 requirement. The patients O2 requirement
dramatically increased as lactate levels increased and pH
decreased.
.
# Hypotension: The patient became increasingly hypotensive as
acidosis worsened and ventilation and sedation were increased.
An arterial line was placed without complication and the patient
was started on levophed, which was uptitrated to maximal
settings, and vasopressin which produced temporary increases in
SBP. Pressors failed to maintain BPs as the patient became more
acidemic, and despite receiving multiple crystalloid boluses
with LR, the patient's MAPs began to steadily decline.
.
# PEA/ arrest: On the morning of [**9-21**] in the above setting, the
patient had an episode of PEA arrest for which he temporarily
responded to epinephrine. His wife, [**Name (NI) **], was contact[**Name (NI) **] with
this information, and chose not to rescusitate any further.
Later that morning the patient had steadily declining BPs and
entered a period of asystole. The patient was pronounced at
7:10am on [**2114-9-21**]. The attending was notified. The family was at
the bedside, and chose to pursue a limited autopsy.
.
# Communication was with [**Name (NI) **] (wife) home [**Telephone/Fax (1) 74072**] cell
[**Telephone/Fax (1) 74073**]
.
Medications on Admission:
Lipitor
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
neuroendocrine tumor, metastatic
liver failure
lactic acidosis
Discharge Condition:
Expired.
ICD9 Codes: 2762, 4275, 4589, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1112
} | Medical Text: Admission Date: [**2154-5-17**] Discharge Date: [**2154-6-4**]
Date of Birth: [**2077-7-20**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
garbled speech and left hemiplegia
Major Surgical or Invasive Procedure:
PEG tube placement
History of Present Illness:
The pt is a 76 year-old woman with HTN, HL, previous embolic
strokes, atrial fibrillation on asa and clopidogrel, recent
pacemaker followed by MI with resultant CHF who presents as a
transfer from OSH for acute onset of garbled speech and left
hemiplegia. The patient had been admitted [**5-13**] for constipation
issues. At 0300 this morning the patient was seen well. At 0330
the patient was found with garbled speech and left hemiplegia. A
NCHCT was done that reportedly did not show any specific
findings. The patient was transferred to the OSH ICU and then
transferred here for evaluation for possible neuro
interventional
procedure.
Past Medical History:
-HL
-HTN
-previous strokes - late [**2153**] embolic with hemorrhagic
conversion. Dx with a-fib at this time and started on Pradaxa
-STEMI [**2154-4-28**] - BMS placed in LAD; subsequent TTE [**2154-5-14**]: EF
was 30% with akinesis of anterior septum/wall, apex, and a
-pAF, sick sinus syndrome, prolonged QT --> pacemaker placed
[**2154-4-22**]; Pradaxa stopped prior to PM placement
-chronic dependent edema
-hx of bleeding stomach ulcer
-osteoporosis
-recurrent UTIs
-hx diverticulosis
-IBS
Social History:
Patient had been living with her daughter up until MI in
[**2154-4-28**],
since which she was in [**Hospital **] Rehab. Prior to this stroke, she
was able to ambulate with a cane/walker. Her two daughters are
her HCP. Widowed.
Family History:
non-contributory
Physical Exam:
Physical Exam on Admission:
Vitals: T: 97.8 P: 98 R: 19 BP: 111/67 SaO2: 98% on 4L NC
General: eyes closed, in bed.
HEENT: NC/AT, no scleral icterus, MMM
Neck: Supple, no carotid bruits. No nuchal rigidity
Pulmonary: decreased breath sounds at bases bilaterally
Cardiac: irreg irreg, nl. S1S2, 2/6 systolic murmur
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: bilateral pitting edema
Skin: no rashes or lesions noted.
Neurologic:
NIH Stroke Scale score was: 14
1a. Level of Consciousness: 1
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 2
3. Visual fields: 0
4. Facial palsy: 2
5a. Motor arm, left: 4
5b. Motor arm, right: 0
6a. Motor leg, left: 4
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 0
10. Dysarthria: 1
11. Extinction and Neglect: 0
-Mental Status: Alert, oriented x [**3-8**] ([**Hospital1 756**]). Able to relate
limited history, speaking in [**2-5**] word phrases. Inattentive,
requiring repeated stimulation during interview. Intact
comprehension. Speech was not dysarthric. Able to follow both
midline and appendicular commands. Denies L hand as own. L
neglect. R gaze preference.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. No blink to threat on left.
III, IV, VI: L gaze palsy, can overcome with OCRs. Limited down
vertical gaze.
V: Decreased facial sensation along left hemiface
VII: Left facial droop
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate unable to be visualized
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Full strength in right side. Left side is flaccid and
plegic.
-Sensory: Decreased sensation on left hemibody. Intact on right.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2+ 2+ 2+ 2 1
R 2 2 2 2 1
Plantar response flexor on right and extensor on left.
-Coordination: No dysmetria in RUE.
-Gait: deferred
Neurologic Exam on Discharge:
-Mental Status: Lethargic, arouses to voice, mostly nods in
response to questions but can occasionally provide [**2-4**] word
responses. Inattentive, requires repeated stimulation.
Comprehension intact, follows some simple commands. +L neglect
but identifies left hand as her own.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk.
III, IV, VI: R gaze preference but able to cross midline to the
left
V: Decreased facial sensation along left hemiface
VII: Left lower facial droop
VIII: Hearing intact to voice bilaterally.
IX, X: Palate unable to be visualized
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Full strength in right side. Left hemiplegia with no
spontaneous movement observed. Increased tone throughout L arm
and leg.
-Sensory: Decreased sensation on left hemibody. Intact on right.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2+ 2+ 2+ 2 1
R 2 2 2 2 1
Plantar response flexor on right and extensor on left.
-Coordination: No dysmetria in RUE.
-Gait: deferred
Pertinent Results:
[**2154-5-17**] 09:30PM CK(CPK)-33
[**2154-5-17**] 09:30PM CK-MB-3
[**2154-5-17**] 02:33PM URINE COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]->1.050*
[**2154-5-17**] 02:33PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
[**2154-5-17**] 02:33PM URINE RBC-25* WBC-67* BACTERIA-NONE YEAST-NONE
EPI-0
[**2154-5-17**] 02:33PM URINE WBCCLUMP-MOD
[**2154-5-17**] 10:54AM GLUCOSE-103* UREA N-6 CREAT-0.9 SODIUM-141
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-26 ANION GAP-13
[**2154-5-17**] 10:54AM estGFR-Using this
[**2154-5-17**] 10:54AM ALT(SGPT)-23 AST(SGOT)-18 LD(LDH)-266*
CK(CPK)-34 ALK PHOS-136* TOT BILI-0.5
[**2154-5-17**] 10:54AM CK-MB-3 cTropnT-0.08*
[**2154-5-17**] 10:54AM ALBUMIN-3.1* CALCIUM-8.4 PHOSPHATE-3.3
MAGNESIUM-1.9 CHOLEST-135
[**2154-5-17**] 10:54AM %HbA1c-6.0* eAG-126*
[**2154-5-17**] 10:54AM TRIGLYCER-103 HDL CHOL-51 CHOL/HDL-2.6
LDL(CALC)-63
[**2154-5-17**] 10:54AM TSH-4.1
[**2154-5-17**] 10:54AM WBC-8.6 RBC-4.21 HGB-10.4* HCT-35.1* MCV-83
MCH-24.7* MCHC-29.6* RDW-18.0*
[**2154-5-17**] 10:54AM PLT COUNT-425
[**2154-5-17**] 10:54AM PT-12.3 PTT-28.2 INR(PT)-1.1
CT/CTA/CTP head/neck [**2154-5-17**]:
IMPRESSION:
1. Occlusion of the right ICA at its bifurcation with no
evidence of
intracranial flow. Lack of right internal carotid atheromatous
disease or
dissection suggests a proximal embolic source.
2. Elevated MTT, low CBV, and low CBF in the entire right MCA
territory,
suggesting completed acute infarction in this region.
3. Large hypodensities of right parietotemporal and left
occipital region
regions, compatible with late subacute right MCA and left PCA
infarction.
4. Atheromatous plaque of left common carotid bifurcation
without significant luminal stenosis.
5. Large bilateral dependent pleural effusions with associated
adjacent
compressive atelectasis.
CT head [**2154-5-19**]:
IMPRESSION:
1. Progressive cytotoxic edema in the right cerebral hemisphere,
compatible with evolving right MCA infarction.
2. No evidence of hemorrhagic transformation at this time.
3. Established left occipital and einferior right frontal
infarctions with encephalomalacia.
CXR [**2154-5-19**]:
FINDINGS: In comparison with the study of [**5-18**], there is a
slight decrease in the diffuse bilateral pulmonary
opacifications, most likely reflecting some decrease in
pulmonary edema despite lower lung volumes. The possibility of
supervening pneumonia would have to be considered in the
appropriate clinical setting.
CXR [**2154-5-21**]:
IMPRESSION:
1. Signficantly improved bilateral diffuse pulmonary opacities.
2. Stable moderate left-sided pleural effusion and resolved
right-sided
pleural effusion.
Video swallow study [**2154-5-28**]:
FINDINGS: Video swallow examination was performed in conjunction
with the
speech and swallow division. Multiple consistencies of barium
were
administered. There was moderate silent aspiration of the nectar
and
honey-thick barium with significantly delayed cough and
swallowing reflexes. There was no aspiration or penetration
with pudding, however, there was significant oral residue, but
no evidence of pharyngeal residue.
CT abdomen without contrast [**2154-5-29**]:
IMPRESSION:
1. Large hiatal hernia.
2. Equivocal perfusion defects in the kidneys, which are of
uncertain
significance but the possibility of infection cannot be entirely
excluded by this study. Correlation with clinical factors is
recommended. The most
distinct abnormality involves the mid to lower pole, where there
is suspected volume loss which may suggest longer chronicity,
and according the lesion may be due to more chronic scarring.
Brief Hospital Course:
Ms. [**Known lastname 14800**] was transferred from an outside hospital to our neuro
ICU on [**5-17**].
Upon arrival to our NICU, approximately 5.5h after the onset of
her symptoms, she was awake and answered questions. Her eyes
were deviated to the right and she had a dense left hemiplegia
along with left sided neglect. Her examination was consistent
with a large right hemispheric MCA parietal syndrome. STAT CT,
CTP, and CTA showed bilateral old infarcts in various arterial
territories (left occipital & right frontal) and a less defined
hypodensity in right parietal region extending into the deep
basal ganglia. CTA showed occlusive lesion and decreased flow
signal in the left right ICA/MCA. These findings were consistent
with new acute/subacute right MCA infarct, likely cardioembolic
due to AF (untreated with OAC, recent MI, and low EF). She was
not a candidate for endovascular intervention/IA t-[**MD Number(3) 6360**]
established infarction on CT. We discussed her condition with
her daughters and confirmed her code status as full. We placed a
Dobhoff tube for feeding and provided supportive post-stroke
care. She was monitored in the ICU overnight and as she remained
stable was transferred to the floor stroke service on [**5-18**].
Neuro:
Her examination has remained largely stable since being
transferred to the floor on [**5-18**]. She is appearing somewhat more
awake, nodding/shaking head to questions, occasionally
verbalizing a few words, and following commands. She continues
to have a significant left hemiplegia. Left-sided neglect is
improving.
She was initially continued on aspirin and plavix for secondary
stroke prevention as well as cardioprotection given her recent
stent. Per discussion with her outpatient cardiologist Dr.
[**Last Name (STitle) 8573**], plavix was stopped on [**5-31**] (approx 1 month after bare
metal stent placement) and she was transitioned to coumadin and
aspirin 81mg daily. Lipid panel revealed TG 103/HDL 41/LDL 63
and HbA1c was 6. She was continued on her home rosuvastatin.
Blood pressure was initially allowed to autoregulate and she was
slowly started back on her home antihypertensives and diuretics.
PT, OT, and speech therapy were consulted. She continued to have
persistent dysphagia and remained NPO despite multiple repeat
swallow evaluations. A Dobhoff tube was placed for feeding but
came out on [**5-25**] and was unable to be replaced. PEG tube was
subsequently placed on [**5-31**]. She has been tolerating tube feeds
well but remains NPO.
CV:
She was maintained on telemetry monitoring during her admission.
She was continued on aspirin and plavix as well as amiodarone,
digoxin, and carvedilol. Lasix was initially held but was then
restarted at her home dose of 40mg daily due to concerns for
volume overload with pulmonary edema. Her respiratory status
improved with diuresis. Spironolactone was also restarted on
[**5-31**]. A TTE performed at the outside hospital prior to her
transfer revealed EF of 30% and no evidence of a cardioembolic
source (although could not fully assess for thrombus).
On [**5-23**] she was noted to be tachycardic to 120-140's. Her
pacemaker was interrogated and revealed abnormal sensing. A CXR
confirmed RV lead migration. Pacemaker settings were adjusted.
Our cardiology team spoke with the patient's daughters about
potentially removing the RV lead but it was decided to hold off
as her tachycardia resolved with adjustment of the pacemaker
settings. Her tachycardia improved once PEG was placed and she
was started back on her home medications.
Per discussion with her outpatient cardiologist Dr. [**Last Name (STitle) 8573**],
plavix was stopped on [**5-31**] (approximately 1 month after bare
metal stent placement) and she was transitioned to coumadin 5mg
daily and aspirin 81mg daily.
ID:
She had one episode of fever to 101 overnight on [**5-19**]. CXR was
concerning for pulmonary edema as well as potential aspiration
pneumonia. UA and cultures were negative, and blood cultures
were negative as well. She was started on Vanc/Zosyn and
completed an 8-day course. She remained afebrile throughout the
rest of her admission. On [**5-27**] she was noted to have some
vaginal discharge and was started on miconazole cream for
presumed candidiasis.
Pulm:
She was restarted on Lasix 40mg daily due to concerns for
pulmonary edema on a CXR [**5-19**]. Her respiratory status improved
and repeat CXR [**5-21**] showed signficantly improved bilateral
diffuse pulmonary opacities. She was continued on lasix and her
respiratory status remained stable. Spironolactone was also
restarted on [**5-31**].
Endo:
She was maintained on finger sticks QID and insulin sliding
scale with a goal of normoglycemia. HgbA1c was 6.
GI/nutrition:
She continued to have significant dysphagia and remained NPO
despite multiple repeat swallow evaluations. A Dobhoff was
placed and tube feeds were initiated. The Dobhoff was lost on
[**5-25**] and unable to be replaced. Per discussion with Ms. [**Known lastname 14800**]
and her family the decision was made to place a PEG tube.
Surgery was consulted and recommended a CT of her abdomen, which
showed a large hiatal hernia. Initially it was thought that this
may preclude the option of a PEG, and the possibility of an open
J-tube placement was discussed with the pt and her family.
Ultimately it was determined that PEG placement would be the
preferred option if possible. She was taken to the OR on [**5-31**]
and underwent successful placement of a PEG tube. She was
started on tube feeds on [**6-1**] which she has been tolerating
well.
Prophylaxis:
She was maintained on subQ heparin for DVT prophylaxis. She was
maintained on a bowel regimen and a PPI for GI prophylaxis. Fall
and aspiration precautions were maintained.
Code Status: Her daughters [**Name (NI) **] [**Last Name (NamePattern1) **] and [**Name (NI) **]
[**Last Name (NamePattern1) 110084**] [**Telephone/Fax (1) 110085**] (health care proxies) confirmed her code
status as full during this admission.
Dispo:
She was discharged to [**Location (un) 16493**]rehab in good condition on
[**2154-6-4**].
TRANSITIONAL CARE ISSUES:
[] She was started on coumadin 5mg daily on [**5-31**]. This was
decreased to 3mg daily on [**6-2**] due to rapidly increasing INR.
INR was 2.9 upon discharge. ***COUMADIN SHOULD BE HELD [**6-4**] and
INR should be rechecked on [**6-5**].*** INR should be closely
monitored until stable at goal [**3-8**]. She will also need to remain
on aspirin 81mg daily.
[] She will need intensive PT and OT as well as speech therapy.
Nutrition should also be involved for adjustment of her tube
feeds.
[] She has a follow-up appointment scheduled with Dr. [**Last Name (STitle) **] in
neurology clinic on [**2154-7-17**] at 2:30pm.
Medications on Admission:
amiodarone 200mg po daily
ampicillin 500mg cap [**Hospital1 **] - to be completed [**2154-5-15**] for UTI
aspirin 325mg po daily
coreg 3.125mg po bid
vitamin B12 1000mcg
digoxin 0.125mg tab
docusate 100 [**Hospital1 **]
famotidine 20 [**Hospital1 **]
ferrous sulfate 325 po daily
folic acid 1mg po daily
furosemide 40mg po daily
lactulose daily
lisinopril 2.5mg po daily
proctofoam HC rectal foam [**Hospital1 **]
Crestor 40mg po daily
spironolactone 12.5mg po daily
acetaminophen 650mg po q6hr
milk of magnesia 30ML daily prn
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day): Hold for loose stools.
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain.
7. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. insulin regular human 100 unit/mL Solution Sig: One (1) unit
Injection ASDIR (AS DIRECTED): As per insulin sliding scale.
9. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times
a day): Hold for loose stools.
11. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid Sig: Five
(5) ml PO DAILY (Daily).
12. miconazole nitrate 2 % Cream Sig: One (1) Appl Vaginal HS
(at bedtime) for 3 days: Through [**6-3**].
13. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
16. modafinil 100 mg Tablet Sig: 0.5 Tablet PO QAM (once a day
(in the morning)).
17. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM: ****HOLD [**6-4**]. RECHECK INR [**6-5**].****.
18. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
19. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 39857**] - [**Location 9583**]
Discharge Diagnosis:
Right MCA (middle cerebral artery) stroke
Pneumonia
Dysphagia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neurologic: Pupils equal and reactive, R gaze preference but
able to cross midline toward left. +Left neglect but recognizes
hand as her own. Left lower facial droop. Left hemiplegia with
increased tone in upper and lower extremity, no spontaneous
movement. Moves right side spontaneously anti-gravity with full
strength. Left toe upgoing.
Discharge Instructions:
Dear Ms. [**Known lastname 14800**],
You were admitted to [**Hospital1 69**] on
[**2154-5-17**] for left sided weakness. You were found to have a
stroke in the right side of your brain. Your stroke is likely
related to your atrial fibrillation, in the context of your
recent heart attack and pacemaker placement. Per discussion with
your cardiologist your plavix was stopped and you were changed
to aspirin and coumadin to help reduce your future risk of
stroke. You were also treated for pneumonia with IV antibiotics.
You were found to have difficulty swallowing due to your stroke.
A nasogastric tube was placed initially to provide you with
nutrition and medications. As you continued to have difficulty
swallowing, a PEG (percutaneous endoscopic gastrostomy) tube was
placed.
You will need intensive PT, OT, and speech therapy after your
discharge to regain your strength and hopefully your ability to
swallow as well.
We made the following changes to your medications:
Started coumadin 3mg daily (**Should be held [**6-4**]. INR should be
rechecked [**6-5**].**)
Started modafinil 50mg daily to help increase your alertness and
energey level
Started celexa 20mg daily to help with depression
You should continue to take the rest of your medications as
prescribed.
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
You have the following appointment scheduled with Dr. [**Last Name (STitle) **] in
our stroke clinic:
Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2154-7-17**] 2:30
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
NEUROLOGY UNIT CC8 (SB)
ICD9 Codes: 5070, 4280, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1113
} | Medical Text: Admission Date: [**2106-9-23**] Discharge Date: [**2106-9-28**]
Date of Birth: [**2039-3-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 67 yo male with PMH of EtOH cirrhosis with HCC s/p
OLT on [**2104-8-22**] p/w acute onset SOB last night. He was watching
TV
when he suddenly epxerienced difficulty breathing that continued
worsen and he went to the hospital in [**Hospital3 **] where he was
found
to have pulmonary edema and increased creatinine to 4. He was
subsequently transported to [**Hospital1 18**]. Patient reports chest
tightness, but denies any chest pain, nausea, vomiting, fevers,
chills. He felt well prior to the episode and had a regular day
at work. He denies any changes in the amount of his urine output
or the urine color. He had no blood transfusions since the last
admission here on [**2106-9-8**]. He denies hematemasis or
hematochezia.
Of note: Patient was admitted to us on [**2106-9-8**] for low
hematocrit
of 19 and stayed overnight. He was transfused 3units of PRBCs on
that admission. The transplant hepatology, transplant
nephrology,
hematology and cardiology services were consulted at that time.
The hematology service determined that patient does not have any
hematologic abnormality that could explain his chrnically low
hematocrit. Patient did not have a work-up to r/o GI bleed as he
refused. There was no need for hemodialysis at that time. His
transplanted liver has been functioning well.
Past Medical History:
- liver transplant ([**2104-8-22**])
- EtOH cirrhosis, diagnosed 06/[**2103**].
- HCC
- Anemia
- Essential thrombocytosis
- Prior complications of ascites, malnutrition,
- portal [**Year (4 digits) **] with grade 2 esophageal varices.
Peritonitis [**7-18**], Duodenitis [**7-18**], Grade I rectal varices
- grade 2 esoph varices and gastritis by EGD [**3-/2106**]
- failure to thrive s/p PEG
- ? pancreatic insufficiency
- CAD
[**2104-7-1**] with
coronary angiography that showed inferolateral akinesis and
substantial lateral hypokinesis. 50% LAD lesion. Circumflex was
occluded distally. The right coronary artery had 40% stenosis
during his hospitalization recently in [**Month (only) 956**] with pneumonia
associated with diarrhea, malnutrition, hyperkalemia, and renal
insufficiency.
ECHO [**3-22**], EF 19%
- 2+ MR
Social History:
The patient owns business in [**Hospital3 **]: a clothing store and a
limousine business. Recently he started working from home due to
his poor health. He lives with his wife, who is very supportive.
He smokes. No drugs. Stopped EtOH in 6/[**2103**].
Family History:
Non contributory
Physical Exam:
O2 saturation 95% on 50% humidified face mask
gen: catechtic man, slightly pale, labored breathing, otherwise
stable, AAOx3, mental status not altered
heent: ncat, mmm, eomi, nonicteric sclera, perrl
[**Year (4 digits) **]: diffuse crackles in the base and mid right lung and in the
base of left lung
cv: RRR, no m/r/g appreciated
abd: thin, NT/ND, NBS, PEG tube in place (not using), incision
well healed
extr: trace b/l ankle edema
neuro: cn 2-12 intact grossly
Pertinent Results:
[**2106-9-23**] 11:04AM BLOOD WBC-16.8*# RBC-3.52* Hgb-8.9* Hct-29.7*
MCV-84 MCH-25.3* MCHC-30.0* RDW-16.0* Plt Ct-990*
[**2106-9-23**] 11:04AM BLOOD Neuts-88.1* Lymphs-9.7* Monos-1.5*
Eos-0.6 Baso-0.2
[**2106-9-23**] 11:04AM BLOOD PT-12.7 PTT-32.5 INR(PT)-1.1
[**2106-9-23**] 11:04AM BLOOD Glucose-89 UreaN-82* Creat-4.6*# Na-146*
K-5.8* Cl-120* HCO3-12* AnGap-20
[**2106-9-23**] 11:04AM BLOOD ALT-7 AST-15 CK(CPK)-43 AlkPhos-54
TotBili-0.3
[**2106-9-23**] 04:54PM BLOOD proBNP->[**Numeric Identifier **]
[**2106-9-23**] 11:04AM BLOOD Albumin-2.9* Calcium-8.1* Phos-5.9*
Mg-2.6
[**2106-9-23**] 10:43AM BLOOD Type-ART FiO2-50 pO2-90 pCO2-24* pH-7.30*
calTCO2-12* Base XS--12 Intubat-NOT INTUBA
[**2106-9-28**] 04:31AM BLOOD WBC-6.2 RBC-2.68* Hgb-6.9* Hct-22.1*
MCV-82 MCH-25.6* MCHC-31.1 RDW-15.1 Plt Ct-965*
[**2106-9-28**] 04:31AM BLOOD Glucose-109* UreaN-82* Creat-4.6* Na-143
K-4.2 Cl-116* HCO3-16* AnGap-15
[**2106-9-28**] 04:31AM BLOOD ALT-4 AST-11 AlkPhos-49 TotBili-0.2
[**2106-9-28**] 04:31AM BLOOD Calcium-7.3* Phos-4.0 Mg-1.8
[**2106-9-27**] 05:26AM BLOOD rapmycn-5.4
CXR:
Study Date of [**2106-9-23**] 10:02 AM Worsening pleural effusions and
confluent bilateral perihilar opacities are consistent with
pulmonary edema.
Study Date of [**2106-9-28**] 12:16 AM In comparison with the study of
[**9-27**], there is continued moderate left pleural effusion and
smaller right effusion. Bibasilar atelectatic changes are seen.
No evidence of acute focal pneumonia or vascular congestion.
RENAL U.S. PORT Study Date of [**2106-9-23**] 11:15 AM
IMPRESSION: Echogenic kidneys, the appearance of which is
suggestive of
diffuse parenchymal disease. No hydronephrosis. Two tiny left
renal cyst.
Echocardiography [**2106-9-23**] 11:00 AM
IMPRESSION: Dilated left ventricle with severe regional systolic
dysfunction, c/w CAD. Normal right ventricular systolic
function. Mild to moderate mitral regurgitation. Mild pulmonary
[**Month/Day/Year **].
Compared with the prior study (images reviewed) of [**2106-3-18**],
mitral regurgitation severity has slightly diminished and RV
regional wall motion abnormalities have resolved. The other
findings are similar.
ECG Study Date of [**2106-9-23**] 12:30:32 PM
Sinus rhythm. Left ventricular hypertrophy. Anteroseptal ST-T
wave changes may be due to left ventricular hypertrophy or
ischemia. Low QRS voltage in the limb leads. Compared to the
previous tracing of [**2106-7-31**] the ST-T wave changes are now
involving lead V4 which may be due to lead placement. Otherwise,
no significant change.
Brief Hospital Course:
The patient was admitted to the surgical ICU. He was diagnosed
with acute CHF exacerbation with pulmonary edema and acute renal
failure. An echo and a renal ultrasound were done (see
results). The nephrology team was consulted for assistance with
diurese. Over the course of his ICU stay he received IV lasix
boluses, then a lasix gtt with good effect. He progressively had
decreasing oxygen requirements. His renal function stabilized
as well. Transplant hepatology was consulted with no further
recommendations. His blood pressure medications were increased
as he had slightly elevated blood pressures during his stay as
he neared discharge.
He was ambulating, tolerating a regular diet, and was breathing
comfortably on room air with SaO2 of 100% on discharge to home.
Medications on Admission:
1. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
2. Epoetin Alfa 40,000 unit/mL Solution Sig: One (1) ml
Injection once a week: On Mondays.
3. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO DAILY
5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
7. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
8. Testosterone 2.5 mg/24 hr Patch 24 hr
9. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
10. Ferrous Sulfate 325 mg (65 mg Iron) (1) tab PO TID (3 times
a
day).
11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID
13. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
14. Aspirin 81 mg Tablet
15. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO once a day.
16. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO
twice a day.
17. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a
day.
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 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
4. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
7. Testosterone 2.5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24
hr Transdermal DAILY (Daily).
8. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*0*
14. Epoetin Alfa 40,000 unit/mL Solution Sig: One (1) Injection
once a week.
15. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*0*
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*0*
17. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
18. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Congestive heart failure
Pneumonia
Discharge Condition:
Good
Discharge Instructions:
Please call if you experience fevers, chills, shortness of
breath, chest pain, dizziness, sputum production, or cough.
Please weigh yourself daily and call if you notice significant
weight gain over a short time period.
Followup Instructions:
Call the transplant center. Followup should be arranged for you
in 1-2wks
ICD9 Codes: 4280, 5849, 486, 2762, 4168, 5859, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1114
} | Medical Text: Admission Date: [**2137-11-15**] Discharge Date: [**2137-12-11**]
Date of Birth: [**2062-12-24**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
Dysarthria and abdominal pain
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
EAST HOSPITAL MEDICINE ATTENDING ADMISSION NOTE .
Date:[**2137-11-15**]
PCP:
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 10066**] [**Name (STitle) 87750**] 2202 65th Street [**Location (un) **]
Bay Parkway and West 6th Street [**Telephone/Fax (1) 87751**]
GI: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 87752**] [**Telephone/Fax (1) 87753**]
_
________________________________________________________________
HPI:
74M s/p recent L hernia repair on [**2137-10-6**] with chest pain,
+pleuritic x 4 weeks, +n/v x 4 weeks, +intermittent abdominal
pain, question recent aphasic episode [**1-22**] pain per family. He
is currently being evaluated by GI for appetite and minimal
weight loss x 3 weeks. + Early satiety. Immediately after
eating he regurgitates solid food. No dysphagia for solids or
liquids or signs of aspiration with eating. Slurred speech x 2
days. No facial asymmetry or focal weakness. Increased weakness
and sweats.
He received ASA and SLNG with some improvement in his pain from
[**9-24**]. R>L asymmetric swelling of the lower extremities
In ER:
Triage Vitals: 8 99 108 108/62 14 99% 4L NC
Meds Given: levoquin 750 mg IV x T
Fluids given: 2L NS
Radiology Studies:
consults called.
VS on transfer HR = 90, BP = 102/58, RR = 16, 98% on 2L
.
PAIN SCALE: 0/10
________________________________________________________________
REVIEW OF SYSTEMS:
CONSTITUTIONAL: [] All Normal
[ ] Subjective fever [ ] Chills [ ] Sweats [ ] Fatigue [
] Malaise [ ]Anorexia [ ]Night sweats
[ +] __5___ lbs. weight loss/ over _1____ months
HEENT: [] All Normal
[ ] Blurred vision [ ] Blindness [ ] Photophobia
[ ] Decreased acuity [ +] Dry mouth [ ] Bleeding gums
[ ] Oral ulcers [ ] Sore throat [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ]Tinnitus [ ] Other: [+]occasional
dbl vision when laying down.
RESPIRATORY: [] All Normal
[ -] SOB [ ] DOE [ ] Can't walk 2 flights [+ ] Cough-
occasional yellow phlegm/
[ ] Wheeze [ ] Purulent sputum [ ] Hemoptysis [++
]Pleuritic pain
[ ] Other:
CARDIAC: [] All Normal
[ ] Angina [ ] Palpitations [+ ] Edema [ ] PND
[ ] Orthopnea [+ ] Chest Pain [ ] Other:
GI: [] All Normal
[ ] Blood in stool [ ] Hematemesis [ ] Odynophagia
[ ] Dysphagia: [ ] Solids [ ] Liquids
[ ] Anorexia [+] Nausea [] Vomiting [ ] Reflux
[ -] Diarrhea [ -] Constipation [+] Abd pain [ ] Other:
GU: [X] All Normal
[] Dysuria [ ] Frequency [ ] Hematuria []Discharge
[]Menorrhagia
SKIN: [] All Normal
[ +]Scaling rash of R knee [ ] Pruritus
MS: [X] All Normal
[ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain
NEURO: [X] All Normal
[ ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
ENDOCRINE: [X] All Normal
[ ] Skin changes [ ] Hair changes [ ] Temp subjectivity
HEME/LYMPH: [X] All Normal
[ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy
PSYCH: [x] All Normal
[ ] Mood change []Suicidal Ideation [ ] Other:
[X]all other systems negative except as noted above
Past Medical History:
Enlarged prostate
Shingles - 18 months ago and he is on lyrica
H/o PNA one year ago during which opacities were found, s/p
bronchoscopy. His PNA was diagnosed as part of an evaluation
for weight loss. He did not have fevers, chills or cough
S/p hernia repair in [**9-/2137**]
Social History:
SOCIAL HISTORY/ FUNCTIONAL STATUS:
Son: HCP [**Name (NI) 2491**] [**Name (NI) 87754**]: [**Telephone/Fax (1) 87755**]
Office: [**Telephone/Fax (1) 87756**]
< 65
Cigarettes: [ X] never [ ] ex-smoker [x] current Pack-yrs: 10
quit: ______
ETOH: [x] No [ ] Yes drinks/day: _____
Drugs: none
Occupation: retired engineer
Migrated from [**Country 532**] in [**2115**]
Marital Status: [X ] Married [] Single
Lives: [ ] Alone [X] w/ family [ ] Other:
Received influenza vaccination in the past 12 months [ ]Y [X ]N
Received pneumococcal vaccinationin the past 12 months [ +]Y [
]N
>65
ADLS:
Independent of ALL ADLS:
Independent of ALL IADLS:
At baseline walks: [+]independently [ ] with a cane [ ]wutwalker
[ ]wheelchair at baseliine
H/o fall within past year: [+]Y- walking []N
Family History:
Sister died of breast cancer
Brother died of lung cancer
Another sibling died of stomach cancer
Physical Exam:
VS: T = 97 P = 86 BP = 108/62 RR 18 O2Sat = 98% on 2L Wt, ht,
BMI
GENERAL: Elderly male laying in bed
Nourishment: At risk, + temporal wasting
Grooming: good
Mentation: Alert, speaks in full sentences. He feels tired
Eyes:NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted
Ears/Nose/Mouth/Throat: dry MM no lesions noted in OP, poor
dentition
Neck: supple, no JVD or carotid bruits appreciated
Respiratory: Decreased BS at R base
Cardiovascular: tachy, nl. S1S2, no M/R/G noted
Gastrointestinal: distended, slightly firm. Tender to palpation
in RUQ and LUQ
Genitourinary:
Skin: no rashes or lesions noted. No pressure ulcer
Extremities: 2+ edema b/l, 2+ radial, DP pulses b/l. R>L edema
Lymphatics/Heme/Immun: No cervical lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: II-XII intact
-motor: normal bulk, strength and tone throughout. No abnormal
movements noted.
Normal gait
Psychiatric: appropriate
On Discharge:
VS: T98.3 BP 138/74 HR 84 RR 18 O2 sat 95%
Gen: pleasant gentleman sitting in chair in NAD
Skin: resolving erythematous rash on back
HEENT: anicteric sclerae, MMM, slight ulceration under tongue,
no exudates
CV: RRR, no murmurs, rubs, gallops
Pulm: slightly decreased breaths sounds in the right base,
otherwise CTAB
Abd: soft, non tender, non distended; pos BS
Extr: 3+ LE edema b/l
Neuro: A&Ox3, CNII-XII intact, motor and sensation grossly
intact
Pertinent Results:
ADMISSION LABS:
[**2137-11-15**] 06:35PM WBC-8.0 RBC-4.15* HGB-11.9* HCT-33.8* MCV-81*
MCH-28.6 MCHC-35.2* RDW-16.8*
[**2137-11-15**] 06:35PM NEUTS-60 BANDS-5 LYMPHS-12* MONOS-16* EOS-0
BASOS-0 ATYPS-4* METAS-3* MYELOS-0 NUC RBCS-1*
[**2137-11-15**] 06:35PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
[**2137-11-15**] 06:35PM PLT SMR-VERY LOW PLT COUNT-77*
[**2137-11-15**] 06:35PM PT-13.8* PTT-33.0 INR(PT)-1.2*
[**2137-11-15**] 06:35PM proBNP-909*
[**2137-11-15**] 06:35PM cTropnT-<0.01
[**2137-11-15**] 06:35PM GLUCOSE-94 UREA N-27* CREAT-1.1 SODIUM-132*
POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-15* ANION GAP-25*
[**2137-11-15**] 07:23PM D-DIMER-1103*
[**2137-11-15**] 08:45PM LACTATE-7.9*
[**2137-11-15**] 11:35PM URINE COLOR-Yellow APPEAR-Clear SP
[**Last Name (un) 155**]-<=1.005
[**2137-11-15**] 11:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-1 PH-6.5 LEUK-NEG
[**2137-11-15**] 11:35PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
MICRO:
[**11-15**] Blood cultures- no growth
[**11-15**] Urine cx- no growth
[**2137-11-18**] 9:29 am SPUTUM Source: Expectorated.
**FINAL REPORT [**2137-11-20**]**
GRAM STAIN (Final [**2137-11-18**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2137-11-20**]):
RARE GROWTH Commensal Respiratory Flora.
[**2137-11-23**] 9:05 am SPUTUM Site: EXPECTORATED
ACID FAST CULTURE X 3 TIMES.
GRAM STAIN (Final [**2137-11-23**]):
<10 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
SINGLY AND IN PAIRS.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final [**2137-11-25**]):
MODERATE GROWTH Commensal Respiratory Flora.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
ACID FAST SMEAR (Final [**2137-11-24**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
[**12-7**] B glucan- negative
[**12-7**] galactomannan- negative
[**11-19**] IgG 473* IgA 52* IgM 302
STUDIES:
[**11-15**] CTA Chest/Abd/Pelvis:
1. Right upper lobe ground-glass parenchymal opacity, suggestive
of
pneumonia. Multifocal coalescent ground-glass nodules,
predominating upper
lobes but also present in left lower lobe, raise question of
metastatic
involvement. Moderate right pleural effusion.
2. Massive conglomerate aortocaval mass with central areas of
necrosis, which compresses the IVC, right common and external
iliac veins, and likely also right proximal ureter. Extensive
mediastinal, hilar, mesenteric, retroperitoneal, and iliac
lymphadenopathy and massive splenomegaly. Overall picture
suggestive of lymphoma/lymphoproliferative disease.
3. Mildly prominent common bile duct. Please correlate with
liver function
test.
4. Diffuse gallbladder mural edema, likely related to systemic
disease,
unlikely due to cholecystitis.
5. Multiple left renal lesions are incompletely evaluated,
including a 12-mm interpolar left renal lesion (3, 301), which
could be further characterized by ultrasound.
[**11-15**] CT Head- 1. No acute intracranial hemorrhage or mass
effect. 2. Although there is no CT evidence of large
intracranial mass, MRI with gadolinium is superior in evaluation
of such lesions and can be considered if not contraindicated.
[**11-15**] LENI- No evidence of right lower extremity deep venous
thrombosis.
[**11-15**] EKG: ST at 108 bpm, no other acute changes
[**11-18**] Trans thoracic Echo- The left atrium is normal in size. No
atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is 0-10mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The aortic root is mildly dilated at the sinus level.
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. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The estimated pulmonary artery systolic pressure is
normal. There is a trivial/physiologic pericardial effusion.
[**11-25**] Renal U/S: 1. No evidence of hydronephrosis, with
resolution of the mild hydronephrosis seen on CT [**2137-11-15**]. 2.
Nonvisualization of left renal interpolar region indeterminate
lesion seen on CT scan [**2137-11-15**], due to limited visualization.
For further evaluation,if clinically relevant, an MR could be
performed.
[**12-3**] CXR: The heart size remains normal and no typical
configurational abnormalities is seen. Thoracic aorta, stable
and within normal limits. Position of previously described left
subclavian approach advanced central venous catheter remains
unchanged terminating overlying the SVC at the level of the
carina. No pneumothorax is seen. In comparison with the next
preceding portable examination, the findings have cleared up
markedly. In particular the basal bilateral densities strongly
suggestive of bilateral pleural effusions as seen on [**2137-11-21**], have now practically cleared completely, as both lateral
and posterior pleural sinuses are free with the patient in
upright position. Also, the parenchymal densities have
regressed; however, significant residuals remain on both sides.
These consist of lateral located hazy parenchymal densities
close to the pleural space at the level of the third and fourth
rib. On the left side these parenchymal densities are also in
peripheral location but somewhat higher up and overlying the
second and third ribs including the corresponding interspace. In
comparison with the preceding single view examination, it is
possible that these parenchymal densities have progressed
slightly and thus, further followup chest examinations in this
patient with history of lymphoma is recommended.
[**12-4**] CT Chest: 1. Widespread peripheral consolidations which
are new or increasing. These are not entirely specific, but the
striking peripheral character of consolidations is very
suggestive of an inflammator etiology such as eosinophilic
pneumonia or organizing pneumonia, either of which could be
associated with a drug reaction. The appearance would be much
less typical for an infectious etiology or progression of
lymphoma, which has apparently responded overall very well to
treatment.
2. New mild extrahepatic biliary ductal dilatation of uncertain
significance. Correlation with liver function tests is
recommended. If the apppearance may be clinically significant
based on laboratory data or clinical presentation, then MRCP
could be considered or follow-up CT or ultrasound. Extrinsic
compression by lymphadenopathy that is not imaged on this study
is a possible, though somewhat unusual, possibility.
[**12-4**] CT Head: 1. No evidence of intracranial metastatic
disease. MR (if feasible) would be more sensitive than CT for
detection of metastatic lesions. 2. No acute intracranial
process.
[**12-9**] CXR: Heart size is normal. Mediastinal position, contour,
and width are unremarkable and stable. The abnormalities
demonstrated on prior chest
radiograph and chest CT appears to be grossly unchanged except
for may be
minimal progression at the level of the left lower lobe and
right upper
superficial area as well as interval development of minimal
amount of pleural effusion on the right. The finding continues
to be nonspecific with the differential diagnosis being broad
including eosinophilic pneumonia, cryptogenic organizing
pneumonia, drug reaction, and less likely infection.
PATHOLOGY:
[**11-17**] Bone marrow biopsy- MARKEDLY HYPERCELLULAR MARROW WITH
EXTENSIVE INVOLVEMENT BY A LYMPHOPROLIFERATIVE DISORDER, MOST
CONSISTENT WITH DIFFUSE LARGE B-CELL LYMPHOMA.
[**11-17**] R axillary lymph node biopsy- DIFFUSE LARGE B CELL
LYMPHOMA, HIGH GRADE.
[**11-17**] Immunophenotyping Flow Cytometry: Immunophenotypic finding
consistent with involvement by a kappa-restricted B-cell
lymphoproliferative disorder. Correlation with concurrent bone
marrow biopsy (S10-48307G) is recommended.
DISCHARGE LABS:
142 107 15 85 AGap=12
-------------
3.4 26 0.8
Comments: Glucose: If Fasting, 70-100 Normal, >125 Provisional
Diabetes
Ca: 9.3 Mg: 2.0 P: 2.4
ALT: 35 AP: 226 Tbili: 0.7 Alb: 3.0
AST: 27 LDH: 249 Dbili: TProt:
[**Doctor First Name **]: Lip:
UricA:3.2
20.5 > 8.8 < 186
24.7
N:98.0 L:0.9 M:0.9 E:0.1 Bas:0.1
Other Hematology
Gran-Ct: [**Numeric Identifier 87757**]
PT: 12.9 PTT: 28.1 INR: 1.1
Brief Hospital Course:
ASSESSMENT:
74 year old male with BPH, s/p R inguinal hernia repair present
with pleuritic abdominal/chest pain found to have a extensive
lymphadenopathy throughout torso and aotocaval large
conglomerate mass with compression of IVC and R common iliac
vein.
.
# Lymphoma- Patient was initially admitted to the medical floor
for expedited evaluation of presumed lymhoproliferative disorder
in the setting of CTA which showed bulky lymphadenopathy and
aortocaval large conglomerate mass with
compression of IVC and right common iliac vein. Initial labs in
the ED were remarkable for lactic acidosis with HCO3 of 15 and a
lactate of 7.9. On the medical floor, he was found to have a
uric acid of 13.5 and an LDH of 604 in the setting of normal
calcium/ phosphate/ potassium. He was started on allopurinol and
IVF due to concern for TLS. A heme-onc consult was called and an
axillary LN biopsy showed prelimary path c/w aggressive
lymphoma. Bone marrow biopsy eventually showed diffuse large B
cell lymphoma. Patient was noted to have increased work of
breathing with ABG showing worsening acidosis 7.32/19/111 and
lactate of 11.4. A bicarb drip was initiated and due to concern
for worsening lactic acidosis, patient was transferred to the
ICU. Lactic acidosis was attributed to tumor mass necrosis vs.
infection and patient was started on vanc/zosyn/azithro for
pneumonia visualized on CT chest (see below). He received [**Hospital1 **]
for treatment of his lymphoma and tumor lysis labs were
monitored q6 given his spontaneous tumor lysis syndrome on
admission. He received rasburicase for persistently elevated
uric acid and new renal failure (creatinine 1.3 from 1.0) with
improvement of his symptoms. He became fluid overloaded and was
diuresed with lasix. He was called out to the floor where he
received a round of RCHOP with good effect and no subsequent
tumor lysis. He had some mucositis which was managed with pain
medications and mouth care. He was discharged home on D5 RCHOP
with follow up scheduled in the 7 [**Hospital Ward Name 1826**] outpatient clinic and
a plan to establish care in NY with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25139**]
(appointment tentatively scheduled for [**12-24**]).
# Pneumonia- Patient had chest CT with ground-glass parenchymal
opacity, suggestive of pneumonia. He was started on
vanco/zosyn/azithro and was continued on these antibiotics for 7
days after he was no longer neutropenic per pulmonary
recommendations. Repeat imaging with CT scan showed widespread
peripheral consolidations concerning for an inflammatory
etiology such as eosinophilic pneumonia or organizing pneumonia,
but ultimately attributed to resolving pneumonia in the setting
of a reconstituted immune system as the patient was asymptomatic
and appeared well. Patient will need repeat imaging in [**12-22**] weeks
after discharge to assess progression.
.
# Rash- Patient developed an erythematous papular eruption on
his back as well as a well demarcated erythematous plaque on his
lower L back. Dermatology was consult and attributed the former
to a resolving drug reaction and that latter to a contact
dermatitis. Triamcinolone was applied topically to the plaque
with gradual improvement.
.
#. Fluid retention: Patient received fluids as part of his
chemotherapy regimen. His weight increased 10 lbs over several
days secondary to fluid retention. He was diuresed with good
effect and subsequently reaccumulated fluid in his legs with the
second round of chemo. He was restarted on lasix and sent home
to continue diuresis with f/u in the outpatient clinic.
.
#. Headache: Patient complained of mild intermittent R
retro-orbital pain without associated visual changes, diploplia,
or floaters. Was seen by opthalmology who attributed his eye
symptoms to dry eyes. CT head w/ and w/o contrast was negative
for bleeds and metastatic disease.
.
# Shingles- Patient complained of continued post herpetic
neuralgia related to his shingles episode six months earlier.
His pain was managed with lidocaine patches and
oxycodone/oxycontin.
.
#. BPH: No active issues. Patient was continued on finasteride
and tamsulosin as his home BPH medications were not on
formulary.
Medications on Admission:
avodart 0.5 mg
uroxatral/alfuzosin alpha 1 blocker 10 mg
Lidoderm patch
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Please take while you are taking oxycodone.
Disp:*60 Capsule(s)* Refills:*2*
2. ranitidine HCl 300 mg Tablet Sig: One (1) Tablet PO at
bedtime.
Disp:*30 Tablet(s)* Refills:*2*
3. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
4. filgrastim 300 mcg/mL Solution Sig: One (1) injection
Injection Q24H (every 24 hours) for 10 days.
Disp:*10 injections* Refills:*0*
5. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*2*
6. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*2*
7. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
8. oral wound care products Gel in Packet Sig: One (1)
Packet Mucous membrane TID (3 times a day) as needed for
Mucositis.
Disp:*20 Packet* Refills:*0*
9. oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours): Do not
drink or drive while taking this medication.
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*0*
10. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day:
Please take while taking lasix.
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
12. dutasteride 0.5 mg Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*2*
13. alfuzosin 10 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Diffuse Large B Cell Lymphoma
Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 87754**],
You were admitted to the hospital with chest and abdominal pain.
You had a CT scan of your chest, lymph node and bone marrow
biopsies which showed that you have diffuse large B cell
lymphoma. You received two rounds of chemotherapy while you were
in the hospital. You were also diagnosed with a pneumonia for
which you were treated with antibiotics. You will need to have a
repeat CT of your chest in [**12-22**] weeks to assess the improvement
of this infection. Your body was retaining fluid so you were
started on a water pill to help remove some of this fluid.
Please continue to take this at home as directed until you
follow up on Friday. Please also weigh yourself daily and call
Dr.[**Name (NI) 14047**] office if your weight increases.
We have made the following changes to your medications:
- START taking filgrastim (injections) as directed for your
blood counts
- START taking fluconazole for prevention of infection
- START taking acyclovir for prevention of infection
- START taking ranitidine for your stomach
- START taking oxycontin for your pain; please take colace and
senna as needed while taking this medication to prevent
constipation; do not drive while taking oxycontin as it is
sedating
- START taking lasix for the fluid in your legs
- START taking potassium as directed while taking lasix
- you may use gelclair as needed for mucositis pain in your
mouth
You make continue taking your other medications as you were
previously.
It was a pleasure taking care of you. We wish you a speedy
recovery.
Followup Instructions:
Please come to the 7 [**Hospital Ward Name 1826**] Outpatient Clinic at 10:00AM on
Friday [**12-13**] for tests to check your blood counts and
your chemistries.
Department: BMT/ONCOLOGY UNIT
When: FRIDAY [**2137-12-13**] at 10:00 AM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
You will be contact[**Name (NI) **] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25139**] at [**Hospital1 107**] [**Doctor Last Name **]
[**Hospital 87758**] Cancer Center in NY about an appointment on [**12-24**]. If you do not hear from his office regarding the timing of
this appointment please contact him at [**Telephone/Fax (1) 87759**]. In the
meantime, if any issues arise, you have an appointment with Dr.
[**First Name (STitle) **] as below (you can cancel this appointment once your
appointment in NY is finalized):
Department: HEMATOLOGY/BMT
When: MONDAY [**2137-12-23**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2137-12-23**] at 3:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5778**], 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
Completed by:[**2137-12-11**]
ICD9 Codes: 486, 2762, 5849, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1115
} | Medical Text: Admission Date: [**2143-12-16**] Discharge Date: [**2143-12-21**]
Date of Birth: [**2082-5-16**] Sex: M
Service: MEDICINE
Allergies:
Clindamycin / Keflex
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
hemoptysis/post-obstructive pneumonia
Major Surgical or Invasive Procedure:
IR embolization of bleeding pulmonary site
History of Present Illness:
Mr. [**Known lastname 51305**] is a 61 year old male smoker with 50 pack year
history, COPD, hemachromatosis, and multiple invasive squamous
cell
carcinoma/basal cell carcinoma who is being transferred to the
ICU for post-procedural monitoring following rigid bronchoscopy
for hemoptysis and likely post obstructive pneumonia.
.
He initially presented who had an episode of hemoptysis and
shortness of breath in the early AM prior to presenting to the
OSH. Patient reports that he had 2 episodes of hemoptysis of
approximately [**5-22**] oz. There, he underwent a CT scan that showed
a mass obstructing the
left main stem bronchus with a post obstructive pneumonia on the
left. The patient was started on CAP coverage with
CTX/azithromycin, to which flagyl was added. Patient denies
and fevers, chills, sweats. Patient reports a diminished
appetite, and 25 weight loss of the past 6-8 weeks. Patient
reports that he has difficulty walking greater than 50 feet
before he becomes short of breath and develops calf pain.
.
Of note, he has a major history of numerous squamous cell
carcinomas of the bilateral frontal and parietal scalp, probably
due to excessive sun exposure. He receives dermatologic care
here at [**Hospital1 18**] from Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] is to see Dr. [**Last Name (STitle) 1837**] for a
Mohs procedure of a recurrent left temporal lesion. He believes
that he has melanoma of the left temporal region though this was
not demonstrated by recent pathology. He also believes he has
melanoma of the lip.
.
He was initially admitted to the general medicine floor in
stable condition. His oxygen saturations intermittently fell to
88-89% and he coughed up a few teaspoons of frank hemoptysis.
With a CXR demonstrating major left lower lobe collapse and
likely obstruction of the LMSB, decision was made to go directly
to OR for rigid bronchoscopy with subsequent MICU admission for
observation.
.
His bronchoscopy revealed a large blood clot in the left main
stem bronchus with a malignancy of 10% stenosis behind it.
There were multiple tumors in the airways of both LUL and LLL,
each of which were cauterized with good effect. Distal slow
oozing was seen in smaller airways NOT amenable to bronchoscopic
intervention. IP recommended IR for angiography/embolization in
the AM.
.
Upon return from the MICU, his initial vitals were:BP:150/65
P:76 R:18 O2:100% 2Lventuri mask. He was comfortable without
complaints, though was still drowsy from anesthesia and a ROS
could not be ellicited
Past Medical History:
-Hemochromatosis
-COPD
-PVD
-HTN
-lymphedema of LUE, RLE
-IBS
-anxiety
-invasive squamous cell carcinoma of left temple.
-multiple squamous cell carcinomas of frontal and temporal scalp
Social History:
lives at home. He has a 50+PY smoking history with continued
use. Major previous sun exposures. ETOH intake ranges [**1-18**]
beers per day.
Family History:
Mother: CAD, DM
Father
Siblings [**Name (NI) **]: DM, CAD
Physical Exam:
Admission exam
Vitals: T: BP:150/65 P:76 R:18 O2:100% 2Lventuri mask
General: patient is fatigued-appearing and weak.
HEENT: Sclera anicteric, MM dry, dried blood on lip with lower
lip lesion. Multiple scaling lesions over the frontal and
parietal scalp bilaterlly, with an ulcerated lesion over the
left temple.
Neck: supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Decreased breath sounds on the left with rhonchi, no
wheezes, rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, asymmetric 2+ pitting edema with L arm >> R, and R
leg >> left.
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Discharge exam: deceased
Pertinent Results:
Admission labs
[**2143-12-17**] 01:32AM BLOOD WBC-23.4*# RBC-3.22* Hgb-9.9* Hct-30.0*
MCV-93 MCH-30.7 MCHC-32.9 RDW-14.4 Plt Ct-439
[**2143-12-17**] 01:32AM BLOOD Neuts-97.5* Lymphs-1.6* Monos-0.8*
Eos-0.1 Baso-0
[**2143-12-16**] 05:20PM BLOOD Glucose-103* UreaN-20 Creat-0.6 Na-139
K-4.1 Cl-108 HCO3-20* AnGap-15
[**2143-12-18**] 04:20AM BLOOD ALT-12 AST-11 LD(LDH)-139 AlkPhos-65
TotBili-0.1
[**2143-12-16**] 05:20PM BLOOD Calcium-7.7* Phos-3.8 Mg-1.7
.
Discharge labs:
Labs stopped being drawn, as patient made [**Year/Month/Day 3225**].
.
Studies
.
PATHOLOGY REPORT OF LUNG MASS
SPECIMEN SUBMITTED: right lower lobe endobronchial bx.
Procedure date Tissue received Report Date Diagnosed
by
[**2143-12-16**] [**2143-12-17**] [**2143-12-19**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/vf
DIAGNOSIS:
Lung, right lower lobe, endobronchial biopsy:
Squamous cell carcinoma, moderately differentiated.
Note: The patient's history of cutaneous squamous cell
carcinoma is noted. Although the endobronchial tumor may
represent metastasis from a cutaneous primary, a primary lung
squamous cell carcinoma cannot be excluded.
.
CT Head [**2143-12-16**]
There is no evidence of hemorrhage, infarction, shift of midline
structures, or mass effect. The ventricles and sulci are normal
in size and
configuration. The visible paranasal sinuses show small amount
of fluid
within the right maxillary sinus. Several tiny calcifications in
the left
frontal lobe (2:18, 2:11)and right frontal lobe (2:14) may be
sequelae of old infection. IMPRESSION: No acute intracranial
process, including large metastasis. If metastasis continue to
be a clinical concern, then an MR is recommended for further
evaluation.
.
LENIs [**2143-12-16**]
No DVT in the right lower extremity. Mild subcutaneous edema and
calcifications within the arterial vessels.
.
CXR [**2143-12-16**]
Single frontal view of the chest demonstrates marked
opacification
of the left middle and lower lung with significant volume loss
as evidenced by marked leftward cardiomediastinal shift. As
correlated to the preceding
reference CT from [**Hospital 882**] Hospital of the same day, there is
significant
endobronchial material obstructing the left main bronchus. There
is likely a combination of consolidation, bronchial wall
thickening, and pleural effusion in the left lung as well as
volume loss, producing the overall opacification. The right lung
remains relatively well aerated. There is evidence of underlying
emphysema, without radiographic evidence of pneumothorax.
Findings consistent with left main bronchial obstruction with
left middle and lower lobe collapse, in addition to
consolidation, bronchial wall thickening, and large left pleural
effusion. Overall constellations are highly concerning for
malignancy, although supervening infection and/or aspiration may
be present.
.
Embolization procedure [**2143-12-17**]
1. Single bronchial artery visualized supplying the left lung
with visualized tumor blush, embolized utilizing 500-700 micron
Embospheres.
2. Post-embolization arteriogram did not demonstrate any
bronchial arteries
either originating from the aorta or the internal mammary artery
supplying the left lung. Despite the suggestion that there is an
additional left bronchial arterial branch on the CT, this could
not be found despite using a number of different catheter
shapes. IMPRESSION: Successful uncomplicated embolization of
left bronchial artery utilizing 500-700 micron Embospheres.
.
CXR [**2142-12-18**]
In comparison with the study of [**12-17**], there has been some
re-aeration of the left lung following bronchoscopy. However,
extensive opacification persists and there is still shift of the
mediastinum to the left with hyperexpansion of the right lung.
Hazy opacification at the right base raises the possibility of
some atelectasis and effusion.
Brief Hospital Course:
Mr. [**Known lastname 51305**] is a 61yoM with multiple squamous cell skin cancers
who presents with hemoptysis and a LLL post obstructive
pneumonia.
.
# HEMOPTYSIS: CXR and CT suggested tumor burden in the left
mainstem bronchus, and this likely explained his hemoptysis. He
was brought for rigid bronchoscopy, which showed a large tumor
burden with distal oozing not amenable to bronchoscopic
engagement. Pathology report from this procedure showed this
tumor to be squamous cell, although could not differentiate
between metastasis from skin squamous cell cancer vs primary
lung squamous cell cancer. He underwent an IR angio/embolectomy,
which was successful in reducing his total amount of hemoptysis.
However, he did continue to have intermittent hemoptysis, and
overall felt very poorly and mildly SOB. Meeting with patient
and family was held, and it was decided that he would not want
any further intervention, and just wanted to be made
comfortable. He was made [**Known lastname 3225**] and transferred to the general
medicine floor.
.
On the general medicine floor, pall care continued to follow the
patient. His pain control was morphine drip initially, and then
he was later transitioned to a fentanyl patch and PO pain
control. The patient was made as comfortable as possible. He
was going to be transferred to outpatient hospice, but the
patient ultimately passed overnight.
.
# COMMUNITY ACQUIRED PNEUMONIA (?POST-OBSTRUCTIVE): His imaging
showed complete collapse of the LLL with a mass compromising the
left mainstem bronchus as well as likely consolidation of the
inferior LUL. OSH labs show concerning bandemia to 25%. His
sputum cultures grew out moraxella + s. pneumo. He initially was
covered broadly, but now that culture data are back he will be
treated with a 7 day total course of antibiotics, now on just
levofloxacin. Although he is [**Name (NI) 3225**], pt and family would like to
treat PNA. His bandemia improved and he remained afebrile. The
patient was on a Levofloxacin course when he passed.
.
# SQUAMOUS CELL CARCINOMA: He has an invasive left temporal SCC
and possible airway metastases. He is now [**Name (NI) 3225**], and ultimately
ended up passing while in the hospital, prior to discharge to
outpatient hospice.
.
# PERIPHERAL ARTERY DISEASE: Plavix was stopped; the only
medications that were continued were those that ensured the
patient's comfort.
.
# COPD: From ongoing smoking, now [**Name (NI) 3225**] and passed during this
hospitalization.
.
# HYPERTENSION: anti-HTN meds held, pt now [**Name (NI) 3225**] and ultimately
passed during hospitalization.
.
# CHRONIC LYMPHEDEMA: asymmetric upper and lower extremity from
unclear source.
Medications on Admission:
-Percocet
-plavix
-trazodone
-diovan
-spiriva
-ventolin
Discharge Medications:
pt passed away
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary diagnosis:
obstructing mass in airway
basal cell/squamous cell carcinoma
Secondary Diagnosis:
COPD
Discharge Condition:
Expired
Discharge Instructions:
Patient was made [**Name (NI) 3225**] and expired on [**2142-12-21**] at 7:45am. Brother
[**Name (NI) **] and [**Name2 (NI) 802**] [**Name (NI) 698**] were present. Autopsy was declined by
all siblings.
Followup Instructions:
N/A
Completed by:[**2143-12-23**]
ICD9 Codes: 3051, 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1116
} | Medical Text: Admission Date: [**2137-12-5**] Discharge Date: [**2137-12-11**]
Service: [**Hospital1 212**]
CHIEF COMPLAINT: Lower gastrointestinal bleed.
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year-old
gentleman with a history of coronary artery disease status
post myocardial infarction times two in [**2134**], aortic
the past who was transferred from an outside hospital on
[**2137-12-5**] with hematochezia. On the day of admission to the
outside hospital the patient awoke with sudden onset of
hematochezia. He denies concurrent abdominal pain, nausea,
vomiting or shortness of breath. After three episodes of
bright red blood per rectum. The patient called EMS and
presented to [**Hospital3 **] with a hematocrit of 32. In the
episode of hypotension, bradycardia requiring intravenous
fluids and Atropine. He was sent to the Intensive Care Unit
where he was transfused 3 units of packed red blood cells to
maintain a hematocrit of 30. The patient was ruled out at
[**Hospital3 **]. A tagged red cell scan was done at [**Hospital3 9683**], which was negative for bleed, but the tagged red
cell scan was repeated the next day and showed bleeding
throughout the mid transverse colon. At [**Hospital1 **] he was
evaluated by both the GI Service as well as Surgery, however,
the patient elected not to pursue surgical interventions. He
was electively transferred to [**Hospital1 18**] on [**2137-12-5**] at the
family's request.
PAST MEDICAL HISTORY: 1. Coronary artery disease status
post myocardial infarction times two in [**2134**]. 2. Aortic
stenosis. 3. Congestive heart failure. 4. Hypertension.
5. Peptic ulcer disease. 6. Blood pressure status post
transurethral resection of the prostate. 7. Status post
cerebrovascular accident. 8. Glaucoma. 9. Lower
gastrointestinal bleed secondary to diverticulosis. 10.
Anemia. 11. Thrombocytopenia. 12. Chronic renal
insufficiency. 13. Arthritis.
MEDICATIONS: Lasix 20 q.d., Enalapril 10 b.i.d., Lopressor
12.5 b.i.d.
ALLERGIES: Hydrochlorothiazide, Aldomet and Minipress.
PHYSICAL EXAMINATION: Vital signs 97.0. 70. 142/74. 17
breaths per minute. 98% saturation on room air. In general,
the patient was awake and alert, pleasant. HEENT examination
showed anisocoria. Pupils reactive. Anicteric. His
oropharynx was clear with no lesions, exudate or erythema.
His mucous membranes are dry. Neck was supple with no
lymphadenopathy. His lungs were clear bilaterally. Cardiac
examination normal S1 S2. 2 out of 6 crescendo decrescendo
murmur at the left upper sternal border radiating to the
carotids and the apex. The patient's neck veins were flat.
The abdomen was soft, nontender with positive bowel sounds.
Extremities the patient had 1+ dorsalis pedis pulses
bilaterally. There was no edema or cyanosis noted.
Neurological examination the patient was alert and oriented
times three. Cranial nerves II through XII intact. Upper
and lower extremity 5 out of 5 strength equal bilaterally.
LABORATORIES ON ADMISSION: The patient's white blood cell
count was 9.0. The patient's hematocrit 29.1, platelet count
94, sodium 138, potassium 3.1, chloride 106, bicarbonate 22,
BUN 22, creatinine .8, glucose 99. Coags from the previous
day at [**Hospital3 **], PT 13.8, INR 1.2, PTT 26.6. The
patient's iron studies, iron 75, ferritin 71, MCV 88, TIBC
424, TRF 326, folate 17, B-12 654, TSH was drawn at 2.6.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit. The patient was placed on intravenous
Protonix b.i.d. The patient was transfused to keep his
hematocrit greater then 30. Both the GI Service and the
Surgical Service were consulted. The patient's hematocrit
was checked q 6 hours initially. The Interventional
Radiology Service was consulted and due to the fact that the
patient was not actively bleeding initially at [**Hospital1 **] the
decision was made that angiography should not be done at that
time and that a tagged red blood cell scan would be
appropriate. In the evening on hospital day one ([**2137-12-5**]),
the patient had one episode of 300 cc of bright red blood per
rectum. The patient was started on Golytely prep and the
patient's hematocrit was stable at 31. On hospital day two
the patient's hematocrit was 27.5. The patient was
transfused 2 units of packed red blood cells. The tagged red
blood cell scan done at [**Hospital3 **] was negative.
The patient was seen by surgery and again expressed his
wishes not to have surgical intervention. The GI Service had
indicated that a colonoscopy would be performed. On [**2137-12-7**]
(hospital day three), the patient was transferred from the
MICU to the floor. His hematocrit had been stable at 34 over
the last two draws. Upon transfer to the floor the patient
had one large maroon stool. His p.m. hematocrit was down to
31.0 from 34.6 the previous day. The patient was feeling
well and asymptomatic. A.m. laboratories on [**12-8**] revealed a
hematocrit down to 29.8 from the previous value of 31.0. The
patient was transfused one unit of blood over four hours. In
the evening on [**2137-12-8**] during his bowel prep, the patient
again passed a large dark red bowel movement, which was
thought to be a rebleed. The patient underwent a fourth
tagged red cell scan, which was negative. The patient was
transfused a second unit of blood overnight.
On hospital day five ([**2137-12-9**]) the patient underwent a
colonoscopy by the GI Service. The findings revealed
nonbleeding grade two internal hemorrhoids and multiple
nonbleeding diverticuli with large openings were seen in the
sigmoid, descending transverse and ascending colon. The
impression was that the previous bleeding episode was likely
due to a diverticular bleed. However, there was no active
bleed at the time. The patient was again offered the
possibility of surgical intervention, however, declined. On
[**12-9**] the patient's hematocrit was stable at 37.0. The
patient remained asymptomatic without further GI bleed on
[**12-9**] through [**12-10**]. On [**2137-12-10**] hospital day six a small bowel
follow through was performed to examine for the possibility
of small bowel bleed. The results of the small bowel follow
through are pending at this time.
The patient's care at this time was assumed by the Geriatric
Service attending Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The patient's hematocrit
on [**2137-12-10**] was stable at 35.2. On [**2137-12-10**] the patient was
restarted on his Lasix and his Enalapril was resumed at his
previous dose of 10 mg po b.i.d. Rehab screening was
beginning for an anticipated discharge on [**2137-12-11**]. The
patient had an uneventful night on the [**12-10**]. The patient was
seen by the Physical Therapy Service who determined that the
patient would benefit from a short course of rehab. The
patient is discharged on [**2137-12-11**] to rehab in the [**Hospital1 1501**] unit at
[**Location (un) 5481**] in good condition prior to returning to his [**Last Name (un) **].
DISCHARGE DIAGNOSIS:
Lower gastrointestinal bleed, most likely diverticular.
DISCHARGE MEDICATIONS: Lasix 20 mg po q.d., Enalapril 10 mg
po b.i.d., Lopressor 6.25 mg po b.i.d., Protonix 40 mg po
q.d., Tylenol 650 mg po pr q 4 to 6 hours prn. Multi vitamin
one tab po q.d.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1598**], M.D. [**MD Number(1) 1599**]
Dictated By:[**Name (STitle) 109684**]
MEDQUIST36
D: [**2137-12-11**] 06:58
T: [**2137-12-11**] 07:03
JOB#: [**Job Number **]
ICD9 Codes: 4280, 4241, 2859, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1117
} | Medical Text: Admission Date: [**2145-10-26**] Discharge Date: [**2145-11-4**]
Date of Birth: [**2101-6-24**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
L frontal hemorrhage
Major Surgical or Invasive Procedure:
Arterial angiogram of the neck and head vessles.
History of Present Illness:
Pt. is a 44 year old with a history of a L MCA infarct 2
months ago who is transferred from OSH ED for concern for new
area of hemorrhage on Head CT.
Pt. reports that he'd been recovering well from his stroke 2
months ago until Tuesday (1 week PTA) He had some residual R
hand weakness, but this had been improving, and he was able to
write, drive a car, and even paddle a canoe. He was still
working with an OT. On Tuesday he noticed that his hand
weakness
was much worse than usual. He was not able to write, and
couldn't operate his stick shift. He has had some numbness in
his hand since the stroke, which was about the same. He does
not
remember an acute time of onset of the symptoms. He present to
[**Hospital3 **] with these symptoms, and reports that he had a
Head CT that was unchanged from prior CTs. He was therefore
discharged home. His hand continued to be weak for the next few
days. On Friday he thinks it got even worse still. He had an
appointment with his cardiologist that day, and reports that he
had another Head CT that was also unchanged (we have no records
from these visits at this time). Over the weekend the weakness
continued, but his family had alot going on (his uncle died over
the weekend and his family was in the hospital with him) so he
did not do anything further about it until today. Finally his
mother became concerned today and encouraged him to go back to
the ED.
He presented to [**Location (un) **] ED. There Head CT showed concern for a
new area of hemorrhage in the left frontal area where he'd had
the prior stroke. INR was 1.6, so he was given Vitamin K 10 mg
and 2 U FFP, and transferred here for further work up.
He has not noticed any changes in his vision or vision loss,
diplopia, headaches, lethargy or confusion, facial droop,
dysarthria, dysphagia, weakness outside of his right hand,
numnbess outside of his right hand, lighheadedness, vertigo, or
change in bowel or bladder habits. His mother feels like his
speech has been slow and he seems to be reaching for words
sometimes.
Past Medical History:
HTN
L MCA stroke 2months ago with residual right hand
weakness/numbness
? vegitation in aorta on Echo 1mo ago
PFO listed on OSH transfer records
Hepatitis B
Prior alcoholism, sober since [**4-24**]
Social History:
lives alone at home; quit smoking 2mo ago; history heavy ETOH,
last drink [**4-24**].
Family History:
NC
Physical Exam:
Gen: Lying in bed, NAD
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: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Says MOYB from
[**Month (only) **]
-> [**Month (only) **] very slowly, and then can't go any further. Speech is
fluent but very slow with responses. Follows 3 steps commands,
both midline and appendicular. Normal comprehension and
repetition; naming intact [**6-23**] with objects on card. No
dysarthria. [**Location (un) **] intact. Registers [**3-20**], recalls [**2-20**] in 5
minutes. No right left confusion. No evidence of apraxia or
neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields are full to confrontation.
Extraocular
movements intact bilaterally, no nystagmus. Sensation intact V1-
V3. R UMN facial droop. Hearing intact to finger rub
bilaterally. Palate elevation symmetrical. Sternocleidomastoid
and trapezius normal bilaterally. Tongue midline, movements
intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
No pronator drift
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 4 5 5 3 2 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, pinprick, vibration and
proprioception throughout.
Reflexes:
+2 and symmetric throughout.
Toes downgoing bilaterally
Coordination: finger-nose-finger normal, RAMs normal.
Gait: Narrow based, steady.
Romberg: Negative
Pertinent Results:
[**2145-10-26**] 03:15PM BLOOD WBC-9.6 RBC-5.23 Hgb-16.1 Hct-47.3 MCV-90
MCH-30.8 MCHC-34.1 RDW-14.7 Plt Ct-472*
[**2145-11-4**] 05:25AM BLOOD WBC-12.2* RBC-4.90 Hgb-15.5 Hct-43.0
MCV-88 MCH-31.6 MCHC-36.0* RDW-15.1 Plt Ct-589*
[**2145-10-26**] 03:15PM BLOOD PT-17.4* PTT-34.3 INR(PT)-1.6*
[**2145-11-4**] 05:25AM BLOOD PT-25.3* PTT-63.2* INR(PT)-2.6*
[**2145-10-26**] 03:15PM BLOOD Glucose-93 UreaN-9 Creat-0.8 Na-133 K-4.6
Cl-98 HCO3-23 AnGap-17
[**2145-11-4**] 05:25AM BLOOD Glucose-73 UreaN-19 Creat-0.8 Na-133
K-5.2* Cl-98 HCO3-24 AnGap-16
[**2145-11-4**] 10:25AM BLOOD K-5.3*
[**2145-10-27**] 10:29AM BLOOD ALT-13 AST-18 LD(LDH)-254* AlkPhos-52
TotBili-0.7
[**2145-10-27**] 10:29AM BLOOD CK-MB-2 cTropnT-<0.01
[**2145-10-26**] 03:15PM BLOOD Calcium-8.8 Phos-3.1 Mg-2.4
[**2145-10-27**] 01:15AM BLOOD %HbA1c-5.2
[**2145-10-27**] 01:15AM BLOOD Calcium-8.7 Phos-4.0 Mg-2.4 Cholest-218*
[**2145-10-27**] 01:15AM BLOOD Triglyc-65 HDL-44 CHOL/HD-5.0
LDLcalc-161*
[**2145-10-28**] 12:08AM BLOOD Homocys-13.3*
[**2145-10-28**] 12:08AM BLOOD TSH-1.6
[**2145-10-28**] 12:08AM BLOOD CEA-2.2 PSA-0.6
[**2145-11-3**] 03:38PM BLOOD FACTOR V LEIDEN-PND
[**2145-11-3**] 03:38PM BLOOD PROTHROMBIN MUTATION ANALYSIS-PND
[**2145-10-26**] - CT -neck with contrast.
CONCLUSION: Moderately high-grade stenosis of the origin of the
left internal carotid artery, likely with a combination of
atheromatous plaque and intraluminal thrombus, the latter
extending over substantial segment of the left internal carotid
artery within the neck. A second intraluminal thrombus appears
present within the distal left intratemporal and pre-cavernous
carotid artery.
10/09/7 - MRA head
CONCLUSION: Findings of concern for intraluminal thrombus within
the distal intra-temporal and pre-cavernous portions of the left
internal carotid artery. This finding appears to correlate with
the acute left middle cerebral artery ischemic zone noted on the
head images. See above report for additional findings.
[**2145-10-26**] - CT without contrast.
IMPRESSION:
1. Focal cortically based hyperdensity within the left frontal
lobe, most consistent with laminar necrosis rather than acute
hemorrhage.
2. Multiple hypodense regions within the left MCA territory
likely represent chronic infarction; however acute- on- chronic
infarction cannot be excluded.
[**2145-10-27**] - cerebral angiogram.
CONCLUSION: [**Known firstname 1158**] [**Known lastname 1182**] underwent _____ cerebral angiogram which
demonstrates left carotid bifurcation plaques, questionable
dissection with thrombus in the left internal carotid artery in
the cervical, petrous, and cavernous segment. There is no flow
limitation and all distal branches appear to be filling well.
[**2145-10-28**] - MRA of the neck with contrast.
IMPRESSION:
Markedly limited study, no definite evidence for dissection
seen.
[**2145-10-28**] - ECHO TEE
IMPRESSION: Thickening of the wall at the right sinotubular
junction suggestive of intramural hematoma or possible
atheromatous disease. A CT of the aortic root may clarify these
findings. No evidence of intracardiac thrombus or shunt.
[**2145-10-30**] - CT chest with and without contrast.
IMPRESSION: Normal aorta with no abnormalities of the aortic
root.
[**2145-11-2**] - CT abdomen and pelvis with contrast.
IMPRESSION: No evidence of intra-abdominal mass.
Brief Hospital Course:
Mr [**Known lastname 1182**] was admitted with worsening right hand
clumsiness/weakness, right facial droop and question of a PFO
and aortic root vegetation. Patient had anticoagulation
reversed at the outside hospital.
CTA here demonstrated clot in the left ICA. Patient was taken
for angiogram which suggested a dissection of the left ICA. MRA
with contrast did not suggest a dissection. There was no
further angiographic intervention.
A source for the clot was not identified. CT of the torso did
not demonstrate a lesion. Transesophageal echocardiogram
revealed thickening of the wall at the right sinotubular
junction suggestive of intramural hematoma or possible
atheromatous disease but no evidence of intracardiac thrombus or
shunt. A CTA of the chest did not demonstrate a sinotubular
abnormality. Hemoglobin A1C was normal. Started on coumadin for
stroke prevention after discussing risks and benefits.
A partial hypercoagulability workup was initiated. Homocysteine
was mildly elevated at 13.3, PSA and CEA were normal, Factor V
leiden and prothrombin gene mutation were pending at the time of
discharge.
Medications on Admission:
Coumadin 15mg/d x 4day/per week; 7.5mg/d x 3day/per week
Atenolol 25 mg [**Hospital1 **]
chantix
vitamin B1
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Warfarin 5 mg Tablet Sig: Three (3) Tablet PO DAILY16 (Once
Daily at 16).
Disp:*90 Tablet(s)* Refills:*2*
3. Outpatient Occupational Therapy
44 year old man status post left MCA infarction that severely
limits the strength and mobility of the right hand.
4. Outpatient Physical Therapy
Patient has been hospitalized with a left-MCA infarction. He
has been in the hospital now for 10 day and is somewhat
deconditioned. He could use some assistance with regaining his
strength.
5. Message to PCP`
Please tell your primary care doctor that your blood pressure
has not been elevated durinig your admnission and so you were
not restarted on your beta blocker. He may choose to restart
you on this medication and the chantix and B1 vitamin you were
taking prior to admission.
Discharge Disposition:
Home
Discharge Diagnosis:
Stroke. Left ICA clot.
Discharge Condition:
Vital signs are stable. The patient has residual right facial
droop, right wrist extensor weakness, and right finger extensor
weakness.
Discharge Instructions:
Please take your medications as prescribed.
Please follow up with your appointments as documented below.
The weakness in your right hand was caused by a stroke. You are
on a medicine called coumadin that thins your blood so that you
do not have another stroke. You will have to have your INR
measured regularly by your primary care physician. [**Name10 (NameIs) 357**]
return
Followup Instructions:
Please follow up with your primary care doctor tomorrow to have
your INR checked. Dr. [**Last Name (STitle) 60750**] ([**Telephone/Fax (1) 74785**]. 1:15pm [**2145-11-5**].
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2145-12-7**] 1:30
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]
Completed by:[**2145-11-10**]
ICD9 Codes: 2761, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1118
} | Medical Text: Admission Date: [**2132-7-22**] Discharge Date: [**2132-7-24**]
Date of Birth: [**2094-8-31**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 3290**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
Upper endoscopy with epinephrine injection and cauterization
History of Present Illness:
37M with history of back pain on ibuprofen presenting with two
days of black stools, severe nausea and vomiting, inability to
tolerate POs. Patient states that vomiting and diarrhea
episodes were occuring every two hours until last night, now
less frequent. Emesis was initially [**Location (un) 2452**], then coffee ground
since Sunday (last two days). Early this morning, he noticed
bright red blood streaks in emesis, small amount. He presented
to PCP today where stool was found hemoccult positive. Reports
epigastric cramping, no other abdominal pain. No hx of GERD,
gastric ulcers, liver disease. No prior abdominal surgeries. No
sick contacts. [**Name (NI) **] recent eating out or travel.
.
In the ED, initial vitals were as follows: 99.0 65 126/88 16
99% RA. Patient was having no abdominal pain or tenderness. NG
lavage was done in the ED which showed 200CC of coffee ground
emesis with some bright red blood. Hemoccult positive. No BRBPR.
Typed and crossed x2 units.
.
On the floor, patient feels well overall. Denies lightheadness.
Endorses abdominal cramping.
Past Medical History:
see admit H&P
Social History:
see admit H&P
Family History:
see admit H&P
Physical Exam:
Vitals: T: 99.2 BP: 145/78 P: 66 R: 14 O2: 99% 2LNC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: tatoos on left upper extremity
Pertinent Results:
On Admission:
[**2132-7-22**] 11:43AM BLOOD WBC-9.9 RBC-4.50* Hgb-14.7 Hct-40.5
MCV-90 MCH-32.6* MCHC-36.3* RDW-13.0 Plt Ct-257
[**2132-7-22**] 12:32PM BLOOD PT-14.3* PTT-20.0* INR(PT)-1.2*
[**2132-7-22**] 11:43AM BLOOD Glucose-133* UreaN-21* Creat-1.3* Na-144
K-3.4 Cl-103 HCO3-32 AnGap-12
On Discharge:
[**2132-7-23**] 06:40AM BLOOD WBC-6.5 RBC-3.95* Hgb-13.1* Hct-37.0*
MCV-94 MCH-33.2* MCHC-35.5* RDW-12.8 Plt Ct-223
[**2132-7-23**] 06:40AM BLOOD Glucose-91 UreaN-16 Creat-1.2 Na-142
K-3.2* Cl-106 HCO3-29 AnGap-10
Studies:
EGD [**2132-7-22**]-A single cratered ulcer was found in the pylorus.
A visible vessel suggested recent bleeding. 4cc epinephrine
1/[**Numeric Identifier 961**] injection was applied. A bipolar cautery probe was
applied for hemostasis successfully.
Erythema and congestion in the antrum compatible with gastritis
No blood was seen in the stomach or duodenal lumen.
The esophageal mucosa had a slightly 'furrowed' appearance,
which is a nonspecific finding. In the proper clinical setting
it can be indicative of eosinophilic esophagitis.
Brief Hospital Course:
Mr. [**Known lastname 10528**] is a 37 year-old man with history of high dose
ibuprofen use who presented with coffee ground emesis.
# Upper GI Bleed-The patient presented with N/V, coffe ground
emesis and dark stools for 2 days. In the [**Last Name (LF) **], [**First Name3 (LF) **] NG lavage
showed 200ml of coffee ground emesis with some bright red blood.
He was hemoccult positive. The patient was brought to the MICU
due to GI bleeding. In the MICU he underwent EGD where a
cratered ulcer with a visible vessel was found in the pylorus.
The vessel was cauterized and he was continued on a PPI gtt x1
day. H. Pylori testing was done and found to be negative. The
patient remained stable during his MICU stay and was ready fir
discharge on [**7-24**]. He will have a repeat upper endoscopy in
[**8-8**] weeks with Dr. [**First Name (STitle) 908**] and Dr. [**First Name (STitle) **] to confirm ulcer
healing. Also counseled to reduce NSAID use as this was likely
etiology of ulceration.
# Depression-No active issues. He was continued on home
citalopram after endoscopy.
Medications on Admission:
citalopram
ibuprofen 800mg - takes 4 times/day for last couple years
Discharge Medications:
1. clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
2. amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO twice a
day for 14 days.
Disp:*56 Capsule(s)* Refills:*0*
3. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*14 Adhesive Patch, Medicated(s)* Refills:*0*
6. acetaminophen 500 mg Capsule Sig: [**12-30**] Capsules PO three times
a day.
Disp:*42 Capsule(s)* Refills:*0*
7. diazepam 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Pyloric ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 10528**], you were admitted to the hospital with a bleeding
ulcer in your stomach. There are two potential causes of this.
First, ibuprofen can causes ulcers. Please stop taking ibuprofen
and discuss alternatives therapies for back pain with your
primary care physician. [**Name10 (NameIs) **], you were found to have a
bacteria called H.pylori that can cause ulcers. You will need to
take antibiotics for the next two weeks. It is important that
you complete the full course of antibiotics.
The gastroenterologists did an endoscopy to find the ulcer, and
they cauterized it. You will need to follow-up with your
gastroenterologist, and also have a repeat endoscopy in about 8
weeks.
You will need to continue a medication to reduce the amount of
acid in your stomach to prevent ulcers in the future.
Continue you current medications with the following changes:
STOP ibuprofen
START pantoprazole 40mg twice a day (for the ulcer)
START amoxicillin 1g twice a day for 14 days (for the H pylori)
START clarithromycin 500mg twice a day for 14 days (for the H
pylori)
START acetaminophen [**12-30**] pills up to three times a day for back
pain
START lidocaine patch once a day as needed for back pain
START donazepam one pill at bedtime as needed for back pain
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] A.
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2261**]
Appointment: Friday [**2132-8-1**] 10:30am
Name: [**Last Name (LF) 26390**], [**First Name7 (NamePattern1) 449**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2296**]
Appointment: Thursday [**2132-8-21**] 4:20pm
Completed by:[**2132-7-24**]
ICD9 Codes: 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1119
} | Medical Text: Admission Date: [**2124-3-8**] Discharge Date: [**2124-3-11**]
Date of Birth: [**2050-9-2**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 6807**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization with Drug Eluting Stent Placement
History of Present Illness:
Mr. [**Known lastname 106495**] is a 73 year old man with a history of AAA repair in
[**2120**], hyperlipidemia, SVT who presents with chest pain this
afternoon and found to have a STEMI. Mr. [**Known lastname 106495**] was running on
the treadmill at the gym and after the work out he noticed he
started to feel uncomfortable. He then noticed left sided chest
pressure that was not getting better. He then noted the pressure
was turning into pain and he turned to look for a trainer. He
noted associated dizziness, diaphoresis. When he found a
trainer, the trainer called 911 and EMS brought him to the ER.
In the ER, the patient was found to have an inferior STEMI. He
was plavix loaded with 600mg PO ONCE, Aspirin 324mg PO ONCE,
heparin bolus, eptifibatide bolus, and was given sublingual
nitroglycerin. He was rushed to the cath lab. In the cath lab,
he was found to have a completely occluded mid RCA clot, that
was removed and a DES was placed with good flow. He was also
noted to have a 60-70% proximal LAD lesion and an 80% distal LAD
lesion, clean LMCA, and LCx with mild dz. Repeat EKG showed
resolution of his ST elevations and his pain completely
resolved.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
- AAA repair in [**2120**], found via a routine KUB looking for kidney
stones
- SVT on metoprolol
3. OTHER PAST MEDICAL HISTORY:
- Asthma: Mild intermittent, uses albuterol PRN
- Nephrolithiasis
- Hernia repair
- GERD
Social History:
He lives in [**Location 745**] with his wife, he is a psychologist.
- Tobacco history: 30 packyears, quit 15 years ago
- ETOH: Rare use
- Illicit drugs: None
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Physical Exam:
PHYSICAL EXAMINATION on admission:
VS: T=98.2 BP=104/HR= 92 RR=14 O2 sat= 98%RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 3cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: AAOx3, CNII-XII intact, 5/5 strength biceps, triceps,
wrist, knee/hip flexors/extensors, 2+ reflexes biceps,
brachioradialis, patellar, ankle.
PULSES:
Right: 2+ DP 2+
Left: 2+ DP 2+
PHYSICAL EXAMINATION on discharge:
VS: T=98.3 BP=102/58 HR= 76 RR=16 O2 sat= 98%RA
GENERAL: NAD. Oriented x3.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 3cm.
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
Pertinent Results:
LABS ON ADMIT:
[**2124-3-8**] 01:20PM BLOOD WBC-14.4* RBC-4.72 Hgb-14.0 Hct-40.1
MCV-85 MCH-29.7 MCHC-35.0 RDW-12.9 Plt Ct-125*
[**2124-3-8**] 01:20PM BLOOD PT-12.2 PTT-130.0* INR(PT)-1.1
[**2124-3-8**] 01:20PM BLOOD Glucose-132* UreaN-24* Creat-1.5* Na-144
K-4.2 Cl-107 HCO3-22 AnGap-19
[**2124-3-8**] 01:20PM BLOOD CK-MB-76* MB Indx-9.0* cTropnT-1.37*
[**2124-3-9**] 03:53AM BLOOD CK-MB-86* MB Indx-5.4 cTropnT-5.94*
[**2124-3-8**] 01:20PM BLOOD Calcium-9.4 Phos-1.8* Mg-2.1 Cholest-138
[**2124-3-8**] 01:20PM BLOOD %HbA1c-5.7 eAG-117
[**2124-3-8**] 01:20PM BLOOD Triglyc-59 HDL-54 CHOL/HD-2.6 LDLcalc-72
CATH:
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
two-vessel coronary artery disease. The LMCA was free of
angiographically significant disease. The LAD had serial
stenoses with a
60-70% stenosis in the proximal segment and an 80% stenosis in
the
distal segment. The LCx had only mild diffuse disease. Overall
the left
system was relatively small compared with the right. The mid-RCA
was
thrombotically occluded. There were no distal collaterals.
2. Limited resting hemodynamics revealed normal resting central
aortic
pressure (105/62mmHg).
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease with mid-RCA occlusion as
culprit
for STEMI.
2. Normal resting central aortic pressures.
3. RCA STENTED WITH BMS
ECHO [**2124-3-9**]: The left atrium is normal in size. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with hypokinesis of the basal and mid inferior and
inferolateral segments. 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) appear structurally normal with good leaflet excursion. No
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. No mitral regurgitation is seen. There is
no pericardial effusion.
IMPRESSION: Mild focal LV systolic dysfunction consistent with
CAD. No significant valvular abnormality seen.
Brief Hospital Course:
73 year old man with a history of AAA repair in [**2120**],
hyperlipidemia, SVT who presents with chest pain this afternoon
and found to have a STEMI who is doing well after PCI.
.
# STEMI: Patient presents with an RCA MI consistent with
inferior territory, who improved significantly after PCI. No
signs of RV failure or shock. His LAD lesions are likely not
symptomatic given his excellent baseline functional capacity,
however, this will need to be reassessed in 1 month. His ASA
was continued at 325 for 1 month, then 81 for life. Plavix 75mg
PO daily was started for at least 1 year. Atorva 80mg PO daily
was started. Pt was given Eptifibatide for 18 hours post PIC. An
Echo was performed which showed. Lisinopril and Metoprolol XL
were started.
# CHF: No signs of CHF on exam.
# RHYTHM: Sinus rhythm at present, no evidence of VT or SVT. Pt
had some PVCs but no runs of SVT.
# LDL pipid panel showed well controlled lipids. Atorva 80 was
started
# Asthma: Stable. Home Albuterol PRN was continued.
# GERD: Pt was dc/ed on home omeprazole.
- DVT ppx with HSC
- Pain management with tylenol
- Bowel regimen with docusate
CODE: FULL CODE
Medications on Admission:
- Metoprolol 25mg PO daily
- Simvastatin 20mg PO daily
- Aspirin 81mg PO daily
- Omeprazole 1 tab PO daily
- Multivitamin 1 tab PO daily
- Calcium and vitamin D
- Albuterol neb PRN
- Tylenol PRN
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. clopidogrel 75 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).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. albuterol sulfate Inhalation
7. Tylenol Oral
8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
Three (3) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2*
9. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. nitroglycerin Sublingual
Discharge Disposition:
Home
Discharge Diagnosis:
ST-ELEVATION Myocardial Infarction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname 106495**],
It was a pleasure taking care of you here at the [**Hospital1 18**]. You were
admitted with concern that you were having a heart attack. You
underwent cardiac catheterization which revealed a blockage in
your arteries which was relieved with a stent. You were
discharged home with several medication changes.
NEW MEDICATIONS:
1. PLAVIX (blood thinner to prevent a blood clot) for at least
one year
2. Atorvastatin (cholesterol lowering medication)
3. LISINOPRIL(blood pressure lowering and heart-protective
medication)
CHANGED MEDICATIONS:
1. ASPIRIN (INCREASED FROM 81 TO 325) - please keep taking
larger dose for at least one month
2. Metoprolol (increased from 25 once daily to 75 once daily)
2. ASPIRIN 325 (blood thinner to prevent a blood clot) for at
least one month.
MEDICATIONS STOPPED:
1. SIMVASTATIN
2. ASPIRIN 81mg
Followup Instructions:
Please follow up with your PCP and your cardiologist, Dr
[**Last Name (STitle) 2257**], for your continued care.
.
Name: [**Last Name (LF) 17528**],[**First Name3 (LF) 17529**]
Specialty: INTERNAL MEDICINE
Location: [**Location (un) 2274**]-[**University/College **]
Address: [**Hospital1 3470**], [**University/College **],[**Numeric Identifier 23943**]
Phone: [**Telephone/Fax (1) 17530**]
Appointment: WEDNESDAY [**3-15**] AT 10:10AM
.
Name: [**Last Name (LF) **], [**First Name3 (LF) 251**] B. MD
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2258**]
Appointment: FRIDAY [**4-7**] AT 11:50AM
**You will be seeing Dr [**Last Name (STitle) 106496**] nurse practioner at this
visit.**
ICD9 Codes: 5849, 2724, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1120
} | Medical Text: Admission Date: [**2101-10-28**] Discharge Date: [**2101-11-1**]
Date of Birth: [**2080-10-3**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p motor vehicle crash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
20yo M s/p MVC, unrestrained, resulting in ejection from car,
intubated in field for GCS 3. The mechanism of the crash is not
known at the time. He was apparently noted to have some arm
twitching activity, and per report, his pupils were not
reactive. He was paralyzed with rocuronium at the field and had
been given ativan in the ED. It is not known if any drugs or
alcohol were involved. Became hypertensive and bradycardic in
ED, given mannitol.
Past Medical History:
ADHD per family
Social History:
social EtOH, positive for smoking
Family History:
non-contributory
Physical Exam:
Upon arrival to trauma bay:
VS: HR 40, BP 180s systolic
GEN: Intubated, sedated with propofol, rigors throughout his
extremities. Multiple lacerations noted.
HEENT: Intubated, left temporal scalp laceration. HARD C-collar
in place.
CV: Slow, regular, no murmurs
RESP: Clear anteriorly
ABD: Soft
EXT: Multiple lacerations, left wrist is particularly affected
NEURO: Pupils are reactive 2.5-1.5mm bilaterally, no corneals,
[**Name8 (MD) **] RN positive gag/cough. VOR not performed. Spontaneous
extensor posturing of his upper extremities, as well as to
nailbed pressure. Lower extremities withdraw to Babinski testing
and nailbed pressure.. Reflexes are symmetric and hyporeflexic
throughout. Toe is upgoing on the left.
Pertinent Results:
[**2101-10-28**] 09:02PM WBC-11.6* RBC-4.35* HGB-14.5 HCT-41.8 MCV-96
MCH-33.3* MCHC-34.7 RDW-12.2
[**2101-10-28**] 09:02PM GLUCOSE-83 UREA N-12 CREAT-1.0 SODIUM-136
POTASSIUM-3.7
[**10-28**] CT chest/abd/pelvis (PRELIM READ): Non-displaced fracture
through R posterior 10th rib. Small amount of dense fluid in the
pelvis. Bibasial dense opacities likely aspiration.
[**10-28**] CT head w/o contrast (PRELIM READ): 1. tiny foci of
hemorrhage in the left basal ganglia, lt subependymal and corpus
callosum (ant genu) concerning for [**Doctor First Name **]. 2. fracture of the left
lamina paprycea. ?? fx left orbital floor - dedicated ct facial
bones advised. 3. no skull fracture. B/l subgaleal hematoma.
[**10-28**] CT c-spine (PRELIM READ): Left C7 superior facet fracture.
no alignment abnormalities.
[**10-28**] CXR (PRELIM READ): Appropriately positioned ET and NG
tubes. No acute intrathoracic process.
[**10-29**] CT head: Decreased conspicuity of one white matter
hyperdense focus with two persistent additional hyperdense foci,
suggestive of diffuse axonal injury.
[**10-29**] CT max/face: Left orbital fracture. Disruption of the
medial wall of the left maxillary sinus with near-complete
opacification of the left maxillary sinus.
10/29 L forearm/elbow: transverse fracture of the proximal shaft
of the left ulna, with slight medial displacement of the distal
fracture fragment.
[**10-30**] CXR: New RLL opacification concerning for aspiration.
Brief Hospital Course:
Mr. [**Known lastname 91747**] was admitted to TICU for monitoring & continued
care. Neurosurgery was consulted for the punctate brain
hemorrhage and surgical intervention not warranted. Repeat CT
head consistent with persistent [**Doctor First Name **]. His neuro exam was followed
closely and continued to improve, moving all extremities and
following commands intermittently.
Orthopedic spine was consulted for the left C7 superior facet
fracture; he was placed in a hard cervical collar which will
remain in place for at least 8 weeks.
Plastics was consulted for the facial fractures which were also
managed non operatively. He was initially recommended for Unasyn
and placed on sinus precautions. Ophthalmology consulted for
assessing for globe entrapment and no acute issues were
identified.
He was seen by orthopedics for the left ulnar fracture which was
placed in a splint, he will return to [**Hospital 1957**] clinic in 2 weeks
for more xrays and assessment for the need for operative repair
at that time.
During his ICU stay he was noted with fever to 103.7 and was
pan-cultured. His CXR showed new RLL opacity; bronch was
performed which showed thick, purulent sputum (R>>L), BAL sent.
Empiric antibiotic coverage for aspiration pneumonia was started
with Vanc/Zosyn/Cipro.
He received 500cc NS bolus x2 given for low urinary output and
tachycardia with good response He remained stable and was
subsequently extubated. As he showed significant improvement he
was transferred to the regular nursing unit for ongoing care.
Once on the surgical [**Hospital1 **] he continued to progress. He was seen
by Occupational therapy and deemed appropriate for home with 24
hour supervision given his head injury. His IV antibiotics were
changed to po Levaquin. At time of discharge he was ambulating
independently and tolerating a regular diet. He and his family
were provided instructions on his necessary follow up
appointments and his medications were reviewed in depth.
He was discharged to home with his family.
Medications on Admission:
none
Discharge Medications:
1. Tylenol Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO
every six (6) hours as needed for pain.
2. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
5. senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day as needed
for constipation.
6. trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Disp:*30 Tablet(s)* Refills:*1*
7. Zyprexa Zydis 5 mg Tablet, Rapid Dissolve Sig: One (1)
Tablet, Rapid Dissolve PO twice a day as needed for agitation.
Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Motor vehicle crash
Injuries:
Closed head injury
Bilateral subgaleal hematomas
Left C7 superior facet fracture
Right post 10th rib fracture
Aspiration
Right femoral hematoma
Left orbital floor fracture
Fracture of the left lamina paprycea
Maxillary sinus medial wall fracture
Left ulnar fracture
Discharge Condition:
Level of Consciousness: Alert and interactive. Impulsive due to
brain injury.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a motor vehicle crash
where you sustained multiple injuries which include a small
closed brain injury with some bleeding beneath the scalp;
fracture of the bones in your face and around your eye called
the orbital bone; a fracture of the lower arm bone called the
ulnar and a spine bone fracture in the cervical bones that are
located in your neck - there was no injury to your spinal cord
itself. Because of this injury you are required to wear a hard
neck (cervical) collar for at least 8-12 weeks. You will then
follow up with the Orthopedic Spine doctor for more xrays after
that time period.
You were seen by the Occupational therapist and being
recommended to follow up with the Cognitive Neurologist after
discharge for your head injury.
Followup Instructions:
Follow up in Cognitive [**Hospital 86820**] clinic with Dr. [**First Name (STitle) **] in 1
week. Call [**Telephone/Fax (1) 1690**] for an appointment.
Follow up in [**Hospital **] clinic with Dr. [**Last Name (STitle) 1005**] in 2 weeks for
reassessment of your ulnar fracture. Call [**Telephone/Fax (1) 1228**] for an
appointment.
Follow up in [**Hospital 3595**] clinic with Dr. [**First Name (STitle) 3228**] for your facial
fractures in 2 weeks. Call [**Telephone/Fax (1) 5343**] for an appointment.
Follow up in Orthopedic Spine with Dr. [**Last Name (STitle) 1352**] clinic in 4
weeks. Call [**Telephone/Fax (1) 1228**] for an appointment.
Completed by:[**2101-11-2**]
ICD9 Codes: 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1121
} | Medical Text: Admission Date: [**2172-9-28**] Discharge Date: [**2172-9-30**]
Service: MEDICINE
Allergies:
Quinolones
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
acute blood loss
Major Surgical or Invasive Procedure:
RBC transfusion
History of Present Illness:
Ms. [**Known lastname **] is an 86yo woman with h/o recent stroke who was
transferred from [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] after being found to have a low
hematocrit. There was no reported bleeding and she was without
complaint. Per review of notes in the chart, there was no
preceeding diarrhea or vomiting. She does not have any
endoscopies or colonoscopies in the [**Hospital1 **] record. Pt denies abd
pain but hx limited by her aphasia/non-verbal status. Per PCP
and family, [**Name9 (PRE) 79134**] invasive treatment/work-up is preferred as
long as there is no significant GI bleed.
.
She was taken to [**Hospital1 18**] ED where her VS were stable, Hct 17.4,
and she was noted to have guaiac +, formed, brown stool. Coags
wnl at 1.2. Also had sodium 151, which has since resolved w/
D5W IF. Pt was given 2uRBCs, including that given in MICU. She
spent 1 day in MICU where her Hct bumped back to 17.4->27.7 o/n.
She was seen by GI who recommended conservative rx w/ PPI and
prn transfusions.
Past Medical History:
Alzheimer's Dementia
h/o L MCA stroke [**9-/2172**] with persistent hemiparesis and aphasia
HTN
B12 deficiency
Anemia with baseline Hct 25-27
h/o UTIs
Cataracts
Glaucoma
Social History:
Lives in [**Hospital3 **] facility ([**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **])
Does not smoke/ ETOH/ take illicit drugs.
Family History:
not available at present
Physical Exam:
VS: 98.1 102 134/95 19 100% RA
Awake, responsive and orients well to examiner. Unable to
produce coherent speech. +Cachectic.
EOMI. Right pupil is round and reactive but left is difficult to
appreciate if it is reacting. Will not open mouth or follow
commands but has a symmetric face.
Neck is supple
Heart is tachycardic and regular with a systolic murmur heard
best at apex, though not holosystolic.
No increased work of breathing, no accessory muscle use. Lungs
clear though does not breathe deeply.
Abd is soft and not tender.
LE are non-edematous b/l.
She is able to squeeze her left hand and slow the rate of fall
of her left leg. Right arm is kept in flexion and is resistant
to movement. 0/5 strength on right side.
Pertinent Results:
CBC: WBC-6.5# RBC-1.92*# Hgb-5.3*# Hct-17.4*# MCV-90# Plt Ct-271
Coags: PT-13.4 PTT-27.0 INR(PT)-1.2*
Chemistries:
153 117 42
-------------< 161
4.2 27 1.1
Hemolysis labs: calTIBC-334 Hapto-287* Ferritn-27 TRF-257
EKG: Sinus tachycardia. Borderline leftward axis. Possible prior
inferior
myocardial infarction. Compared to the previous tracing of
[**2172-9-8**] the findings are similar.
CXR: IMPRESSION: No evidence of pulmonary edema.
Brief Hospital Course:
This is an 86yo woman with dementia and h/o recent left MCA
stroke complicated by persistent aphasia and hemiparesis
admitted with acute hematocrit drop and guaiac positive stool.
.
# Anemia: Pt has chronic anemia w/ baseline Hct 25-27.
Hemolysis work-up was negative. Acute drop in Hct was thought
to be from GI source. Pt's Hct bumped appropriately with 2u RBC
transfusions, and she was monitored for 1 day in MICU, where she
remained hemodynamically stable. GI was consulted, and given
her family's desire for minimal intervention, she was managed
conservatively with PPI, Hct checks, and PRN transfusions. She
was also taken off ASA ppx for stroke, in setting of GIB.
Although labs do not show iron deficiency, she was supplemented
as she may continue to have GIB. Her Hct remained stable at ~25
on day of discharge. She should have her hematocrit checked on
the day after discharge. Her hematocrit should be regularly
monitored afterwards according to her attending doctor's
discretion, but we would advise that another Hematocrit be
checked this [**Last Name (LF) 2974**], [**10-2**], and that she be transfused
as needed to keep her Hct at baseline ~ 25
.
# Hypernatremia: Pt arrived with sodium of 153, which was
thought to be due to free water deficit from poor access to
water. She was gently hydrated with D5W and her hypernatremia
resolved and has remained within normal range.
.
# Elevated troponin: Patient unable to verbalize chest pain.
EKG does not show changes from prior tracing 3 weeks ago. Her
troponin remained stable at 0.03 after 3 sets of enzymes. She
was continued on home simvastatin.
.
# s/p Left MCA stroke: Continues to have significant aphasia and
right sided weakness. Keppra was continued. ASA was held in
setting of active bleed.
.
# HTN: Remained HD stable throughout hospitalization with good
BP control. Norvasc was held b/c of GI bleed, but discharge
instructions were to re-start her anti-hypertensive medications
at her long term care facility if she remained hemodynamically
stsable.
.
# h/o cataracts and glaucoma: Pt was continued on levobunolol.
She was given xalatan eye drops instead of travatan due to
formulary issues.
.
# Heel ulcer: Stage 1 pressure ulcer was identified this
admission. The pt's legs were kept in waffle boots to minimize
pressure to this area.
.
# Code: DNR/DNI
Medications on Admission:
ASA 325mg daily
Keppra 500mg [**Hospital1 **]
Simvastatin 20mg QHS
Norvasc 2.5mg QHS
Risperdal 0.25mg QHS--recently stopped [**Name8 (MD) **] MD
Lasix 20mg PO daily
Calcium + Vit D 500mg/200IU [**Hospital1 **]
Colace
Senna
Dulcolax
Travatan eye gtt OU QHS
Levobunolol 0.5% eye gtt OU QHS
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. Levobunolol 0.5 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. Ferrous Sulfate 325 mg (65 mg Iron) 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 Q12H (every 12 hours).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed.
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed.
8. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
This was held during the hospitalization, but should be
re-started if the patient's SBP remains stable >100.
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day: This
was held during the hospitalization, but should be re-started
and added back to her regimen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
-Acute-on-chronic anemia with guaiac + stools and no further GI
work-up secondary to family's desire for minimal intervention
-Hypernatremia secondary to inability to take adequate water,
resolved with IV fluids
Secondary:
-s/p left MCA stroke with persistent hemiparesis and aphasia
-Left heel ulcer
-Alzheimer's dementia
-Hypertension
-History of glaucoma & cataracts
Discharge Condition:
Improved hematocrit, hemodynamically stable
Discharge Instructions:
You were admitted for an acute drop in your blood count. Your
blood count stabilized after 2 units of blood transfusion. It
was thought that you are bleeding from your GI tract. Because
your family desires minimal interventions, we plan to
conservatively treat your bleeding by monitoring your blood
count and giving transfusions on an as needed basis.
Please continue to have your blood count monitored at your
living facility.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2172-10-5**] 1:30pm
Completed by:[**2172-10-1**]
ICD9 Codes: 2851, 5789, 2760, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1122
} | Medical Text: Admission Date: [**2145-11-17**] Discharge Date: [**2145-11-19**]
Service: CCU/MED
CHIEF COMPLAINT: Here for elective alcohol septal ablation.
HISTORY OF THE PRESENT ILLNESS: Ms. [**Known lastname 111649**] is a
79-year-old female with a history of heart failure secondary
to hypertrophic obstructive cardiomyopathy who presents to
the CCU following an alcohol ablation of her septum. The
patient has had the diagnosis of septal hypertrophy with
outflow obstruction, and cardiac catheterization in [**2144-10-3**] showed mild diagonal disease, severe mitral
regurgitation, diastolic dysfunction, severe left ventricular
outflow tract gradient of 100-110 mmHg. The patient has had
over the last few months worsening dyspnea on exertion,
fatigue with chores, and decreased exercise tolerance. She
has been followed in the Advanced Heart Failure Clinic by
both Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] as well as Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. She
denied any chest pain. She was referred by Dr. [**Last Name (STitle) **] for
alcohol ablation, which occurred on [**2145-11-17**].
Subsequently, she was transferred to the CCU team.
In the Cath Lab, alcohol ablation was successfully performed,
with a reduction of her peak left ventricular outflow tract
gradient to 10-15 mmHg (from 100-110 mmHg). There was also a
limited LCA injection which showed a normal large LCA.
Following her catheterization, she was transferred to the CCU
where she presented essentially denying any chest pain,
shortness of breath. She had no fever, chills, no urinary
symptoms, no vomiting, and no other complaints with the
exception of feeling tired.
PAST MEDICAL HISTORY: Significant for hypertrophic
cardiomyopathy, chronic DDD pacer for complete heart block
placed in [**2140-4-2**], history of endocarditis in [**2140-4-2**], and inguinal node biopsy that was notably benign.
FAMILY HISTORY: Her father had CAD (versus HOCM) and her
brother has CAD (versus HOCM).
CARDIAC RISK FACTORS: Include hypertension, hyperlipidemia.
SOCIAL HISTORY: She lives alone at home. She has two
daughters who are involved in her care; one lives in
[**State 4565**]. She is a nonsmoker and does not drink alcohol.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg q.d.
2. Verapamil 180 mg q.d.
3. Toprol XL 100 mg q.d.
4. Fosamax 70 mg q. week.
5. Wellbutrin 100 mg b.i.d.
6. Amiloride 5 mg q.d.
7. Nexium.
PHYSICAL EXAMINATION ON ADMISSION: Her heart rate was 64,
blood pressure 94/43. She was saturating 100% on 2 liters
nasal cannula. In general, she was pleasant and slightly
fatigued but in no apparent distress. Her eyes were
anicteric. Her oropharynx was clear without exudates. She
had a cardiac examination that was significant for regular
rate and rhythm, S1, S2, and a III/VI systolic ejection
murmur at the left upper sternal border consistent with
hypertrophic cardiomyopathy. Her lung examination was clear
to auscultation bilaterally without wheezes. Her abdomen was
soft, nontender, nondistended, with no organomegaly. Her
extremities had palpable pedal pulses bilaterally. Her right
groin site was without ecchymosis, nontender, and without
bruits. Neurologically, she was alert and oriented times
three. Her cranial nerve examination was grossly intact and
the remainder of her neurological examination was nonfocal.
LABORATORY STUDIES ON ADMISSION: Her white blood cell count
was 5.8, hematocrit 38.3, platelets 199,000. Her INR was
1.1. Her sodium was 137, potassium 5.0, BUN 29, creatinine
1.2, glucose 92.
IMAGING ON ADMISSION: On [**2145-11-17**], she had a
transthoracic echocardiogram status post ethanol ablation.
It demonstrated hyperenhancement of the basal septum. Her
left systolic function was excellent with an ejection
fraction of greater than 65%. She was also noted to have
mild to moderate mitral regurgitation. This was in
comparison to her preablation echocardiogram which again
demonstrated and EF of greater than 65% and left ventricular
outflow tract peak of 36-40. Her EKG postablation on
admission to the CCU demonstrated DDD pacing at 87 beats per
minute with a left bundle branch block (this is an old
finding).
HOSPITAL COURSE:
1. CARDIAC: Ischemia; the patient received an ethanol
ablation which is consistent with a deliberately induced
myocardial infarction. She had peak creatinine kinases of
868, peak MB 122, peak index 14.1. She had no ensuing chest
pain following her ablation. She was maintained on aspirin
at 325 mg q.d.
PUMP: Her postablation echocardiogram demonstrated an EF of
greater than 65%. She was maintained on her anticontractile
agents of Toprol XL at 100 mg q.h.s. and her verapamil SR was
slowly tapered from 180 mg to 120 mg q.a.m. upon discharge.
RHYTHM: The patient is chronically DDD paced. She had some
episodes of her native AV conduction demonstrated on
telemetry throughout her postablation course. Upon
discharge, she remained DDD paced with no further issues.
2. NEUROLOGY: Sedation was withheld postablation. The
patient was alert and oriented times three and had no further
issues in this regard.
Overall, the patient did well postprocedure, ambulated well
on postprocedure day number two, and was discharged home with
no further issues.
MEDICATIONS UPON DISCHARGE:
1. Toprol XL 100 mg p.o. q.h.s.
2. Verapamil SR 120 mg p.o. q.a.m.
3. Amiloride 5 mg p.o. q.d.
4. Bupropion 100 mg b.i.d.
5. Alendronate 70 mg q. week.
6. Aspirin 325 mg q.d.
Of note, the patient received a flu shot prior to discharge.
FOLLOW-UP: The patient will follow-up in three months with
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] appointment of which has already been
scheduled. Prior to this visit, she will receive a repeat
transthoracic echocardiogram which has already been
scheduled.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSIS: Hypertrophic cardiomyopathy, status
post alcohol septal ablation.
[**First Name11 (Name Pattern1) 420**] [**Last Name (NamePattern4) 421**], M.D. [**MD Number(1) 422**]
Dictated By:[**Name8 (MD) 17844**]
MEDQUIST36
D: [**2145-11-23**] 15:27
T: [**2145-11-26**] 06:54
JOB#: [**Job Number **]
ICD9 Codes: 4280, 4240, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1123
} | Medical Text: Admission Date: [**2125-6-16**] Discharge Date: [**2125-7-4**]
Date of Birth: [**2075-10-3**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
Cholangitis
Major Surgical or Invasive Procedure:
ERCP
Laparoscopic cholecystectomy.
Laparoscopic liver biopsy.
History of Present Illness:
49F transferred from [**Hospital3 **] Hospital after admission and
discharge for ERCP and stent placement 4 days ago for
cholelithiasis. Worsening jaundice, nausea, and vomiting x 24
hours.
Past Medical History:
hypothyroid and MR
Social History:
lives at group home
Family History:
Noncontributory
Physical Exam:
Upon presentation to [**Hospital1 18**]:
98.0 102 136/115 18 86
intubated
jaundiced
scleral icterus
CTAB
RRR
epigastric and ruq tenderness
no overt peritoneal signs
abd distended
dark urine
Pertinent Results:
[**2125-6-16**] 07:45PM GLUCOSE-88 UREA N-10 CREAT-0.9 SODIUM-136
POTASSIUM-3.0* CHLORIDE-102 TOTAL CO2-23 ANION GAP-14
[**2125-6-16**] 07:45PM ALT(SGPT)-35 AST(SGOT)-40 ALK PHOS-230* TOT
BILI-10.0*
[**2125-6-16**] 07:45PM WBC-15.4* RBC-3.67* HGB-12.0 HCT-37.4
MCV-102* MCH-32.8* MCHC-32.2 RDW-19.5*
[**2125-6-16**] 07:45PM PLT COUNT-202
[**2125-6-16**] 07:45PM PT-16.8* PTT-25.2 INR(PT)-1.5*
[**2125-6-16**] 07:45PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-8* PH-6.5 LEUK-NEG
[**2125-6-16**] 07:45PM URINE RBC-[**3-9**]* WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
CT abdomen: [**2125-6-19**]
1. Small hepatic abscess measuring up to 2.1 cm with gallbladder
likely source of the abscess as it abuts the gallbladder fundus.
2. No focal hepatic masses or intrahepatic biliary dilatation.
Biliary stent remains in place. Small amount of perihepatic
ascites.
3. Cholelithiasis.
4. Small bilateral pleural effusions with bibasilar compressive
atelectasis.
US [**2125-6-17**]:
1. Limited study. Multiple gallbladder stones without evidence
of gallbladder distention, wall thickening or pericholecystic
fluid. [**Doctor Last Name **] sign cannot be assessed secondary to patient's
intubated state.
2. Echogenic liver suggestive of fatty infiltration. Other forms
of liver disease including hepatic fibrosis/cirrhosis are not
excluded on the basis of this study.
Endoscopy histories:
ERCP [**2125-6-17**]:
A single, smaller size plastic stent placed in the biliary duct
was found in the major papilla, where a prior sphincterotomy had
been performed.
The stent appeared to be partially occluded, and was removed
using a metal snare.
After removal of the stent, drainage of purulent material was
noted.
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
Contrast medium was injected resulting in complete
opacification.
Multiple filling defect were noted in the biliary duct,
consistent with stones.
A 9cm by 10FR Cotton [**Doctor Last Name **] biliary stent was placed successfully
using a Oasis 10FR stent introducer kit over a guidewire.
Successful bile drainage was noted after stent placement.
Impression/Plan: 49 yo MR F s/p ERCP and stent placement for
cholelithiasis, complicated hospital course including sepsis p/w
persistent hyperbilirubinemia. The most likely etiology of pt's
persistent hyperbilirubinemia would be sepsis-induced
cholestasis. The other ddx includes extrinsic compression from
liver abscess or residue stones.
CXR [**2125-6-28**]
Left PICC is in place. Small bilateral pleural effusions, larger
on the left side, are unchanged allowing the difference in
positioning of the patient. Mild-to-moderate pulmonary edema
has minimally improved.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**2125-6-18**] at 4:00:00 PM FINAL
Test Information
Date/Time: [**2125-6-18**] at 16:00 Interpret MD: [**Name6 (MD) **] [**Name8 (MD) 4082**], MD
Test Type: Portable TTE (Congenital, complete) Son[**Name (NI) 930**]:
[**First Name8 (NamePattern2) 4134**] [**Last Name (NamePattern1) 4135**], RDCS
Doppler: Full Doppler and color Doppler Test Location: West
SICU/CTIC/VICU
Contrast: None Tech Quality: Suboptimal
Tape #: 2010W000-0:0 Machine: Vivid q-1
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.4 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.4 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.4 m/s
Left Atrium - Peak Pulm Vein D: 0.4 m/s
Right Atrium - Four Chamber Length: 4.4 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.5 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 2.4 cm
Left Ventricle - Fractional Shortening: 0.47 >= 0.29
Left Ventricle - Ejection Fraction: >= 65% >= 55%
Aorta - Sinus Level: 3.6 cm <= 3.6 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 1.2 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A ratio: 2.00
Mitral Valve - E Wave deceleration time: 225 ms 140-250 ms
TR Gradient (+ RA = PASP): <= 20 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Normal LA and RA cavity sizes.
RIGHT ATRIUM/INTERATRIAL SEPTUM: The patient is mechanically
ventilated. Cannot assess RA pressure.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%). Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded. No resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets. Mild (1+)
AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No
MVP.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA systolic pressure.
PERICARDIUM: There is an anterior space which most likely
represents a fat pad, though a loculated anterior pericardial
effusion cannot be excluded.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - poor parasternal views. Suboptimal
image quality - body habitus. Suboptimal image quality -
ventilator. Resting bradycardia (HR<60bpm).
Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened (?#). Mild (1+)
aortic regurgitation is seen. 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 an anterior space which
most likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Mild aortic regurgitation.
Normal biventricular cavity sizes with preserved global
biventricular systolic function. No definite congenital cardiac
anomalies identified.
CLINICAL IMPLICATIONS:
Based on [**2122**] 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.
Brief Hospital Course:
She was admitted to the surgical service and transferred to the
SICU due to sepsis. She was sedated and vented, requiring
pressors to maintain her blood pressure. Hepatology was
consulted, she underwent liver ultrasound and ERCP with stent
placement. Her LFT's were followed closely and have been
intermittently elevated; her Alk Phos and AST have trended
downward; the bili and ALT are very slowly coming down but
remain elevated. Her LFT's will need to be checked regularly
once at rehab.
She was eventually weaned from her pressors and off of the
ventilator and was taken to the operating room on [**7-2**] for
laparoscopic cholecystectomy and laparoscopic liver biopsy.
Postoperatively she was returned back to the SICU where she
continued to improve and was then eventually transferred to the
regular nursing unit.
She underwent a Speech and Swallow evaluation who recommended a
bedside swallow; her diet was upgraded to pureed and nectar pre
thickened liquids.
She was evaluated by Physical and Occupational therapy who have
recommended rehab after her acute hospital stay.
Medications on Admission:
abilify, aricept, levothyroxine, enulose, prilosec,
primidone, loratidine, vit c, vit d, klonopin, claritin, colace,
lactulose (doses not given in transfer)
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
2. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
3. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)).
4. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO BID
(2 times a day) as needed for constipation.
5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO 5X/WEEK
(MO,TU,WE,TH,FR).
6. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO 2X/WEEK
([**Doctor First Name **],SA).
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
Cholangitis
Discharge Condition:
Level of Consciousness: Alert and oriented x 2
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
No heavy lifting greater than 10 lbs for 6 weeks.
No tub baths but may shower.
Followup Instructions:
Follow up next week with Dr. [**Last Name (STitle) **], call [**Telephone/Fax (1) 600**] for an
appointment in the Acute Surgery clinic.
Completed by:[**2125-7-18**]
ICD9 Codes: 0389, 2761, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1124
} | Medical Text: Admission Date: [**2163-4-21**] Discharge Date: [**2163-5-5**]
Date of Birth: [**2100-9-29**] Sex: F
Service: SURGERY
Allergies:
Hydralazine Hcl / Iodine; Iodine Containing
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
several month history of intermittent changes in mental status
(odd affect, word finding problems, delayed verbal responses
progressing to unresponsiveness and - perhaps - right sided
weakness).
carotid stenosis
Major Surgical or Invasive Procedure:
[**2163-5-3**] Left internal carotid artery stent
History of Present Illness:
62 y/o female known to Dr. [**Last Name (STitle) **] for PVD now admitted
with multi-lobar pneumonia, NSTEMI and AMS. During workup for
episodic AMS issues during hospitalization, she received duplex
of carotid arteries showing 80-99% stenosis of the left internal
carotid artery, then confirmed by CTA. On retrospect, the
patient does not recall ever having any motor or sensory
deficits that would indicate a prior CVA or TIA. She does
relate a very short burst of garbled words that occurred approx
2-3mos ago. No other episodes of aphasia or dysphagia.
Past Medical History:
1) IDDM - Has had diabetes for 20 years. Checks fingersticks QAM
and sometimes QPM. Fingersticks generally in 100s. No problems
with hypoglycemia.
2) HTN - Baseline SBP generally 150-160 before dialysis, 130
after dialysis.
3) Anemia [**2-22**] chronic kidney disease
4) ESRD, on hemodialysis
5) Arthritis in her knees
6) Hyperlipidemia
7) COPD
8) Left Posterior tibial angioplasty [**2151**]
9) C-section [**2142**]
10) Cholecystectomy [**2132**]
Social History:
Immigrant from Barbados. Former hospital employee. 1 child, 18
years old. Husband also involved in care. Denies tob / etoh /
drug abuse
Family History:
mom / dad/ sister w/ DM type 2, sister had ESRD, sister with
CAD. Father w/ lung ca, though non-smoker
Physical Exam:
PHYSICAL EXAM:
98.8 74 121/43 18 94% ra FS 110-182
A&O, NAD
No focal neurologic deficits, CNII-XII intact, motor [**5-25**] b/l
LE/UE, sensory intact globally.
No dysarthria, no aphasia
No carotid bruits appreciated
RRR
Lungs clear bilaterally
Abd soft, obese, ND/NT, no AAA appreciated
No LE edema
Pulses Fem DP PT
Rt P Dop Dop
Lt P P Dop
Groin- C/D/I. No hematoma or bleeding
Pertinent Results:
[**2163-5-5**] 08:40AM BLOOD WBC-10.5 RBC-4.66# Hgb-13.3# Hct-38.1
MCV-82 MCH-28.6 MCHC-35.0 RDW-17.1* Plt Ct-247
[**2163-5-5**] 08:40AM BLOOD Plt Ct-247
[**2163-5-5**] 08:40AM BLOOD Glucose-141* UreaN-14 Creat-4.2*# Na-139
K-5.0 Cl-97 HCO3-30 AnGap-17
[**2163-4-28**] 08:50AM BLOOD ALT-28 AST-28 LD(LDH)-342* AlkPhos-68
TotBili-0.4
[**2163-5-5**] 08:40AM BLOOD Calcium-9.4 Phos-3.1# Mg-1.8
Brief Hospital Course:
[**Date range (1) 109294**]/10 On Medical Service
Altered Mental Status: Patient was working with nursing and
after standing from the comode and standing from the bedside
chair she was noted to have a "glazed" look on her face, become
slow to respond, and improve with lying flat, though not to her
full baseline. An EKG was checked, electrolytes were checked,
cardiac enzymes were checked, a CXR was checked and a blood gas
was drawn. EKG was unchanged from prior, electrolytes were
notable for a bicarb of 35, CE were not elevated, and CXR was
unchanged. ABG was 7.47 PCO2 51 and pO2 78. The patient had
positive orthostatics. Our conclusion was that the patient was
dry between being run negative in dialysis and having had
diarrhea all day yesterday. However as this continued to recurr
we became suspicious for other pathologies. Doppler of the
carotids was undertaken revealing an 80-99% stenosis of the left
carotid leading ot vascular consult and below hospital course.
.
PNEUMONIA: The shortness of breath, cough, elevated white count
with left shift and RUL infiltrate on chest film are consistent
with pneumonia. Given her history of dialysis, she meets the
definition for a healthcare acquired infection. Agree with
antibiotic choices in MICU as patient is clinically improving.
ID ok'd vancomycin today
- attempt sputum culture
- f/u blood cultures
- continue vancomycin, ceftriaxone, azithromycin plan 7-10d
course
- supportive treatment of cough
- Duonebs
.
NSTEMI: Patient ruled in with Cardiac enzymes, cards was
consulted in the unit and was briefly placed on heparin. Noting
that she is pain free this likely demand ischemia. Her MB
fraction remains low and stable, and its hard to interpret her
CK and Troponins in the setting of her renal faillure. Cards
was following and was consulted last night and stated that there
would be no benefit to cathing uless the patient is either a)
having a STEMI or b) having chest pain as cathing for angina or
demand ischemia has only a symptomatic benefit without a
survival benefit. We will cycle her enzymes again for full rule
out, though this mornings event was highly unlikely to be
cardiac.
- monitor on telemetry
- continue aspirin
- continue statin
- continue beta blocker
- finish rule out
.
ESRD: Patient with ESRD on hemodialysis on
Monday/Wednesday/Friday schedule currently being evaluated for
renal transplant. Patient with electrolytes at baseline.
.
PVD: aspirin and plavix were continued
.
DM:
- We continued home insulin regimen with ISS
.
HYPERTENSION:
- We continued labetalol, amlodipine, lisinopril
.
# FEN: No IVF, replete electrolytes, regular diet
# Prophylaxis: Subcutaneous heparin
# Access: peripherals
# Communication: [**Name (NI) 109295**] (husband) [**Telephone/Fax (1) 109296**]
# Code: Full (discussed with patient)
# Disposition: Floor for now
[**2163-5-3**] Underwent uneventful left carotid stent and transfered
from medical service to vascular surgery/[**Doctor Last Name **] service.
POC- VSS, on nitro for BP control (SBP kept 110-140). Neuro
intact. RT groin with small amount of bloody drainage. No
hematoma. Bedrest, NPO overnight.
[**2163-5-4**]- VSS. No events. Renal following for HD. Nephrocaps
requested by renal and ordered. Jolsin following for BS
management, no new orders. WIll continue current insulin regime.
Nitro weaned to off. Neuro follwoing. Neuro exam stable post
carotid stent, signed off. Transfused 2u PRBCs with HD.
[**2163-5-5**] VSS. No events. RT groin is stale. Discharged home.
Follow up visit and duplex with Dr. [**Last Name (STitle) **] scheduled in 4 weeks.
Medications on Admission:
Active Medication list as of [**2163-4-21**]:
Medications - Prescription
AMLODIPINE [NORVASC] - 10 mg Tablet - one Tablet(s) by mouth
once
a day
ATORVASTATIN [LIPITOR] - 40 mg Tablet - 1 Tablet(s) by mouth
once
a day
CALCITRIOL - (Prescribed by Other Provider) - 0.25 mcg Capsule
-
1 (One) Capsule(s) by mouth three days a week, on Monday,
Wednesday and Friday. Pt. states she is not taking, ran out.
CALCIUM ACETATE - (Prescribed by Other Provider) - 667 mg
Capsule - 1 Capsule(s) by mouth three times a day
CLOPIDOGREL - 75 mg Tablet - 1 Tablet(s) by mouth once a day
FLUOCINONIDE - 0.05 % Cream - applly to affected areas twice a
day
INSULIN LISPRO PROTAM & LISPRO [HUMALOG MIX 75-25] - 100 unit/mL
(75-25) Suspension - inject subcutaneously 30u in am/45u in pm
IPRATROPIUM-ALBUTEROL [COMBIVENT] - 18 mcg-103 mcg (90
mcg)/Actuation Aerosol - 1-2 puffs(s) po every six (6) hours sob
LABETALOL - 200 mg Tablet - 1 Tablet(s)(s) by mouth twice a day
LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth twice daily
hold
a.m. dose on dialysis days
TRAMADOL - 50 mg Tablet - 1 Tablet(s) by mouth twice daily as
needed for pain
Medications - OTC
ASPIRIN - 81MG Tablet - ONE BY MOUTH EVERY DAY
B COMPLEX-VITAMIN C-FOLIC ACID - 400 mcg Tablet - 1 Tablet(s) by
mouth daily
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - use
as directed to test blood sugar up to qid
DOCUSATE SODIUM - (OTC) - 100 mg Capsule - 1 Capsule(s) by
mouth
twice a day as needed for constipation
INSULIN SYRINGE-NEEDLE U-100 [BD INSULIN SYRINGE] - 28 gauge X
[**1-22**]" Syringe - use as directed for insulin twice a day .5 cc
LANCETS - Misc - AS DIRECTED FOR CHECKING BLOOD SUGAR
POLYVINYL ALCOHOL [ARTIFICIAL TEARS] - (OTC) - Dosage uncertain
SENNA - (OTC) - 8.6 mg Tablet - 1 Tablet(s) by mouth twice
daily
as needed for constipation
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Month/Day (2) **]:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): refill per PCP.
[**Name Initial (NameIs) **]:*60 Tablet(s)* Refills:*0*
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Do not discontinue with discussing with Dr.
[**Last Name (STitle) **] or Dr. [**Last Name (STitle) **].
[**Last Name (STitle) **]:*30 Tablet(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-22**]
Inhalation every six (6) hours as needed for cough.
8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
[**Month/Day (2) **]:*qs ML(s)* Refills:*0*
10. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
12. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
[**Month/Day (2) **]:*30 Capsule(s)* Refills:*0*
13. Insulin
Breakfast Dinner
Humalog 75/25- Take 20 Units at Brekfast and DInner
Breakfast Lunch Dinner Bedtime
Humalog Sliding Scale
Glucose Insulin Dose
0-70 mg/dL eat/drink, [**Name8 (MD) 138**] MD
[**MD Number(1) 109297**] mg/dL 0 Units
151-200 mg/dL 3 Units
201-250 mg/dL 5 Units
251-300 mg/dL 7 Units
301-350 mg/dL 9 Units
351-400 mg/dL 11 Units
> 400 mg/dL Notify M.D.
14. Humalog Insulin 75/25 Sig: 20 units twice a day:
breakfast and dinner.
15. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily): refills per renal.
[**MD Number(1) **]:*30 Cap(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Vascular:
62F w/ 80-99% stenosis of the left internal carotid artery, ?
asymptomatic found during w/u of altered mental status; MRI
evidence of infarct, now s/p L carotid stent
Admitted with Primary diagnosis:
-Hospital acquired pneumonia
-NSTEMI
-Altered mental status
-Orthostatic in setting of diarrhea
Secondary:
-End-stage renal disease
-Diabetes mellitis, type 2
-Hypertension
-Hypercholesterolemia
Discharge Condition:
Alert and oriented x3
Discharge Instructions:
The following changes were made to your medications:
-Started Loperamide 2mg up to 4x a day as needed for diarrhea
-Started Guaifenesin 5-10ml every 6 hrs as needed for cough
-Aspirin increased to 325mg daily
-Atorvastin increased to 80mg daily
.
Continued the following medications:
Calcium acetate
Labetalol
Plavix
home regimen of insulin
lisinopril
combivent nebs
senna
colace
artificial tears
amlodipine
vitamin B and vitamin C complex
tramadol
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Division of Vascular and Endovascular Surgery
Carotid Stent Discharge Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Take Plavix (Clopidogrel) 75mg once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? You should not have an MRI scan within the first 4 weeks after
carotid stenting
?????? Call and schedule an appointment to be seen in [**3-24**] weeks for
post procedure check and ultrasound
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
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Dr. [**Last Name (STitle) **] [**6-1**] at 9am. You will have a carotid ultrasound and
then see Dr. [**Last Name (STitle) **]. [**Telephone/Fax (1) 2395**]
IT IS EXTREMELY IMPORTANT THAT YOU CALL YOUR PRIMARY CARE DOCTOR
ON MONDAY TO SET UP AN APPOINTMENT FOR SOMETIME IN THE NEXT WEEK
[**Telephone/Fax (1) 250**]
.
Department: [**Hospital3 1935**] CENTER
When: TUESDAY [**2163-5-10**] at 11:15 AM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 252**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: TRANSPLANT CENTER
When: FRIDAY [**2163-5-20**] at 1 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: TRANSPLANT CENTER
When: FRIDAY [**2163-5-20**] at 2:00 PM
With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Neurology: Dr. [**Last Name (STitle) **] on [**6-7**] at 1pm
Completed by:[**2163-5-12**]
ICD9 Codes: 486, 5856, 496, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1125
} | Medical Text: Admission Date: [**2135-1-26**] Discharge Date: [**2135-2-2**]
Date of Birth: [**2066-7-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
respiratory difficulty
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Briefly, 68 yo M with obesity, COPD, DM2, atrial flutter on
warfarin, who presented with increased SOB and cough x 2 days. A
week ago PTA he had a sore throat, some rhinorhea followed by a
productive cough with clear sputum. Two days PTA he noticed to
have increased SOB associated with wheezing. At baseline,
patient is on 2L of O2 with saturation from the high 80s into
the low 90s. The night PTA he had decreased O2 sats. The morning
of admission, his temperature was 101F. No chills, rigors,
nightsweats, mylagias or arthralgias. He reports a about 20 lbs
weight gain over the last six month after loosing about 50lbs in
the year prior.
.
The patient also reports a buttock abscess that has been present
for several days. The abscess is initially very painful and then
bursts and drains and then resolves. He has had recurrent rectal
abscesses in the past and surgery was been suggested.
.
ED course: VS 100.0, HR 131, BP 166/83, RR 23, 97 NRB. ABG
7.42/74/72. Pt was given Dilitazem 20mg x2 and 25mg x1 for Afib
with RVR and then started on a Dilitazem gtt for rate control.
He was given one Albuterol nebulizer, Methylprednisolone, O2 was
titrated down ot 40% Venti mask. He also received 1L NS. He
maintained pressures in the 110-150s systolic. A CXR was done
and was negative for a overt infiltrate or pulmonary congestion.
His INR was elevated at 4.9.
.
MICU course: He couldn't tolerated BIPAP/CPAP, gradually
improved on Vmask with standing nebs. He was started on
azithromycin for presumed pneumonia. Prednisone 60 mg qday was
started on [**2135-1-27**]. His diltiazem drip was slowly weaned off, and
he was back on PO dilt with HR around 100, with no symptom. His
warfarin was held because of INR 5.0. Transferred to the floor
for more management.
Past Medical History:
Diabetes mellitus II
Morbid Obesity
COPD - no hx of intubations or steroids, uses inhalers?
Cor Pulmonale, Pulmonary hypertension- admitted to [**Hospital Unit Name 196**] for
Obstructive sleep apnea- does not use CPAP; sleeps upright in
chair
Polycythemia [**Doctor First Name **]- has received multiple phlebotomies in past
Diverticulitis- s/p partial colectomy and colostomy in [**2097**] w/
reanoastomeses in [**2099**]
Status post partial colectomy
Gout
Psoriasis
Morbid obesity
partial tear of R. achilles tendon
Oateomyelitis and cellulitis- [**2122**]
Social History:
Smoked tobacco 2 packs per day for 40 years, stopped smoking in
[**2122**], but has [**11-24**] cigarettes/week. 1 drink of alcohol per day,
either beer, whiskey. Married and lives with wife.
Family History:
no CAD, no COPD. Father- died of cancer, mother- [**Name (NI) **],
stroke
Physical Exam:
VS T 98.2 BP 127/80 HR 122 RR 20 O2Sat 89% 50% Venti mask
Gen: NAD, AAOx3
HEENT: NC/AT, PERRLA, mmm
NECK: no LAD, no JVD, no carotid bruit
COR: tachycardic, S1S2, regular rhythm, no m/r/g
PULM: decreased breath sounds in the bases, moderate air
movement, diffuse wheezing
ABD: + bowel sounds, soft, nd, nt
Skin: warm extremities, psoriatic rash, abscess open on L
buttock, mild erythema around, no tenderness
EXT: 2+ DP, no edema/c/c, no CVA tenderness
Neuro: moving all extremities, moving all extremities, PERRLA,
AAOx3
Pertinent Results:
[**2135-1-26**] 10:50AM WBC-12.3*# RBC-4.88 HGB-13.9* HCT-44.1 MCV-90
MCH-28.5 MCHC-31.6 RDW-16.1*
[**2135-1-26**] 10:50AM PLT COUNT-270
[**2135-1-26**] 10:50AM PT-43.9* PTT-40.7* INR(PT)-4.9*
[**2135-1-26**] 10:50AM GLUCOSE-210* UREA N-15 CREAT-0.8 SODIUM-141
POTASSIUM-4.6 CHLORIDE-91* TOTAL CO2-43* ANION GAP-12
.
Brief Hospital Course:
68 yo with COPD, morbid obesity, now p/w with COPD exacerbation,
likely triggered by URI.
.
# Hypoxia: admission exam c/w with COPD exacerbation. ABG with
PCO2 at baseline. No evidence of pulmonary infiltrate suggestive
of PNA. Trigger for COPD exacerbation could be recent URI, also
?influenza, although patient received vaccine. DFA neg. Low
probablity of PE. Patient's respiratory status improved with
ipratropium Q6h, albuterol Q2h prn, Q4h standing, prednisone,
azithromycin.
.
# Afib: with episodic RVR. Patient was transferred to the
cardiology service for rate control of atrial fibrillation with
rapid ventricular response. His rate controlling regimen was
changed to diltiazem 120mg po q6hrs and lopressor 125mg po tid.
The high dose of beta blocker did not worsen his breathing with
his COPD flare and in fact his breathing had improved likely due
to the effect of steroid / abx / bronchodilators he had been on.
His outpatient EP fellow was contact[**Name (NI) **] and agreed with the rate
control choices, the patient should follow up with EP as an
outpatient. Rate controlled to a range of 90-110 on the
cardiology floor and patient was transferred back to medicine
service for further management of COPD flare.
.
# Recent fever: likely due to URI. Unlikely to be due to rectal
abscess. Cultures were negative. Fever resolved.
.
# Diabetes mellitus: Continued on metformin and insuline
regimen.
.
# Coagulopathy: on warfarin for atrial flutter, goal [**12-26**]; INR 5
on admission with no sign of bleeding, and warfarin was held.
His INR gradually decreased to 1.9 and warfarin was restarted.
.
# HTN: was continued on diltiazem and metoprolol. Lisinopril and
furosemide were initially held due to signs of dehydration but
were then restarted.
.
# FEN: Regular; Low sodium / Heart healthy, Diabetic/Consistent
Carbohydrate, replete lytes
.
# Code: Full
Medications on Admission:
Allopurinol 100 mg daily
Diltiazem 360 mg daily
Lasix 80 mg twice a day
Lisinopril 10 mg daily
Glucophage 1000 mg tablets twice a day
Metoprolol 25 mg twice a day
Omeprazole 20 mg twice a day
Percocet as needed
Pregabalin (Lyrica) 50 mg daily
Simvastatin 10 mg daily
Warfarin 7.5 mg four days a week and 5 mg, three days a week
Ambien 10 mg daily
Aspirin 325 mg daily
Colace daily
Flax seed oil daily and glucosamine chondroitin daily and MVI
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Diltiazem HCl 240 mg Tablet Sustained Release 24 hr Sig: Two
(2) Tablet Sustained Release 24 hr PO once a day.
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
3. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
Disp:*225 Tablet(s)* Refills:*2*
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
8. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Pregabalin 50 mg Capsule Sig: One (1) Capsule PO once a day.
13. Ambien 10 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
14. Warfarin 5 mg Tablet Sig: As directed Tablet PO DAILY16
(Once Daily at 16): 7.5 mg four days a week and 5 mg, three days
a week .
15. Prednisone 10 mg Tablet Sig: As directed Tablet PO once a
day for 10 days: 40mg x 2 days
20mg x 4 days
10mg x 4 days.
Disp:*20 Tablet(s)* Refills:*0*
16. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*1 Cap(s)* Refills:*2*
17. Insulin Lispro 100 unit/mL Insulin Pen Sig: As directed
Subcutaneous three times a day: Please see attached insulin
sliding scale.
Disp:*1 pen* Refills:*2*
18. Glucometer Elite Classic Kit Sig: One (1) Kit
Miscellaneous once a day.
Disp:*1 Kit* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
1. Chronic obstructive pulmonary disease, exacerbation
2. Atrial fibrillation with rapid ventricular rate
3. Depression
Secondary:
1. Diabetes mellitus, type II
Discharge Condition:
Hemodyamically stable with oxygen saturations in the low 90s on
2 liters.
Discharge Instructions:
You were admitted with an exacerbation of COPD and elevated
heart rates. Please be sure to follow-up with your primary care
provider and pulmonologist.
For your COPD, please complete a taper of prednisone, as
directed. Continue with home oxygen with monitoring of O2
saturations.
For your atrial fibrillation, your heart rate medication regimen
has been changed; please note the following:
1. Your diltiazem dose has been increased to 480mg daily
2. Your metoprolol dose has been increased to 125mg THREE TIMES
daily
While on prednisone, you should be sure to check your blood
sugar 3 times daily and administer insulin based on the sliding
scale provided.
Followup Instructions:
1. PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2135-4-21**]
12:55
2. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2135-4-21**] 1:15
3. PFT,INTERPRET W/LAB NO CHECK-IN PFT INTEPRETATION BILLING
Date/Time:[**2135-4-21**] 1:15
You also have an appointment scheduled with Dr. [**First Name (STitle) 1313**] for
Tuesday [**2-8**] at 4pm.
ICD9 Codes: 486, 4280, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1126
} | Medical Text: Admission Date: [**2188-5-20**] Discharge Date: [**2188-5-25**]
Date of Birth: [**2129-7-6**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 371**]
Chief Complaint:
58y Male presenting via transfer from OSH. Involved in low speed
scooter accident with loss of consciousness, intubated at OSH.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient in scooter accident, GCS 14 at scene, repetitive verbal
response, intubated at [**Hospital **] transfered to [**Hospital1 18**]. CT of head,
c-spine, face, torso performed. No evidence of intracranial
bleed, c-spine injury, or intrabdominal injury. Facial CT
demonstrated nasal bone fracture and chronic R maxillary sinus
fracture. CT torso: Left ribs [**2-28**] fractured.
Social History:
ETOH abuse, horse trainer
Physical Exam:
GEN: Intubated and sedated
HEENT: PERRL, abrasions on left face, 3cm lac on left forehead
RESP: Bilateral breath sounds, clear lung fields,
CV: Regular rate rhythum, no murmurs, gallops, rubs
ABD: Soft, non-distended
GU: no blood at meatus, good rectal tone, no blood on DRE
EXT: no gross deformities, no edema/clubbing/cyanosis
SKIN: 3-4cm lac left forehead, abrasion left cheek,
Pertinent Results:
[**2188-5-20**] 10:24PM 7.28/129/50
[**2188-5-20**] 05:28PM ALT(SGPT)-102* AST(SGOT)-141* LD(LDH)-273*
ALK PHOS-100 AMYLASE-99 TOT BILI-1.1
[**2188-5-20**] 05:28PM WBC-8.8 RBC-3.59* HGB-12.4* HCT-35.3* MCV-98
MCH-34.5* MCHC-35.1* RDW-13.2
[**2188-5-20**] 05:28PM PT-15.0* PTT-30.1 INR(PT)-1.3*
[**2188-5-20**] 05:28PM GLUCOSE-82 LACTATE-1.4 NA+-146 K+-4.1 CL--109
TCO2-24
CT chest-Multiple left-sided rib fractures extending from rib 4
to rib 10 are noted. The fractures are anterior superiorly and
aligned obliquely in more lateral and posterior regions
inferiorly. There is no pneumothorax
CT face-1. Bilateral nasal alar lucencies could represent
nondisplaced fractures of unknown chronicity. Correlation with
physical exam is recommended.
2. Right zygomatic arch and lateral maxillary sinus wall
deformity could
reflect healed, old fractures.
Brief Hospital Course:
Pt admitted to T-SICU, intubated. CTLS spine cleared, CT showed
left rib fractures, [**2-28**], nasal bone fractures, old R maxillary
sinus fracture. Pt. weaned from vent and extubated on HD 2
(7/2/08/). Pain control post-extubation was managed via
placement of a thoracic epidural. Ativan given per CIWA scale.
Pt transfered out of T-SICU on HD 3 ([**2188-5-22**]). Epidural was
displaced during transfer, pt opted not to have cathter
replaced, oral pain meds started, oxycodone SR 10mg and
neurontin 200mg TID. Physical therapy evaluated for safety and
need for rehabilitation, recommendation home without rehab.
Discharged to home with follow-up in trauma clinic on [**2188-6-3**]
Medications on Admission:
none
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*20 Capsule(s)* Refills:*0*
2. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO twice a day.
Disp:*30 Tablet Sustained Release 12 hr(s)* Refills:*0*
3. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO three times
a day.
Disp:*45 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left rib fractures, #[**2-28**], nasal bone fracture, R maxillary
sinus fracture
Discharge Condition:
Good, hemodynamically stable, pain controlled, tolerating
regular diet.
Discharge Instructions:
Return to emergency department if intolerable pain, chest pain,
shortness of breath, fever >101.4.
Followup Instructions:
f/u in trauma clinic on [**2188-6-3**] call [**Telephone/Fax (1) 79580**] for
appointment
Completed by:[**2188-5-27**]
ICD9 Codes: 5180, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1127
} | Medical Text: Unit No: [**Numeric Identifier 65427**]
Admission Date: [**2154-11-30**]
Discharge Date: [**2154-12-19**]
Date of Birth: [**2154-11-30**]
Sex: F
Service: Neonatology
HISTORY: This patient is a 2.7 kg product of a 38 week
gestation, born by Cesarean section for an abnormal
biophysical profile on the day of delivery. The patient was
being followed by maternal fetal medicine for a bilateral
cleft lip and palate. According to maternal fetal medicine,
the remainder of the fetal survey was unremarkable. A
karyotype was reported as normal. The mother was seen by
[**Name (NI) 65428**] at TCH and had a neonatology consult prior to delivery.
Mother is a 23 year-old, Gravida I, Para 0, now I mother. HBSAG
negative. RPR nonreactive. Rubella immune. Blood type is B
positive, antibody negative.
At delivery, the infant emerged pale, had decreased respiratory
effort and a heart rate in the 60 to 80 range. The heart rate
responded to bagged mask ventilation. Pulses were palpable
bilaterally. The Apgars were 3, 5 and 7. The infant was brought
to the NICU. Parents both speak Portuguese only and have
required a translator throughout the course in the NICU.
PHYSICAL EXAMINATION: There is a unilateral cleft lip on the
left with a bilateral cleft palate. Otherwise, non dysmorphic
infant. Extremely pale on admission with normal skin color
following a transfusion and an isovolemic exchange. The eyes
were normal. Neck was supple without any sinus tract. Skin had
no lesions. Normal S1 and S2 and heart sounds, without any
murmur. Lungs had mild grunting initially with good air entry.
The abdomen was soft and benign. Genitalia were normal female.
Hips normal. Neurologically, there was nothing focal except for
the presence of an extensor posturing on occasion. The tone was
initially decreased but then became normal on admission.
Infant's birth weight was 2705. Head circumference was 34 cm and
length was 47.5 cm.
HOSPITAL COURSE BY SYSTEMS:
1. Respiratory: On admission to the NICU, the infant was on
blow-by oxygen with moderate respiratory distress evident by
grunting . The initial ABG was 7.02 pH, 21 C02, P02
of 322; bicarbonate of 6 and base excess of negative 24.
The infant received sodium bicarbonate at that time. A
repeat blood gas shortly after showed a pH of 7.01, C02
of 39, P02 of 67, bicarbonate of 8 and base excess of
negative 23. The infant received a subsequent dose of
sodium bicarbonate. The grunting started to resolve and
the infant went to room air shortly thereafter. Due to
intermittent desaturations, the infant then went back on
nasal cannula oxygen briefly prior to going back to room
air the next day.
The infant received a total of 7 meq/kg of sodium bicarbonate
in the first 24 hours of life for metabolic acidosis. The
infant was placed in nasal cannula oxygen again on day of
life 1 which is [**2154-12-1**] for borderline desaturation. She
remained in nasal cannula oxygen until [**2154-12-8**], day of life
8 when she successfully weaned to room air. She has remained
stable on room air with only occasional drifting
desaturations which resolved by [**2154-12-12**], day of life 12.
2. Cardiovascular: The infant presented with mild
hypotension on the first day of life and required a
Dopamine infusion with a maximum of 5 mcg/kg per minute
but quickly weaned off Dopamine by day of life 1. A soft
murmur presented on day of life 1 which is [**2154-12-1**]. An
EKG was done which was essentially read as normal.
Cardiology consultation was done with an echocardiogram
on [**2154-12-3**]. The echocardiogram showed a PFO versus an
ASD. Dr. [**Last Name (STitle) 10123**] was the cardiologist who evaluated the
baby and recommends follow-up at 3 to 6 months to re-
evaluate the ASD versus the PFO. Dr.[**Name (NI) 65429**] phone
number is [**Telephone/Fax (1) 37115**].
3. Fluids, electrolytes and nutrition: The infant was made
n.p.o. on admission to the NICU. Intravenous fluids were
started with D-10 with heparin through a UVC line. The
infant required an isometric exchange transfusion and the
electrolytes over the next 48 hours remained
significantly abnormal with significant hypokalemia with
the lowest potassium [**Location (un) 1131**] being a 2.4. Hypocalcemia
with the lowest calcium being 5.4. The infant also had a
mild hyponatremia and hypochloremia. These were corrected
with electrolyte infusions in the intravenous fluid over a
period of 2 days at which time the electrolytes began to
normalize.
A UAC was placed on day of life one. The UVC remained in
place until day of life 4 at which time a PICC line was
placed for IV nutrition. The UAC was discontinued on day
of life 3, [**2154-12-3**]. Enteral feedings were initiated on
[**2154-12-5**] day of life 5 and advanced to full feedings by
[**2154-12-10**] at which time the PICC line was discontinued.
The infant has been po/pg feeding up until [**2154-12-15**] and
since that point, she has been able to take all feedings
orally with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 38296**] feeder. She is presently feeding
breast milk with Enfamil powder to equal 24 calories per
ounce and taking approximately 60 to 70 cc every 4 hours.
The estimated intake over the past couple of days has
been approximately 130 ml/kg per day and she showed
steady weight gain on this amount. Tri-Vi-[**Male First Name (un) **] vitamins (1
cc per day) were started on [**2154-12-12**]
On [**2154-12-19**], her L=53cm, wt=3020g, HC=35.5 cm.
4. Endocrinology: An endocrine consult was obtained due to
the profound electrolyte instability on day of life 1.
Numerous tests have been done and those include growth
hormone testing, growth hormone result was 21.5 which is
slightly high. BHEA-S was 71 and that was within normal
limits. Luteinizing hormone, FSH was 5.9 which is within
normal range. IGF is 46 which is slightly low. IGF binding
protein 3 was 1.3 which is within normal range.
Endocrinology has been given these results and, at this
point, feel that there is no longer an endocrinology work-
up to be done. They feel that most of the electrolyte
instability was related to the severe illness at birth
and the isometric exchange transfusion that the infant
received. No follow-up will be needed with endocrinology.
5. Gastrointestinal: The infant had a peak bilirubin level
of 5.9 over 0.3 on [**12-4**] and has not required
phototherapy. LFTs were drawn on [**2154-12-2**]. ALT was 809.
AST 353. Alk phos was 10.7. Those results were repeated
on [**2154-12-4**]-- ALT was 455. AST was 65.
6. Hematology: Infant's blood type is B positive, DAT
negative. The infant was born severely pale and anemic
with an initial hematocrit of 12 at birth and a
reticulocyte count of 3.3. The infant received 10 mg/kg
of packed red blood cells over 20 minutes on admission to
the NICU, followed by half volume exchange transfusion of
packed red blood cells. After the exchange transfusion,
the hematocrit bumped up to 27.6 on day of life 1. The
infant received 20 ml/kg of packed red blood cells and a
follow-up hematocrit after that on [**12-2**] was 37. The
most recent hematocrit was on [**2154-12-4**] and that was 39.
The infant has received a total of 3 transfusions of
packed red blood cells, all within the first 48 hours of
life. The infant also developed a thrombocytopenia with
a platelet count that slowly dropped to 50 on day of life
2, [**2154-12-2**]. The infant received 2 platelet transfusions
with a follow up platelet count of 189. Most recent platelet
count was 145 on [**2154-12-5**].
A Kleihauer-Betke study was done on the mother, looking for
maternal fetal hemorrhage as the cause for the etiology of
the infant's severe anemia at birth and it was found to be
positive with 41.6 ml of fetal red blood cells in the
mother's blood stream. This is the cause of the infant's
severe anemia at birth.
7. Infectious disease: On admission to the NICU, a CBC and
blood culture were screened. The blood culture remains
negative. The infant received 48 hours of Ampicillin and
Cefotaxime and then the antibiotics were discontinued.
The infant has had no further issues with sepsis since
that time.
8. Neurologic: The infant presented with initial seizures
by 36 hours of life. At that time, a phenobarbital bolus
was given. A MRI was done on [**2154-12-2**] which showed
diffuse abnormal cavum septum pellucidum and a question
of a low-lying interhemispheric fissure. [**Hospital1 62374**] pediatric neuroradiologist read this study as a
subcortical diffusion abnormality, consistent with
subacute hypoxic ischemic encephalopathy, known as HIE.
An EEG was also done on [**2154-12-2**], which showed:no
epileptiform discharges but did show persistent of the sleep
state and failure of sleep cycling..
Neurology has been involved with this family and the
infant will be followed after discharge (Dr. [**Last Name (STitle) 48342**]. She
will need to be followed in the neonatal neurology [**Hospital 702**]
clinic at 6 weeks post discharge. The infant remains on
phenobarbital and most recent phenobarbital level was drawn
on [**2154-12-19**] = 18.5. The infant will be discharged on
phenobarbital at 14 mg po q day (increased on [**12-19**] due to
low level. Neurology would prefer to presently keep the
phenobarbital level 20-30. A follow-up phenobarbital level
is recommended within the next 2 weeks.
9. Plastics: Dr. [**Last Name (STitle) 40701**] has been involved with this
family for the issues of cleft lip and palate and have
come in to evaluate the infant. There is a plan for
surgical repair as the infant becomes older and follow-up
appointment will be needed with Dr. [**Last Name (STitle) 40701**] one month
after discharge from the NICU.
10. Genetics: Chromosomes were sent on the infant on
[**2154-11-30**]. A genetics consult was also obtained.
Chromosomes came back normal and a fish-22-Q11 was sent
and that was also normal. Genetics would like to see
this infant in follow-up post discharge at one month.
The genetics physician who evaluated the baby was Dr.
[**First Name4 (NamePattern1) 333**] [**Last Name (NamePattern1) 9022**].
11. Sensory: A hearing screen was performed on [**2154-12-18**] and
the results are normal.
12. Ophthalmology: No ophthalmology exams have been done on
this infant as there have been no indications to do so.
13. Psychosocial: A [**Hospital1 18**] social work person has been
involved with this family. The contact social worker is
[**Name (NI) 4457**] [**Name (NI) 36244**] and she can be reached at [**Telephone/Fax (1) 65430**] if
there are any concerns.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: The infant will be discharged home to
the parents.
PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 46690**],
CARE RECOMMENDATIONS: Ad lib p.o. feeds of breast milk,
augmented with Enfamil powder to equal 24 calories per ounce,
to be fed with a Habermann feeder.
Medications at discharge are the Tri-Vi-[**Male First Name (un) **] 1 ml per day and
Phenobarbital dose at 14 mg po q day.
State newborn screen was sent on [**2154-12-3**] and all the results
came back out of range. A repeat state screen was sent on
[**2154-12-6**] with normal results except for a low T4, normal TSH.
Another state screen was sent on [**12-19**].
IMMUNIZATIONS RECEIVED:Hepatitis B
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following three criteria: (1) Born at less than
32 weeks gestation; (2) Born between 32 and 35 weeks
gestation with two of the following: Either day care during
RSV season, a smoker in the household, neuromuscular disease,
airway abnormalities or school age siblings; or (3) 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 household
contacts and out-of-home caregivers.
FOLLOW UP: Follow-up appointments to be scheduled and
recommended are:
1. Cardiology follow-up with Dr. [**Last Name (STitle) 10123**] at 3 to 6 months of
age. Phone number [**Telephone/Fax (1) 37115**].
2. Neurology follow-up with Dr. [**Last Name (STitle) 48342**] at 6 weeks of age.
3. Genetics follow-up at one month.
4. Plastics follow-up with Dr. [**Last Name (STitle) 40701**] in one month.
5. Early intervention referral.
6. VNA visit for [**2154-12-20**].
7. Pediatric visit with Dr. [**Last Name (STitle) 46690**] on [**2154-12-19**].
DISCHARGE DIAGNOSES:
1. Respiratory distress.
2. Profound anemia due to a fetomaternal hemorrhage.
3. Perinatal depression.
4. Rule out sepsis.
5. Cleft lip.
6. Cleft palate.
7. Profound hypokalemia, hypocalcemia, hyponatremia,
hypochloremia.
8. Hypoxic ischemic encephalopathy.
9. Polycythemia.
10. Neonatal seizures.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Name8 (MD) 62299**]
MEDQUIST36
D: [**2154-12-19**] 00:26:09
T: [**2154-12-19**] 05:22:30
Job#: [**Job Number 65431**]
ICD9 Codes: 2761, 2768, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1128
} | Medical Text: Admission Date: [**2192-3-2**] Discharge Date: [**2192-3-15**]
Service: Neurology
CHIEF COMPLAINT: Found unresponsive.
HISTORY OF PRESENT ILLNESS: This is an 83-year-old woman
with a past medical history of dementia, hypertension,
hypercholesterolemia, and diabetes, who was found
unresponsive in bed by her husband at around 10:30 p.m. on
the evening of admission, which was [**2192-3-2**]. The husband
stated that she was doing well all day, but around 9 p.m., he
went into the kitchen to have cereal and she did not join him
in the kitchen. He went back to check on her, and she was on
the bed moving only very slightly and wound not arouse. She
did vomit once there.
A nurse, who lives in the building, came and checked on her,
and then decided to call EMS. Her blood pressure was noted
by EMS to be over 200 systolic and they thought they saw some
jerking of her right arm. Upon arrival to the [**Hospital1 18**] ED, she
was still unresponsive and was noted to have some jerking of
the right arm as well as the head. There was urinary
incontinence at the time as well. She was given a total of 3
mg of Ativan and then intubated for decreased level of
consciousness. She was then admitted to the Neuro ICU.
On head CT, she did have a right thalamic hemorrhage with
extension into the lateral ventricles as well as the third
and fourth ventricles. There was some hydrocephalus as well
as a 5 mm midline shift.
PAST MEDICAL HISTORY:
1. Dementia during which her husband has been taking care of
her for the last month including everything around the house
like cleaning, cooking, bills, and shopping. She apparently
still dresses herself and knows other family members.
2. Hypertension.
3. Hypercholesterolemia.
4. Diabetes.
5. History of breast cancer in [**2184**] status post lumpectomy
and XRT.
6. Peripheral vascular disease status post right leg bypass.
7. Osteoarthritis.
8. Glaucoma.
9. TIAs of unclear etiology and characteristics.
10. Uterine fibroids.
ALLERGIES: No known drug allergies.
MEDICATIONS UPON ADMISSION:
1. Metoprolol 50 mg p.o. q.d.
2. Glyburide 2.5 mg p.o. q.d.
3. Nolvadex 10 mg p.o. b.i.d.
4. Lipitor 20 mg p.o. q.d.
5. Zestril 20 mg p.o. q.d.
6. Aspirin 81 mg p.o. q.d.
7. Tylenol prn.
8. Aleve prn.
9. Multivitamins.
10. Tums.
11. Fosamax.
12. Aricept.
13. Timolol eyedrops.
SOCIAL HISTORY: She lives with her husband in [**Name (NI) **].
Her daughter and her son-in-law live in [**State 2748**].
PHYSICAL EXAM UPON PRESENTATION: Temperature was 99.8, blood
pressure was 238/45. Her heart rate was 119 and regular.
Her respiratory rate. Her respiratory rate was 19, and her
O2 saturation was 100% prior to intubation on room air. In
general, she was intubated and sedated having just received
Versed. Her HEENT exam revealed moist mucous membranes with
clear oropharynx. There was no scleral icterus. Her neck
was supple. There were no carotid bruits appreciated. Lungs
were clear bilaterally to auscultation. Heart was regular
rate and rhythm with a normal S1, S2. Abdomen is soft,
nontender, and nondistended. Extremities were warm and
showed no edema. On neurologic examination, her mental
status: She was intubated and sedated. Did not follow
commands and did not open her eyes to stimulation. Cranial
nerves: Pupils are equal, round, and reactive to light. The
corneals were present bilaterally. There is a positive gag.
There was a grimace with pain that made the face appear
symmetric. Motor examination: Her left upper extremity was
flaccid and not moving. Rest of the extremities had normal
tone. The lower extremities appeared to be moving
spontaneously bilaterally. The reflexes: Decreased in the
left upper extremity initially with the rest of the extremity
appearing slightly brisk, although symmetric in the lower
extremities. There were no Achilles reflexes. The left toe
was upgoing and the right toe was mute. Sensation: She
withdrew to pain in all four extremities except for the left
upper extremity.
LABORATORIES UPON ADMISSION: White count was 13.6,
hematocrit was 35, and platelets were 286. Her coag studies
were normal. Her Chem-7 revealed a sodium of 145, glucose of
238, and bicarb of 30, otherwise was unremarkable. Cardiac
enzymes were negative upon admission.
HOSPITAL COURSE BY PROBLEMS:
1. Thalamic hemorrhage: The patient's level of consciousness
remained fairly depressed for the first week of her hospital
course, but towards the end of the first week, she started to
open her eyes and although she did not follow commands, she
appeared to keep her eyes open for a good deal of time. The
prognosis of the patient's hemorrhage was discussed with the
family in that the thalamic region controlled the level of
consciousness, however, if she did regain some consciousness,
she might be left only with a left-sided hemiparesis.
Neurosurgery evaluated the patient in the Emergency Room upon
admission, and they felt that extraventricular [**State 19843**] might be
helpful in her management. One was placed with not much CSF
draining and there appeared on the CAT scan to be ample room
for any potential hydrocephalus to be a problem. This [**Name2 (NI) 19843**]
was D/C'd on [**3-3**], and CSF cultures withdrawn from the
[**Month (only) 19843**] prior to removal were negative for any infection. She
also did receive some doses of Ancef prophylactically for the
[**Month (only) 19843**] presence.
We also explained, however, that because she had a premorbid
dementia, that recovery might be less significant, that it
might be otherwise suspected. Because of the level of
consciousness, she remained intubated and the family decided
for a trial of extubation and to see if she would be
successfully extubated.
On [**3-10**], she was extubated and given steroids prior to
extubation to prevent laryngeal edema, but she began to have
stridor, and a few hours later, the family requested that she
be reintubated and this was done. Thereafter, her level of
consciousness remained about the same with her eyes being
open, but not following commands. The tone has increased in
the left upper and lower extremities and appeared to be less
responsive to stimuli than the right. The left toe remains
upgoing.
With regards to the right arm shaking, this was not thought
to be a seizure, but she was given Dilantin prophylactically
in the Emergency Room until it could be straightened out.
The movement was irregular, it was coarse, and it appeared
more like a tremor, but was fairly stimulus sensitive.
Dilantin level was therapeutic for about three days, and it
was discontinued. An EEG done during the movement revealed
no electrographic seizures during this.
2. Ventilator dependence: The patient's original reason for
intubation was depressed level of consciousness. The
presumed etiology behind her inability to wean successfully
on [**3-10**] was perhaps due to laryngeal edema. She, as
mentioned, remained intubated and plans were made for
tracheostomy and percutaneous endoscopic gastrostomy tube
placement. She received both of these on [**2192-3-13**]
without any event.
Currently she was weaned off of the ventilator to just a
trach mask at 40% FIO2 and has been oxygenating well. Recent
chest x-ray showed some atelectasis versus consolidation in
the left lower lobe, which has been present throughout the
hospital course, but this does not appear to be getting
worse.
3. Fever: The patient did have fevers during her first week
of hospital course. These were initially treated with
levofloxacin for presumed aspiration and vancomycin was later
added in the case of a nosocomially acquired MRSA infection.
No specific MRSA organism was ever identified and cultures
from the CSF as I mentioned were negative. There were a
couple of sputum samples showing gram-positive cocci in
pairs, and on [**3-10**], the report on the Gram stain
gram-negative rods and gram-positive rods 2+ and 3+, but the
respiratory culture shows only sparse growth of oropharyngeal
flora.
Nevertheless, her levofloxacin was continued for a total of
11 days given the recent tracheostomy and PEG tube placement.
She has been afebrile now for three days, and will not
require any further antibiotic treatment at this point. In
addition, it should be noted that she did have Clostridium
difficile sent, which was negative as well.
She did have a central line that was discontinued, and that
was sent for culture, and that is also negative for
organisms. Urine cultures remained negative throughout the
hospital course.
Communication with family: The family was updated on her
prognosis and throughout the hospital course, the daughters
and sons of the patient helped the husband make decisions
regarding her care. Therefore, the plan is to send her to a
facility that accepts tracheostomy tube care. At this time
that facility is pending. They did state their wishes that
if she were to ever be dependent on the ventilator, they
would like to withdraw care.
Code status at this point is do not resuscitate and do not
intubate.
DISCHARGE DIAGNOSES:
1. Right thalamic hemorrhage.
2. Pneumonia.
3. Dementia.
4. Hypertension.
5. Hypercholesterolemia.
6. History of breast cancer.
7. Diabetes.
8. Peripheral vascular disease.
9. Osteoarthritis.
10. Glaucoma.
11. Transient ischemic attacks.
12. Uterine fibroids.
DISCHARGE MEDICATIONS:
1. Bisacodyl 10 mg p.o. q.d. prn constipation.
2. Tylenol 325-650 mg/elixir per G tube prn fever or pain.
3. Lisinopril 20 mg p.o. q.d., hold for blood pressure less
than 100.
4. Metoprolol 150 mg p.o. t.i.d. for blood pressure control,
and please hold for systolic blood pressure less than 100 and
a heart rate less than 60.
5. Lansoprazole 30 mg per G tube q.d.
6. Heparin 5000 units subq b.i.d.
7. Glyburide 2.5 mg per G tube q.d.
Of note, patient's Fosamax, Aricept, and Lipitor were held
during this hospital admission, but there does not appear to
be any contraindication to restarting these after she gets to
the rehab facility.
DISCHARGE CONDITION: Fair.
DISCHARGE DISPOSITION: To skilled nursing facility.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], M.D. [**MD Number(1) 4269**]
Dictated By:[**Name8 (MD) 4064**]
MEDQUIST36
D: [**2192-3-14**] 12:00
T: [**2192-3-14**] 12:27
JOB#: [**Job Number 109741**]
ICD9 Codes: 431, 5070, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1129
} | Medical Text: Admission Date: [**2161-11-23**] Discharge Date: [**2161-11-25**]
Date of Birth: [**2128-4-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Iodine; Iodine Containing / Zofran
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
weakness, confusion
Major Surgical or Invasive Procedure:
paracentesis
History of Present Illness:
Ms. [**Known lastname 73200**] is a 33 year old female with end stage metastatic
melanoma admitted for weakness and confusion/somnolence.
Patient has had slowly declining functional status over the past
few weeks and has been more somnolent and dozing off during
conversations. She is appropriate when awake, but frequently
falls asleep. Today, she presented to [**Hospital 5871**] Hospital for
confusion and weakness. At [**Location (un) 5871**], she was noted to be
tachycardia and to have a positive UA, so was given vancomycin
and Zosyn. She had a head CT which was negative and CXR which
was normal. Her lactate was noted to be 5.8. She was noted to
be in ARF and so was given 500 cc of NS. She was sent to [**Hospital1 18**].
.
In the ED, vitals were T96.6, HR 130, BP 100/63, RR 18, 97% on
3LNC. Hr blood pressure was 98/54 at its lowest and her HR was
128 at it's highest. She was given 3LNS for dehydration and
ARF. She underwent V/Q scan for workup of tachycardia,
shortness of breath, and metastatic melanoma which was found to
be low prob. Bilateral LENIs were also negative. She cannot
get a CTA due to iodine allergy. She got a CT abd/pelvis which
showed new significant ascites from [**2161-8-7**]. CXR showed low
lung volumes, but lung cuts on abdomen CT showed moderate
plerula effusions with atelectasis. Labs were notable for acute
renal failure and newly elevated LFTs.
.
Upon arrival to the floor, patient denies shortness of breath,
though is speaking in short sentences. She denies chest pain,
abdominal pain, fevers, chills, headache, change in vision. Her
husband notes increased somnolence over one week. Patient
reports lightheadedness and thirstiness over the past few days.
Past Medical History:
Metastatic melanoma. Patient was diagnosed with melanoma 2
years ago when she noted an enlarging groin node found to be
positive for metastatic melanoma. Patient underwent
lymphadenectomy and was found to have positive inguinal, pelvic,
ileac, and peri-aortic nodes. She began IL-2 chemotherapy in
[**8-13**] with disease progression. She then began ipilimumab on the
compassionate use protocolat [**Hospital1 1012**] with disease progression on
her week 12 scans. She then enrolled in the RAF-265 clinic
trial on [**2161-4-7**],but had disease progression. She was then
treated with two cycles of DTIC unsuccesfully. She is now being
treated by NIH Surgery Branch for adoptive cellular
immunotherapy. She is now approximately 1.5 months out from
conditioning regimen and 1 month out from receiving TIL.
Social History:
She is former English professor [**First Name (Titles) **] [**Last Name (Titles) 73201**] [**Location (un) **]. She does
not smoke. She does have an occasional glass of wine or beer.
.
Family History:
She has no family history of melanoma, no family history of
cancer.
Physical Exam:
Gen: cachectic, tachypneic
HEENT: temporal wasting, o/p clear
CV: Tachycardic, no m/r/g
Pulm: diminished breath sounds at bases bilaterally
Abd: soft, NT, distended, + fluid wave, bowel sounds present
Ext: 2+ bilateral pitting edema
Neuro: somnolent, falling asleep mid-sentence
Pertinent Results:
Admission Labs:
.
.. \ 11.4 /
8.6 ------ 63
.. / 32.5 \
.
Diff: 85%N, 11.7%L, 2.9%M, 0.1%E, 0.3%B
.
.
128 | 99 | 48 /
-------------- 78
4.9 | 18 | 1.3 \
.
(baseline Cr 0.7)
.
ALT 105
AST 475
AP 359
T. bili 0.8
Alb 2.6
.
Micro:
UA. 21-50 WBCs, small LE, protein 30, [**3-11**] epis, 21-50 hyaline
casts
.
Lactate 5.3
.
[**2161-11-22**].
LENIs.
no DVT of right or left leg. subcutaneous edema. prominent right
groin lymph nodes.
.
CXR. [**2161-11-22**]. No PNA.
.
CT abd/pelvis. [**2161-11-22**].
IMPRESSION: Extremely limited examination secondary to lack of
intravenous and oral contrast and extensive intra-abdominal
pelvic ascites.
1. Moderate bilateral pleural effusions with associated
atelectasis.
2. Large volume of intra-abdominal and pelvic ascites.
3. Right-sided double-J ureteral stent with moderate associated
hydronephrosis.
4. Extensive retroperitoneal lymphadenopathy, incompletely
assessed on this evaluation.
5. Probable normal appendix visualized in the right lower
quadrant. No CT findings suggestive of bowel obstruction or
perforation.
.
Renal ultrasound [**2161-11-20**].
IMPRESSION:
1. Persistent moderate hydronephrosis of the right kidney and
right
hydroureter suggestive of stent malfunction. This stent appears
to be in the appropriate location.
2. Thick-walled bladder with sediment identified in the
posterior aspect. Significant post-void residual of 187 cc.
3. Increased echogenicity of the kidneys bilaterally with an
appearance suggestive of medullary nephrocalcinosis. The three
most likely causes of this are hyperparathyroidism, medullary
sponge kidney, and renal tubular acidosis.
4. Small amount of ascites.
.
EKG. NSR at 126 bpm. Normal axis. Normal pr, qrs, qt inerval.
q wave in III. No ST elevations or depressions. EKG
unachanged except for rate from [**2161-3-31**].
Brief Hospital Course:
In summary, Ms. [**Known lastname 73200**] is a 33 year old female with metastatic
melanoma admitted with somnolence, liver failure, renal failure,
new chylous ascites and persistent tachycardia of unclear
etiology, who ultimately was made comfort measures only and
passed away on a morphine drip with family at bedside.
Fatigue/somnolence. Patient admitted with symptoms of fatigue
and somnolence which appeared to me multifactorial. Patient was
hydrated for dehydration. Patient was taking standing opioids
at home and presented with renal and liver failure, so impaired
clearance of toxins and meds likely contributed to her mental
status. Detrol, compazine, and opiods (initially) were withheld
and mental status mildly improved. She had a head ct without
contrast (patient has contrast allergy) which was reportedly
negative.
Tachpnea/Hypoxia. Patient did not report subjective shortness
of breath on admission, but appeared tachypneic and had new
oxygen requirement of 4LNC. Patient noted to have new
significant ascites with bilateral pleural effusions and
atelectasis which may have contributed. VQ scan was low prob
for PE, though echo shows increased TR gradient and pulmonary
artery pressures. No evidence of pneumonia. Patient did not
have significant relief of tachypnea with therapeutic
paracentesis.
Ureteral stent. Patient presents with positive UA though urine
culture was negative. She was treated with vancomycin and
zosyn. Given that cultures were negative, positive UA was
likely the effect of the ureteral stent which had been placed at
NIH one month prior. Urology evaluated the stent who felt it
was working well, though CT abd/pelvis showed persistent
hydronephrosis suggesting the possibility of stent malfuction.
Chylous Ascites. Patient had mild ascites in [**8-14**], and was
admitted with significant worsening of ascites over two months.
No history of cirrhosis, though patient has been receiving
various chemotherapies (though exact medications unclear). [**Name2 (NI) **]
evidence of portal vein thrombus on [**Name (NI) 5283**] sono with doppler. SAAG
suggestive of exudative secondary to malignancy. Diagnostic
para consistent with chylous ascites, likely due to infiltration
of melanoma into lymphatics.
Elevated LFTs. Noted to have newly elevated LFTs, likely
secondary to liver infiltration of lymphatics. Abdominal
ultrasound did not show portal vein thrombus. Hepatitis
serologies were pending at time of death.
Thrombocytopenia. New thrombocytopenia in setting of elevated
LFTs and worsening ascites were though to possibly be due to
liver failure. She was noted to have mild splenomegaly on
abdominal ultrasound. She had received chemotherapy (unclear
which medications) > 1 month ago making marrow supression less
likely. Also concern for DIC or TTP-HUS, though DIC labs were
normal.
Renal failure. Patient recently had right sided ureteral stent
placed and presented with elevated Cr of 1.3 that did not
respond to > 5 L of IVF. Moderate hydronephrosis noted on
abodinal CT suggestive of a non-functioning stent, though
urology evaluated the patietn and felt it was working but
recommended further imaging studies.
Melanoma. Patient has end stage metastatic melanoma and failed
multiple chemotherapy regimens. She was receiving experimental
chemotherapy from NIH with 11 percent tumor reduction. However,
patient's presentation suggested worsening disease with
multiorgan failure and no reversible etiology. After discussion
with family, decision was made to make patient DNR/DNI and then
comfort measures only. She was placed on a morphine drip for
comfort. Her husband was at the bedside when she passed away.
Medications on Admission:
Cipro completed on Tuesday for UTI
Morphine 15-30 mg prn
MS contin 30 mg [**Hospital1 **]
Compazine PRN
Ranitidine
Scopolamine
Detrol [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **]
Colace 100 mg [**Hospital1 **]
Senna
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
metastatic melanoma
multiorgan failure
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
ICD9 Codes: 5849, 2762, 5990, 5119, 2761, 2875 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1130
} | Medical Text: Admission Date: [**2187-12-10**] Discharge Date: [**2187-12-11**]
Date of Birth: [**2119-11-27**] Sex: M
Service: MEDICINE
Allergies:
Aspirin / Ibuprofen / Motrin
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Aspirin Desensitization
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
Mr. [**Known lastname 78172**] is a 68 yo male with history of dilated
cardiomyopathy, pulmonary embolism, severe asthma and severe
diffuse tracheobronchomalacia s/p tracheobronchoplasty, who
presents today for aspirin desensitization prior to RHC/LHC to
evaluate coronaries and pressures.
Based on previous cardiac MRI, there seems to be disease within
the coronaries, and possibly evidence of scar of the myocardium.
A previous ECHO showed an EF of approx 25%, but CMR EF was
approx 40%. He is being evaluated for ischemic cardiomyopathy.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, bleeding at the time of surgery,
myalgias, joint pains, cough, hemoptysis, black stools or red
stools. S/he denies recent fevers, chills or rigors. S/he denies
exertional buttock or calf pain. he denies chest pain, DOE,
PND, Orthopnea, palpitations or presyncope. All of the other
review of systems were negative. (+) include postnasal drop
with resultant intermittent cough. neck stiffness resolving w/
movement.
Per OMR not from Dr. [**Last Name (STitle) **], "he has been working several days
in the construction business for up to 4 hours at a time without
limiting symptoms. He is also active at home, taking care of his
horses, carrying heavy hay bales, and ascending the [**Doctor Last Name **] to his
barn without chest discomfort, dyspnea on exertion, fatigue,
lightheadedness, or any palpitations." This was confirmed with
patient and is unchanged.
Past Medical History:
1. CARDIAC RISK FACTORS:
(-)Diabetes
(-)Dyslipidemia
(-)Hypertension
.
2. CARDIAC HISTORY:
-CABG: N/A
-PERCUTANEOUS CORONARY INTERVENTIONS: N/A
-PACING/ICD: N/A
3. OTHER PAST MEDICAL HISTORY:
1. Postoperative atrial fibrillation status post tracheoplasty.
2. Severe global cardiomyopathy of unknown etiology diagnosed
on
[**2187-5-16**] with CTA revealing probable nonobstructive coronary
disease.
3. Bilateral pulmonary emboli found incidentally on CTA.
4. Gastroesophageal reflux.
5. Diffuse tracheobronchomalacia, status post tracheobronchial
stent on [**3-8**], removed on [**3-26**]. Subsequent surgical
tracheobronchoplasty on [**5-9**].
6. Severe persistent asthma.
7. Recurrent pneumonia for 30 years.
8. Chronic sinusitis status post three sinus surgeries.
9. Nasal polyps.
10. Left meniscectomy of the left knee.
11. TURP secondary to BPH.
12. Tonsillectomy.
13. Ankle plating for fracture.
14. Vasectomy.
15. Three right-sided inguinal hernia repairs.
Social History:
-Tobacco history: 34 pk/yr smoker Quit smoking: 32 yrs ago
-ETOH: up to 3 beers/day in the past, currently none
-Illicit drugs: denies
He previously worked as a carpenter and an insurance [**Doctor Last Name 360**] and
is married and lives with his wife. Now retired from insurance
x4 years.
Family History:
Parents are both deceased, father in his 80s from COPD and
throat cancer, mother in her 80s of congestive heart failure.
He has one sister who is without cardiac history. He has several
maternal uncles who died of strokes.
Physical Exam:
VS: T=98.7F BP=144/98 HR=87 RR= 22-27 O2 sat=98% RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
No angioedema, some post nasal drip. Trachea to midline.
NECK: Supple with JVP of 4 cm, no carotid bruits.
CARDIAC: RR, occasional premature beat, normal S1, S2. No m/r/g.
No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities. Resp were unlabored, no
accessory muscle use. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+
Left: Carotid 2+ Femoral 2+ DP 2+
Pertinent Results:
[**2187-12-10**] 06:14PM GLUCOSE-104 UREA N-24* CREAT-1.0 SODIUM-140
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-27 ANION GAP-10
[**2187-12-10**] 06:14PM CALCIUM-9.3 PHOSPHATE-3.1 MAGNESIUM-2.0
[**2187-12-10**] 06:14PM WBC-6.5 RBC-3.84* HGB-12.2* HCT-34.5* MCV-90
MCH-31.8 MCHC-35.4* RDW-13.7
[**2187-12-10**] 06:14PM PLT COUNT-215
[**2187-12-10**] 06:14PM PT-12.4 PTT-29.1 INR(PT)-1.0
STUDIES
EKG: Sinus rhyth, LAD, possible LVH. TwI V1. V1-V4 nonspecific
repolrization anl.
2D-[**Month/Day/Year **] [**2187-5-16**]:
The left atrial volume is markedly increased (>32ml/m2). The
left atrium is dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated.
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.]
Diastolic function could not be assessed. Right ventricular
chamber size and free wall motion are normal. The aortic root is
moderately dilated at the sinus level. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve leaflets are mildly
thickened. Moderate to severe (3+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion. EF 20-25%.
IMPRESSION: Severe global left ventricular hypokinesis with
moderate to severe mitral regurgitation and moderate left
ventricular dilatation. Mild pulmonary artery systolic
hypertension with preserved right ventricular systolic function.
CARDIAC MRI [**2187-7-4**]:
Impression:
1. Mildly increased left ventricular cavity size with mild
global hypokinesis and more pronounced hypokinesis of the basal
to mid portion of the septum. The LVEF was mildly decreased at
41%. There was patchy mid-myocardial late gadolinium enhancement
of the basal to mid portion of the septum.
2. Normal right ventricular cavity size and systolic function.
The RVEF was normal at 60%.
3. Mild pulmonic regurgitation.
4. The indexed diameters of the ascending and descending
thoracic aorta were mildly increased and normal, respectively.
The main pulmonary artery diameter index was mildly increased.
5. Biatrial enlargement.
6. Normal coronary artery origins. There were lesions noted in
the proximal LAD, proximal LCx, and mid RCA.
Cardiac cath [**2187-12-11**]:
COMMENTS:
1. Selective coronary angiography of this right dominant system
revealed
single vessel coronary artery disease. The LMCA was normal. The
LAD was
normal, but gave of a D1 with 80% stenosis. The LCx was normal.
THe RCA
was normal.
2. Resting hemodynamics revealed normal right sided filling
presures
with a RVEDP of 9mm Hg and slightly low left sided filling
pressures
with a LVEDP of 9mm Hg. Systemic vascular resistance was
decreased at 11
[**Doctor Last Name **] unit. The PVR was also decreased at 0.9 [**Doctor Last Name **] unit.
Systemic
arterial pressures were low at 98/68mm Hg. The baseline cardiac
output
and cardiac index were 6.6 L/min and 3.3 L/min/m2, respectively.
3. Pericardial calcifications were noted.
4. Patient had a severe vagal reaction during the procedure,
requiring
atropine (2m IV) and transient dopamine support.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Low filling pressures.
Brief Hospital Course:
68 yo male with h/o h/o dilated cardiomyopathy, PE,
tracheobronchomalacia s/p tracheobronchoplasty, who presents for
aspirin desensitization and RHC/LHC to evaluate for ischemic
cardiomyopathy
# CORONARIES: Based on CMR, it seems there are lesions noted in
the proximal LAD, prox LCX and mid RCA with enhancement of the
basal to mid portion of septum which could be c/w scar. Given
these findings, and previous ECHO with EF 25%, there is a
concern for ischemic cardiomyopathy. Patient admitted for ASA
desensitization with eventual goal of LHC/RHC to evaluate
coronaries and cardiac pressures. The patient underwent ASA
densitization per protocol given his ASA allergy. His ASA
desensitization was completed without event and he underwent a
cardiac cath on [**12-11**] which showed.... He was discharged home on
81 mg of ASA daily.
# PUMP: The patient has a history of dilated cardiomyopathy 25%
on echo, then following CMR with EF 41%. Unclear etiology of
cardiomyopathy. Query ischemic cardiomyopathy. His lisinopril
and B-blocker were held given the ASA desensitization, howevr
they were restarted on discharge.
# RHYTHM: The patient has a history of post-op Afib, last holter
recordings all NSR with some ectopy, but no e/o afib. Currently
off coumadin x6wks. ECG NSR w/ LAD, LVH and nonspecific
repolarization anl. The patient was monitored on tele during
his stay.
#. Aspirin desensitization: The patient was desensitized to ASA
per protocol without event.
# Asthma: Severe persistent. No wheezing on exam. Last
exacerbation > 1year. The patient was continued on Advair and
singulair.
# Allergic rhinitis: Currently stable. Postnasal drip w/
occasional cough. The patient was continued on loratadine,
Singulair, and Flonase.
Medications on Admission:
Lipitor 10 QD
Metoprolol 50 mg QD
Lisinopril 10mg QD
Singulair 10 mg QD
Advair 100/50 1 puff [**Hospital1 **]
Flonase 50 mcg [**Hospital1 **]
Tums [**Hospital1 **]
Ergocaliferol 400u qD
MVI daily
Loratadine 10mg QD
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Flonase 50 mcg/Actuation Spray, Suspension Sig: One (1) spray
Nasal twice a day.
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Coronary Artery Disease
Cardiomyopathy
Aspirin Desensitization
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2 liters daily
You were admitted for an elective heart catheterization as well
as aspirin desensitization. You were admitted to the cardiac
ICU, and were monitored overnight and tolerated the aspirin well
without complications. You then had a cardiac catheterization
which showed one blockage of an artery but was not felt to need
intervention.
You will be discharged on an aspirin given this one blockage.
No other medication changes were made.
If you develop any of the following symptoms, please call your
PCP, [**Name10 (NameIs) 2085**], or go to the ED: chest pains, shortness of
breath, fevers, chills, bleeding or oozing from the groin site,
or loss of sensation in your foot or leg.
Followup Instructions:
Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2188-3-4**] 11:00
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2188-3-31**]
10:00
Please call Dr.[**Name (NI) 14643**] office at [**Telephone/Fax (1) 62**] to schedule a
followup appointment in the next 4-6 weeks.
Completed by:[**2187-12-13**]
ICD9 Codes: 4254 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1131
} | Medical Text: Admission Date: [**2119-2-3**] Discharge Date:
Date of Birth: [**2071-6-5**] Sex: M
Service: Transplant Surgery
HISTORY OF PRESENT ILLNESS: This is a 47-year-old gentleman
admitted to the surgical intensive care unit on [**2119-2-20**], with hepatic encephalopathy and hypoxia. Mr. [**Known lastname **]
has hepatitis C related cirrhosis of longstanding since
childhood. Until recently, he has been in good health
despite his cirrhosis and displayed Child's A function. He
sustained a motor vehicle accident on [**2118-12-31**], which
resulted in a right hemothorax sternal fracture and was
complicated by acute decompensation of his hepatic function which
required an admission to the [**Hospital1 69**]
with hepatic encephalopathy, jaundice with a rise in his total
bilirubin count from 3.9 to 5.7, and acute renal failure with a
creatinine rise from 0.5 to 2.1.
He was discharged following this admission and readmitted on
[**2119-2-3**], for persistent encephalopathy, nausea,
vomiting, diarrhea, and abdominal distention. He had gained
40 pounds at home after discharge. He was transferred from
the floor the surgical intensive care unit for liver dialysis
on [**2-16**] without much benefit. Subsequently, he vomited
his tube feeds while on the floor and developed a cough
followed by decreased mental status and hypoxia. He was
started on antibiotics for a presumed diagnosis of aspiration
pneumonitis. He was subsequently transferred the surgical
intensive care unit again, on [**2-20**], for management of
hypoxia and hepatic encephalopathy.
Physical examination and further workup suggested a possible
aspiration pneumonitis involving the right upper and middle
lobe.
HOSPITAL COURSE: The patient was initially managed in the
surgical intensive care unit and was closely monitored in the
surgical intensive care unit and initially did not require
intubation. On [**2-23**], he underwent left thoracocentesis
with 1 liter of bloody fluid aspirated from the left pleural
cavity. He was also intubated and ventilated at this point
and was further resuscitated with fluids. He was also
started Zosyn. At this stage, the patient had Child's C
cirrhosis with hepatic encephalopathy, hepatorenal syndrome,
and hypoxia, possibly secondary to an aspiration pneumonitis.
He was placed on the hepatorenal protocol and was given
Octreotide and Midodrine.
Despite these measures, Mr. [**Known lastname **] continued to remain very
sick, and his renal function deteriorated as did his liver
hepatic function, as well as transaminases. His renal
function also deteriorated, and he was upgraded to a 2-A
transplant status.
On [**2-27**], Mr. [**Known lastname **] received an orthotopic liver
transplant. This was done as a piggyback procedure. There
was end-to-end anastomosis of the donor and recipient IVC.
End-to-end anastomosis of the donor and recipient portal
vein. End-to-end anastomosis of the donor and recipient
hepatic artery. There was also end-to-end anastomosis of the
donor and recipient of the donor and recipient bile duct with
T-tube insertion. During the intraoperative course, the
patient received 13 units of packed red blood cells, 10 units
of platelets, 18 units of fresh frozen plasma, 7 liters of
Cell [**Doctor Last Name **], 20 units of cryoprecipitate, and 5.5 liters of
crystalloids. His cold ischemia time was 10 hours and 10
minutes. The warm ischemia time was 50 minutes. There were
no complications during the procedure.
The patient was started on Solu-Medrol taper and CellCept for
immunosuppression. In the immediate postoperative period was
fairly uneventful, and Mr. [**Known lastname **] required minimal further
transfusions. He was hemodynamically stable, and by
postoperative day two his ventilator support started to wean
down. His Swan-Ganz catheter and left chest tube were
removed on postoperative day two.
He underwent a therapeutic bronchoscopy on [**1-31**], at
which time purulent secretions with plugging of the right
main stem and bronchus intermedius were noted. The right
middle lobe and right lower lobe lavage with normal saline.
The left bronchus appeared normal. Following the
bronchoscopy, a repeat chest x-ray revealed opening up of the
right upper lobe. A pigtail catheter was also inserted under
ultrasound guidance into the right chest to drain the right
pleural effusion. He received some further packed red blood
cell transfusions, and Zosyn was started after he was noted
to be febrile. Antifungal medication was also started at
this time.
By postoperative day four, rapamycin was added to his
immunosuppressive regimen. His fever was worked up with pan
cultures, and he was started on acyclovir, and central lines
were changed and tips sent for cultures. His blood and
sputum cultures grew Pseudomonas aeruginosa, and he received
double coverage with Zosyn and ciprofloxacin.
However, by postoperative day seven, his cultures and
sensitivities results suggested that the pseudomonas was
resistant to these medications, and he was changed to
meropenem. Once again, the previous central line was
removed, and a fresh right internal jugular line was
established. The right chest pigtail catheter was also
removed.
At this stage, his liver function tests kept rising, and his
AST on postoperative day seven was 510, up from 105 on
postoperative day five. His ALT was 111, up from 312 on
postoperative day five, and his alkaline phosphatase was 199,
up from 77. His total bilirubin was 9, up from 7.7 on
postoperative day five. His biliary drainage through the
T-tube had also diminished. He thus received a 500-mg
Solu-Medrol pulse on postoperative day seven.
He also underwent an ultrasound-guided liver biopsy on
postoperative day eight, and the biopsy suggested
preservation injury with some elements of infection.
Mr. [**Known lastname **] was otherwise stable at this stage.
Mr. [**Known lastname 27608**] white count had decreased after the first few
postoperative days, and based on that his CellCept dose had
been reduced from 1 g b.i.d. to 500 mg b.i.d. At this
stage, his immunosuppression consisting of prednisone 20 mg
once a day, rapamycin 5 mg once a day, and CellCept [**Pager number **] mg
twice a day. As he continued to have thick purulent
secretions from his lung which required very frequent
suctioning, and this was preventing weaning from the
ventilator, we decided to give him double coverage with
antibiotics and add gentamicin to the meropenem that he was
already on.
He also received a T-tube cholangiogram on postoperative day
eight. There was a suggestion of extravasation of contrast
at the point of entry of the T-tube into the bile duct. This
seemed to contain extravasation. To better delineate the
extent of extravasation, he underwent an ultrasound of the
liver which did not show any biloma, and it in fact showed
normal architecture of the bile duct and patent vessels with
normal flow through them.
In view of his persistent depressed mental status, he
underwent a head CT to rule out any intracranial infarct, and
the head CT was negative for hemorrhage or infarct but possible
Central Pontine Myelinolysis could not be ruled out. An attempt
at extubation was made around postoperative day 11, which failed,
and he was required to be reintubated.
On postoperative day 15, he had a low-grade temperature and
some further adjustments were made to his antibiotic regimen.
Based on sensitivity results, gentamicin was changed to
tobramycin, and the vancomycin which he received for a few
days was discontinued. In view of his prolonged intubation
and ongoing aggressive pulmonary toilet needs, he underwent
an percutaneous tracheostomy on postoperative day 16.
On postoperative day 17, bilateral lower extremity deep
venous thromboses were noted, and he was anticoagulated with
heparin infusion.
On postoperative day 18, he again had a temperature spike for
which he was pan cultured, and he central venous line was
changed. He received further bronchoscopies at intervals of
three to four days for pulmonary toilet for recurrent right
lower lobe collapse.
By this stage (that is, going into the end of the second week
and going into the third week) postoperatively, his liver
function tests had plateaued out and then remained
persistently elevated. His AST on postoperative day 20
was 129. ALT was 108, and alkaline phosphatase was 426. His
total bilirubin at this stage was 9.1. Repeat
bronchoalveolar fluid cultures grew Pseudomonas aerogenesis.
The sensitivity of the organism had changed and was again
sensitive to Zosyn. So, again, he was changed to IV Zosyn
and tobramycin.
By the third week postoperatively, he had persistent
pseudomonas tracheobronchitis, lower extremity deep venous
thrombosis, and persistently elevated bilirubin and
transaminases, which was felt to be secondary to
sepsis-related cholestasis.
On postoperative day 22, his immunosuppression was changed.
His CellCept was discontinued, and he was started on Prograf
at 2 mg p.o. b.i.d. His mental status changes issues were
revisited, and he underwent an MRI of his head which showed
some high density signals in the pontine and extra pontine
area, the significance of which was unclear.
On postoperative day 24, a PICC line was inserted. He also
developed some smelly stools, and Clostridium difficile
cultures were sent off for the stools which came back
negative. He had another therapeutic bronchoscopy at that
time which showed that the secretions had lessened.
By this stage, he had completed his course of Zosyn and
tobramycin and subsequent surveillance blood cultures were
all negative. IV antibiotics were therefore stopped at this
stage, and he was switched tobramycin nebulizer treatment for
his tracheobronchitis. Bile culture taken on [**3-21**] had
grown pseudomonas as well as enterococcus. This was felt to
be the colonization of his biliary tree and was therefore not
treated. Mr. [**Known lastname **] remained hemodynamically stable. At
this stage, he was afebrile. His neurologic examination was
stable. He was extremely weak physically with severe
deconditioning resulting from his prolonged illness and
intensive care unit stay.
On [**3-28**], that is postoperative day 28, he underwent
and ultrasound-guided liver biopsy. The biopsy did not show
any evidence of rejection. A Doppler ultrasound of the liver
done at the time also revealed patent vessels with good flow,
and no evidence of biliary duct obstruction.
By postoperative day 29, that is on [**3-29**], Mr. [**Known lastname **]
was four weeks out from his orthotopic liver transplant with
ongoing issues of pseudomonas, tracheobronchitis, and
persistently elevated liver function tests which appeared to
be secondary to sepsis-related cholestasis. He also had
lower extremity deep venous thrombosis. His
immunosuppression at this stage was prednisone 20 mg once a
day, rapamycin 5 mg once a day, Prograf 6 mg twice a day.
CONDITION AT DISCHARGE BY ISSUE:
1. From a neurological standpoint, he has had a stable
examination for quite a while. He was alert and seemed to
clearly follow what is being said and could follow all
commands. He had no cranial nerve deficits. No focal
neurological signs, and could move all four extremities.
2. From a respiratory standpoint, he had a tracheostomy in
place. He continued to require aggressive pulmonary
toilet in the form of suctioning and chest physical therapy.
He had not required bronchoscopy for pulmonary toilet for
several days now; however, he was physically very weak and
had myopathy from his prolonged illness, immunosuppression,
and ventilator dependence, and cannot generate good
spontaneous coughing.
3. From a cardiovascular standpoint, he had been on
Lopressor for several weeks to manage his tachycardia and had
been stable.
4. From a renal perspective, his renal function had been
stable for a while with BUN and creatinine of 35 and 0.8 on
[**2119-3-29**]. His urine output was about 30 cc to 40 cc
an hour for the past few days.
5. From a gastrointestinal point of view, he had a
postpyloric feeding tube to which he was being fed. He was
being fed NutriHep 85 cc an hour, and he was meeting his
calorie requirements.
6. From an infectious disease perspective, he had no further
positive cultures from his blood, and he is currently on
tobramycin nebulizer for his pseudomonas tracheobronchitis,
and has not had any fevers for a while.
7. From a hematologic standpoint, his hematocrit had been
slowly drifting down with a hematocrit of 24.6. Also, he was
being therapeutically anticoagulated with Coumadin to treat
his deep venous thrombosis.
8. From an immunosuppression standpoint, he is currently on
prednisone, rapamycin, and Prograf with adequate Prograf
levels as of [**2119-3-28**].
CONDITION AT DISCHARGE: Stable with tracheostomy requiring
less ventilator support but close monitoring and physical
therapy.Patient is very deconditioned and weak but medically
stable with excellent graft function and no evidence of
rejection.
DISCHARGE DIAGNOSES: A 47-year-old Caucasian male, status
post orthotopic liver transplant for hepatitis C related
cirrhosis with pseudomonas tracheobronchitis, lower extremity
deep venous thrombosis, and persistently raised liver
function tests secondary to sepsis-related cholestasis.
MEDICATIONS ON DISCHARGE:
1. Prednisone 20 mg p.o. q.d.
2. Rapamycin 5 mg p.o. q.d.
3. FK 506 6 mg p.o. b.i.d.
4. Lopressor 37.5 mg p.o. t.i.d.
5. Albuterol MDI 2 puffs to 4 puffs q.4h.
6. NPH 35 units subcutaneous q.a.m. and 30 units
subcutaneous q.p.m.
7. Lactulose 30 cc p.o. q.d.
8. Coumadin 2 mg p.o. q.d.
9. Neutra-Phos 1 packet t.i.d.
10. Acyclovir 400 mg p.o. b.i.d.
11. Actigall 300 mg p.o. b.i.d.
12. Mycostatin swish-and-swallow 5 cc q.6h.
13. Prilosec 20 mg p.o. q.d.
14. Tobramycin nebulizers 300 b.i.d.
15. Multivitamin 1 p.o. q.d.
16. Reglan 10 mg p.o. q.6h.
17. Glutamine 5 mg p.o. b.i.d.
18. Vitamin E 400 units p.o. q.d.
19. Thiamine 100 mg p.o. q.d.
20. Epogen 10,000 units subcutaneous every week (every
Wednesday).
21. Folate 1 mg p.o. q.d.
22. Zinc 220 mg p.o. q.d.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 27128**]
Dictated By:[**Name8 (MD) 27609**]
MEDQUIST36
D: [**2119-3-29**] 23:37
T: [**2119-4-1**] 10:50
JOB#: [**Job Number 27610**]
ICD9 Codes: 5715, 5185, 5070, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1132
} | Medical Text: Admission Date: [**2159-10-13**] Discharge Date: [**2159-10-16**]
Date of Birth: [**2092-10-15**] Sex: F
Service: MEDICINE
Allergies:
Diphenhydramine / Penicillins / Fluoxetine / Trimethoprim
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
66 year old female with h/o severe COPD on home 2LO2 who
presents with shortness of breath.
She states that 1.5 weeks ago she began to have cold symptoms
consisting of a cough and congestion. She wasn't treated for
the first few days but then began to feel more SOB and saw her
PCP [**Last Name (NamePattern4) **] [**2159-10-7**]. She was reportedly given levaquin and a
prednisone taper (starting at 40mg, presently at 20mg). She
reports increasing cough productive of yellow sputum and
worsening dyspnea over the last week. She reports that she has
also been smoking more than usual over the last several weeks,
but quit on the morning of admission. She became very SOB and
called EMS due to respiratory distress. She was found to have
O2 sat 43% on RA.
In the ED, initial vitals were T 98.4 HR 100 BP 160/70 RR 20 O2
Sat 100%2L. She then dropped her O2 sats to mid to high 80's
and low 90's on a NRB. Received 125mg IV solumedrol, 3
treatments with atrovent, and 500mg po azithromycin. She was
weaned to 50% facemask with O2 sat of 90% with some improvement
but persistent dyspnea. Vitals on transfer HR 95 BP 141/76 RR
22 O2 Sat 90% 50%FM.
Review of systems: Negative for fever, chills, night sweats,
chest pain, abdominal pain, nausea, vomiting, diarrhea. Does
have some constipation.
Past Medical History:
- Severe COPD on home O2 (2L). PFTs [**9-4**]: FVC 54%pred, FEV1
24%pred, FEV1/FVC 45%pred. Last admission for COPD exac [**8-4**].
- Depression
- Incontinence x 33 years
Social History:
Patient lives in [**Hospital3 **]. Previously had difficulty
with medication administration and meals. Still smoking 1/2ppd
- states that she quit on the morning of admission. Denies
alcohol or illicit drug use. Has 3 children, [**Doctor First Name **] is closest
to the patient.
Family History:
[**Name (NI) **] mother died of severe COPD.
Physical Exam:
VS: Tm=99.0, Tc=96.8, 122/86, 80, 22, 100%2L NC
GEN: Elderly female, sitting up in bed, tremulous (baseline), no
apparent respiratory distress
HEENT: PERRL, EOMI, sclerae anicteric, MM dry, OP without
lesions, no supraclavicular or cervical lymphadenopathy, JVP low
RESP: Diffuse coarse wheezing and slightly decreased breath
sounds throughout, improved.
CV: RRR without MRG
ABD: Soft, NT/ND, BS+, no rebound or guarding
EXT: No cyanosis, clubbing, or edema. Left shin ulcer bandaged.
SKIN: White skin discoloration lesions, appearing like vitiligo,
noted on her upper back and arms. Multiple ecchymoses arms and
back as well.
NEURO: AAOx3. CN II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. Patient is
noticeably tremulous from head to toe.
Pertinent Results:
ADMISSION LABS:
[**2159-10-13**] 07:15PM WBC-11.0 RBC-4.64 HGB-14.0 HCT-43.9 MCV-95
MCH-30.2 MCHC-31.9 RDW-14.9
[**2159-10-13**] 07:15PM NEUTS-85.2* LYMPHS-8.6* MONOS-4.9 EOS-0.6
BASOS-0.8
[**2159-10-13**] 07:15PM PLT COUNT-359
[**2159-10-13**] 07:15PM PT-11.8 PTT-25.9 INR(PT)-1.0
[**2159-10-13**] 07:15PM cTropnT-<0.01
[**2159-10-13**] 07:15PM GLUCOSE-202* UREA N-13 CREAT-0.7 SODIUM-135
POTASSIUM-5.1 CHLORIDE-89* TOTAL CO2-42* ANION GAP-9
[**2159-10-13**] 07:29PM LACTATE-1.7
[**2159-10-13**] 07:15PM BLOOD proBNP-427*
DISCHARGE LABS:
[**2159-10-16**] 06:00AM BLOOD WBC-9.7 RBC-4.19* Hgb-12.7 Hct-38.2
MCV-91 MCH-30.4 MCHC-33.4 RDW-15.1 Plt Ct-276
[**2159-10-16**] 06:00AM BLOOD Glucose-85 UreaN-11 Creat-0.5 Na-137
K-4.1 Cl-95* HCO3-39* AnGap-7*
[**2159-10-16**] 06:00AM BLOOD Albumin-3.8 Calcium-9.5 Phos-2.3* Mg-2.4
IMAGING:
CHEST (PA & LAT) Study Date of [**2159-10-13**] 8:13 PM
IMPRESSION: COPD without definite sign of superimposed pneumonia
or CHF.
MICROBIOLOGY:
- [**2159-10-13**] 7:00 pm BLOOD CULTURE: pending on discharge
- [**2159-10-14**] 2:05 am MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Final [**2159-10-15**]): POSITIVE FOR METHICILLIN RESISTANT
STAPH AUREUS.
- [**2159-10-14**] 4:07 pm SPUTUM Site: EXPECTORATED
GRAM STAIN (Final [**2159-10-15**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2159-10-16**]):
HEAVY GROWTH Commensal Respiratory Flora.
YEAST. MODERATE GROWTH.
Brief Hospital Course:
66 yo F with PMH of severe COPD on 2L home O2 and severe anxiety
who presented [**10-13**] to [**Hospital1 18**] and was admitted to the MICU for
shortness of breath related to a COPD exacerbation, then
transferred to the medical floor for further management.
# COPD exacerbation: The patient described an increased
productive cough and worsening dyspnea in the setting of a
recent viral syndrome and increased smoking. She has a
significantly reduced FEV1 of 24% predicted and has severe COPD
on baseline home O2 of 2L NC. Patient afebrile with no evidence
of pneumonia on CXR. Received azithromycin 250mg PO x 5 days
(last dose 9/22). Also received one 100mg dose of doxycycline to
cover MRSA; this was stopped when the final sputum culture came
back. She was treated with methylprednisolone 60mg IV q6h on
admission, then switched to PO prednisone 60mg on [**10-14**]. She will
be discharged on a prednisone taper. She received scheduled
albuterol nebs q4h and was written for ipratropium nebs q6h
which she refused. On the floor, her O2 requirement was weaned
back to her baseline of 2L O2 via nasal cannula; her sats were
maintained 88-92%. On the day of discharge (after receiving a
nebulizer treatment), rest saturation was 93% on 2L, then
ambulatory saturation was down to 88% on 2L. She was counseled
about smoking cessation.
# Elevated bicarbonate: Has chronically elevated bicarbonate,
likely related to CO2 retention from COPD.
# Anxiety/Depression: The patient has a noteable tremor on exam
which she attributes to recently decreased dose xanax. She was
continued on her home dose and encouraged to speak to her
psychiatrist about possibly increasing the dose if she is not
able to tolerate the lower dose. Risperdal and paroxetine were
also continued.
# Prophylaxis: Patient received heparin products during this
admission.
# Code status: Full code
Medications on Admission:
Prednisone 20mg po daily
Alprazolam 0.5mg po bid, 0.75mg po qhs
Risperidone 2mg po qhs
Combivent 18mcg-103mcg 2 puffs inh q4h prn SOB
Fluticasone 220mcg 2 puffs [**Hospital1 **]
Formoterol 12 mcg Capsule, w/Inhalation Device
Spiriva 18mcg 1 puff inh daily
Docusate 100mg po bid
Senna 1 tab po bid
Alprazolam 1mg po bid prn
Paroxetine 60mg po daily
Vitamin D 800units po daily
Calcium 1000mg po daily
Discharge Medications:
1. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
2. Alprazolam 0.25 mg Tablet Sig: Three (3) Tablet PO QHS (once
a day (at bedtime)).
3. Risperidone 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) puffs Inhalation every four (4) hours as needed for
shortness of breath or wheezing.
5. Fluticasone 220 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
6. Formoterol Fumarate 12 mcg Capsule, w/Inhalation Device Sig:
One (1) inhalation Inhalation every twelve (12) hours.
7. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) puff Inhalation once a day.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Paroxetine HCl 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
11. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
12. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: Two
(2) Tablet, Chewable PO DAILY (Daily).
13. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 1 doses: last dose 9/22.
Disp:*1 Tablet(s)* Refills:*0*
14. Prednisone 10 mg Tablet Sig: As directed Tablet PO AS
DIRECTED for 11 days: 40mg (four tabs) x 2 days ([**2072-10-15**]), THEN
30mg (three tabs) x 3 days ([**Date range (1) 50299**]), THEN
20mg (two tabs) x 3 days ([**2078-10-21**]), THEN 10mg (one tab) x 3 days
([**Date range (1) 8258**]).
Disp:*26 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis:
1. Chronic obstructive pulmonary disease exacerbation
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:
1. You were admitted to the hospital for shortness of breath and
found to have an exacerbation of your chronic obstructive
pulmonary disease, also known as COPD. This was likely caused by
the cold you experienced last week.
2. You were started on a 5-day course of azithromycin (last dose
on [**10-17**]). You were also started on a prednisone taper:
40mg x 2 days ([**2072-10-15**])
30mg x 3 days ([**Date range (1) 50299**])
20mg x 3 days ([**2078-10-21**])
10mg x 3 days ([**Date range (1) 8258**])
3. We observed that your oxygen saturation dropped while you
were walking with the physical therapists and nurses, therefore,
you should use 3L O2 while you walk for the next 1 week and then
have the physical therapists re-evaluate your ambulatory oxygen
saturation. Otherwise, you can use your baseline of 2L O2 at
rest.
4. Your respiratory symptoms are made much worse by smoking. You
should discuss options for smoking cessation with your PCP.
5. It is important that you take all of your medications as
prescribed.
6. It is important that you keep all of your follow up
appointments.
Followup Instructions:
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2159-10-18**] at 3:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2159-10-18**] at 3:30 PM
With: DR. [**Last Name (STitle) 11071**] / DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
**You should schedule a follow up appointment with your PCP (Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1266**] [**Telephone/Fax (1) 608**]) within the next 1 week.
Completed by:[**2159-10-18**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1133
} | Medical Text: Admission Date: [**2110-5-8**] Discharge Date: [**2110-5-15**]
Date of Birth: [**2051-3-22**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 19833**] is a 57 year-old
male with known coronary artery disease status post
percutaneous transluminal coronary angioplasty in [**2102**], [**2108**]
and in [**2109**] who has had increasing dyspnea on exertion with
occasional chest discomfort over the past few months. He was
catheterized on the day of admission and that revealed an
occlusion of the left anterior descending coronary artery and
right coronary artery with instent stenosis and moderate
obtuse marginal disease.
PAST MEDICAL HISTORY: Coronary artery disease status post
myocardial infarction in [**2109**]. Hypertension,
hypercholesterolemia, chronic back pain, question of a
transient ischemic attack versus a cerebrovascular accident
at the time of his angioplasty in [**2102**] with no residual
deficit. Degenerative joint disease. Status post total hip
replacement on the left.
MEDICATIONS PRIOR TO ADMISSION:
1. Toprol XL 100 mg q.d.
2. Lipitor 20 mg q.d.
3. Diovan 80 mg q.d.
4. Aspirin 325 q.d.
5. Motrin 800 q.d.
6. Percocet on a prn basis.
7. Plavix 75 mg q.d.
8. Imdur no dose provided.
9. Multivitamin.
ALLERGIES: Zestril to which he gets a cough.
LABORATORY DATA: White blood cell count 7.9, hematocrit 44,
platelets 225, INR 0.91, sodium 140, potassium 4.8, chloride
109, CO2 25, BUN 14, creatinine 0.8.
PHYSICAL EXAMINATION: Neurological grossly intact.
Pulmonary lungs clear to auscultation bilaterally. Heart
regular rate and rhythm. S1 and S2. No murmur. Abdomen
obese, soft and nontender. Positive bowel sounds.
Extremities are warm. No edema. Pulses bilaterally.
HOSPITAL COURSE: Following his cardiac catheterization
cardiothoracic surgery was consulted and the patient was seen
and accepted for surgery. While awaiting surgery he had a
carotid duplex that showed no significant hemodynamic lesions
in the right or left. On [**5-9**] the patient was brought to
the Operating Room. Please see the OR report for full
details. In summary the patient had coronary artery bypass
graft times three with a left internal mammary coronary
artery to the left anterior descending coronary artery,
saphenous vein graft to obtuse marginal and saphenous vein
graft to the right posterior descending coronary artery.
Bypass time was 66 minutes. Cross clamp time was 39 minutes.
He tolerated the procedure well and was transferred from the
Operating Room to the Cardiothoracic Intensive Care Unit. At
that time he had Propofol at 30 mcs per kilogram per minute.
The patient did well in the immediate postoperative period.
His anesthesia was reversed. Sedation discontinued. He was
weaned from the ventilator and successfully extubated. On
the morning of postoperative day one the patient remained
hemodynamically stable. Swan-Ganz catheter and central
venous access lines were discontinue. If a bed had been
available he would have been transferred to the floor,
however, there were none and he stayed in the Intensive Care
Unit where is activity level was gradually increased.
On postoperative day two the patient's chest tubes were
discontinued and he was transferred to the floor for
continuing postoperative care and cardiac rehabilitation.
Once on the floor a chest x-ray revealed significant right
pneumothorax. A chest tube was placed at that time and the
lung was successfully reexpanded. Over the next two days the
patient's activity level was increased. On postoperative day
five the chest tube that was placed for the pneumothorax was
discontinued. The patient ambulated to a level five and it
was decided that he was stable and ready to be discharged to
home.
PHYSICAL EXAMINATION ON DISCHARGE: Vital signs temperature
99. Heart rate 83, sinus rhythm. Blood pressure 116/56.
Respiratory rate 20. O2 sat 99% on room air. Weight
preoperatively is 147.5 kilograms, at discharge it is 145.6
kilograms. Alert and oriented times three, moves all
extremities. Follows commands. Respirations scattered
rhonchi, distant breath sounds. Cardiac regular rate and
rhythm. S1 and S2. No murmurs. Sternum was stable.
Incision with Steri-Strips open to air, clean and dry.
Abdomen is obese, soft, nontender, nondistended with positive
bowel sounds. Extremities are warm and well perfuse with 1+
bilateral edema. Right leg incision with Steri-Strips open
to air clean and dry.
LABORATORY DATA: White blood cell count 11.7, hematocrit 32,
4, platelets 224, sodium 138, potassium 3.7, chloride 97, CO2
29, BUN 19, creatinine 0.9, glucose 124.
DISCHARGE MEDICATIONS:
1. Metoprolol 75 mg b.i.d.
2. Lasix 20 mg q.d. times two weeks.
3. Potassium chloride 20 milliequivalents q.d. times two
weeks.
4. Enteric coated aspirin 325 q.d.
5. Lipitor 20 mg q.d.
6. Percocet 5/325 one to two tabs q 4 hours prn.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery
bypass grafting times three.
2. Hypertension.
3. Hypercholesterolemia.
4. Chronic back pain.
5. Degenerative joint disease.
6. Status post total hip replacement of the left.
He is to be discharged to home and follow up in the wound
clinic in two weeks. Follow up with his primary care
physician in two to three weeks and follow up with Dr.
[**Last Name (STitle) 70**] in six weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Doctor Last Name 9076**]
MEDQUIST36
D: [**2110-5-15**] 12:36
T: [**2110-5-15**] 12:55
JOB#: [**Job Number 35024**]
ICD9 Codes: 4111 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1134
} | Medical Text: Admission Date: [**2148-6-27**] Discharge Date: [**2148-7-10**]
Date of Birth: [**2128-1-16**] Sex: M
Service: TRA
ADDENDUM:
FINAL DIAGNOSIS: Paraplegia.
Closed head injury.
Cord injury/T12 burst fracture with cord impingement.
Left first rib fracture.
Aspiration with right upper lobe, right lower lobe collapse,
status post bronchoscopy.
Stellate laceration to face and nose.
Bilateral nasal bone fracture.
SURGICAL/INVASIVE PROCEDURES: Anterior and posterior spinal
fusion, C9 to L2, done in without separate operations, [**6-29**]
and [**7-2**].
Nasal bone fracture reduction [**2148-6-28**].
Bronchoscopy [**2148-6-28**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 13037**]
Dictated By:[**Last Name (NamePattern1) 27758**]
MEDQUIST36
D: [**2148-7-10**] 07:20:05
T: [**2148-7-10**] 07:41:47
Job#: [**Job Number 55425**]
ICD9 Codes: 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1135
} | Medical Text: Admission Date: [**2167-3-12**] Discharge Date: [**2167-3-18**]
Date of Birth: [**2096-3-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
cough, sob x 2days
Major Surgical or Invasive Procedure:
None
History of Present Illness:
70 year-old man w/ systolic CHF, CAD s/p 5V CABG, Afib
(coumadin/dig), type II DM, hypothyroidism, chronic renal
failure, who was transferred from an [**Hospital3 **] ED for
hypotension, coagulopathy, fever. He initially presented to
[**Location (un) 4444**] health clinic on [**3-12**] with 2 days of SOB, worsening
DOE, orthopnea, dry cough. At the clinic, the pt was given 80mg
IV lasix for presumed CHF exacerbation. He was then sent to
[**Hospital3 2783**] where he was found to have gross
coagulopathy (PT 215, PTT 109, INR 8.2), possible PNA, and fever
(?101). At the OSH, he became hypotensive w/ SBP of 50's. He was
given NS 250ml x 2 and levaquin 750mg for empiric tx of presumed
pna, although the CXR was read as normal. CE were neg. Lacate as
2.44. Blood cx were collected. Of note, pt. had 2 recent med
changes (metformin->actos, tricor -> [**Hospital3 107356**]).
In the [**Hospital1 18**] ED: initial vitals were- T 99.2 BP 92/56 HR 70 RR
20 02sat 99% on 4L. The pt again became hypotensive and was
given 2L of NS. After IVF, he developed SOB (02 sat 90% on 3L)
and was briefly required a NRB. He was given 2u of FFP and
started on peripheral levophed. He was given 1g of ceftrioxone
and admited to the MICU for further management. On arrival to
the MICU pt. had a new pruritic, erythematous rash on abdomen
chest and knees, which responded to benadryl/famotadine.
ROS: denies fevers, chill, sick contacts. Admits to dry cough.
denies urinary symptoms or diarrhea. Notes a recent fall with
fractured R 6th rib. DOE w/ 1 flight of stairs, orthopnea, PND
over the past 2 days. Denies poor wound healing or bleeding
recently.
Past Medical History:
CAD s/p CABG [**85**] years prior
CHF (unknown EF)
DMII
CRI
Afib
hypothyroidism (s/p ablation for multinodular goiter)
gout
Social History:
quit smoking 26 years ago (prior 1.5ppd x 20 years), occasional
alcohol, no drug use. Retired building maintenance engineer. 4
children. lives alone.
Family History:
Father- MI.
Physical Exam:
VS: Temp: 99.2 BP: 116/71 (on levophed) HR: 84 RR: 21 O2sat 94%
on 5L NC
GEN: NAD, laying in bed
HEENT: MMM, adentulous, NC in place, no JVD
RESP: fine crackles diffusely R>L
CV: irregularly, irregular, III/VI SEM best at LLSB
ABD: erythematous, pruritic papular rash. NT/ND, normoactive BS
EXT: 2+ DP, WWP, non edematous, well-healed RLE surgical scar
s/p bypass surgery. erythematous, papular rash in knees
bilaterally
SKIN: rash as described above.
NEURO: AAOx3.
Pertinent Results:
[**2167-3-12**] 03:00AM BLOOD WBC-5.8 RBC-4.06* Hgb-11.9* Hct-36.2*
MCV-89 MCH-29.4 MCHC-33.0 RDW-13.8 Plt Ct-154
[**2167-3-12**] 03:00AM BLOOD Neuts-72.9* Lymphs-15.3* Monos-9.6
Eos-1.6 Baso-0.5
[**2167-3-12**] 03:00AM BLOOD PT-150* PTT-63.6* INR(PT)-22.8*
[**2167-3-14**] 04:05AM BLOOD PT-15.3* PTT-26.8 INR(PT)-1.4*
[**2167-3-12**] 03:00AM BLOOD Glucose-149* UreaN-54* Creat-2.6* Na-137
K-5.0 Cl-100 HCO3-23 AnGap-19
[**2167-3-14**] 04:05AM BLOOD Glucose-60* UreaN-28* Creat-1.6* Na-136
K-4.3 Cl-99 HCO3-25 AnGap-16
[**2167-3-12**] 03:00AM BLOOD CK(CPK)-40
[**2167-3-12**] 03:00AM BLOOD CK-MB-NotDone proBNP-4439*
[**2167-3-12**] 03:00AM BLOOD cTropnT-0.03*
[**2167-3-14**] 04:05AM BLOOD Calcium-8.5 Phos-2.6* Mg-2.2
[**2167-3-12**] 09:45AM BLOOD Digoxin-0.8*
[**2167-3-12**] 03:08AM BLOOD Lactate-2.1*
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2167-3-13**]):
POSITIVE FOR INFLUENZA B VIRAL ANTIGEN.
REPORTED BY PHONE TO DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2167-3-13**] 125P.
[**2167-3-12**] Renal U/S: IMPRESSION:
1. No evidence of hydronephrosis. Nonobstructing 7 mm left renal
calculus.
2. 8-10 mm echogenic foci with tram tracking appearance in the
right kidney suggestive of an intraureteral stent but may also
represent renal calculi in the absence of such history. Clinical
correlation is recommended.
[**2167-3-12**] CXR: IMPRESSION:
1. Vague increased patchy opacity in the right lower lung. This
may be the area where prior pneumonia has been seen. Comparison
with prior would be helpful.
2. No evidence of congestive heart failure.
[**3-12**] ECG: Atrial fibrillation with moderate ventricular
response. Occasional ventricular
premature beats. Poor R wave progression suggests possible prior
old
anteroseptal myocardial infarction. Modest inferolateral ST-T
wave changes
which are non-specific. Compared to the previous tracing of
[**2153-2-28**] there is no significant diagnostic change.
[**2167-3-12**] ECHO: The left atrium is moderately dilated. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. Overall left ventricular systolic function is moderately
depressed (LVEF= 30-40 %). [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size is normal. with
depressed free wall contractility. [Intrinsic right ventricular
systolic function is likely more depressed given the severity of
tricuspid regurgitation.] The aortic root is moderately dilated
at the sinus level. The ascending aorta is moderately dilated.
The aortic valve leaflets are severely thickened/deformed. There
is moderate to severe aortic valve stenosis (area 0.8-1.0cm2).
No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. There is
severe mitral annular calcification. There is a minimally
increased gradient consistent with trivial mitral stenosis.
Moderate (2+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] Moderate [2+] tricuspid
regurgitation is seen. There is no pericardial effusion.
-----------------
RADIOLOGY Final Report
CHEST (PA & LAT) [**2167-3-17**] 11:36 AM
CHEST (PA & LAT)
Reason: Please evaluate for interval change
[**Hospital 93**] MEDICAL CONDITION:
70 year old man with Aortic Stenosis, CAD, s/p CABG, a/w
influenza and pneumonia
REASON FOR THIS EXAMINATION:
Please evaluate for interval change
INDICATION: Aortic stenosis, now with influenza, and persistent
cough.
CHEST, TWO VIEWS: Comparison with [**2167-3-12**]. In the
interim, a small right pleural effusion has accumulated.
Cardiac, mediastinal, and hilar contours are unchanged, with
cardiomegaly again noted. The interstitial abnormality
throughout both lungs including [**Last Name (un) 16765**] B-lines and indistinct
pulmonary vasculature can represent interstitial changes from
chronic cardiac failure. There are no focal consolidations.
Osseous structures including midline sternotomy wires and CABG
staples are unchanged.
IMPRESSION: Small right pleural effusion and chronic
interstitial changes, which can be seen in chronic heart
failure. No focal consolidations. Findings discussed with Dr.
[**Last Name (STitle) **] by phone at 2:00 p.m., [**2167-3-17**].
ab
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: WED [**2167-3-18**] 6:07 AM
-------------
Brief Hospital Course:
A/P: 70 yo M w/ CHF, Afib, CAD s/p CABG, DMII, acute on chronic
RF, recent DOE and cough, transferred from OSH for hypotension,
fever, gross coagulopathy, acute on chronic RF.
.
# Fever and pneumonia due to influenza A: The patient's DFA was
positive for flu. In ICU started empirically on levaquin for
pneumonia and then transitioned to unasyn. After stabilization,
patient was transferred to the floor for management. Kept on
droplet precautions for influenza and continued on unasyn
overnight. Then transitioned to PO augmentin. Patient
subsequently developed low grade temperatures on a nightly basis
despite improvement in cough, shortness of breath, and overall
clinical status. Fever work-up was non-revealing with negative
blood cultures, and negative CXR. Augmentin was discontinued
and patient remained afebrile for 36 hours thereafter, so we
suspect that drug fever may have been the etiology.
# Hypotension due to cardiogenic shock: Pt presented to clinic
and was given IV lasix IV x 2 for presumed CHF. He has moderate
to severe AS by echo, and in setting of preload dependence may
have decompensated to the point of requiring both fluid
rescusitation and pressors. Was only transiently on pressors
once admitted and since SBPs have been stable in low 110s.
.
#Aortic Stenosis/CHF: TTE confirmed moderate to severe AS by
echo. Impression was for pre-load dependent AS that was overly
diuresed prior to admission and precipitated hypotension. Actos
was held due to concern it may exacerbate CHF. Patient advised
to to resume until discussing with PCP.
.
# Renal function elevated on admission and returned to baseline
prior to discharge.
.
# Coagulopathy: Initial coags here were PT 150 PTT 63 INR 22,
now coags are normalized (PT 20.5, PTT 31.5,INR 1.9). Pt.
received 2 units of FFP and vitamin K in ED. Per pt. he has his
INR checked every 4 weeks and has not had any problems in the
past. Of note, he has recently started [**Year (4 digits) **] which has
been reported to interact with warfarin. Coumadin was restarted
prior to discharge. INR was therapeutic on 2mg warfarin per day
and patient was advised to continue with this dose in the future
with further blood tests/monitoring to be conducted by his PCP.
[**Name10 (NameIs) **] was held on discharge.
.
# Rhythm: H/o afib. Per PCP [**Last Name (NamePattern4) **]. is very non-compliant with
coumadin compliance and checking his INR.
.
#:DMII: Covered with RISS while in house. Resumed glyburide on
discharge.
.
# gout: renally dosed allopurinol
.
# Hyperlipidemia:
- held [**Last Name (NamePattern4) 107356**] as this medication may interact with
warfarin.
.
# HTN: Resumed lisinopril at low dose of 2.5mg qd. Beta blocker
held and patient advised to resume after discussion with PCP.
Medications on Admission:
allopurinol 100mg qdaily
atenolol 100mg qdaily
digoxin 250mcg qdaily
lasix 40 qdaily
glyburide 10mg [**Hospital1 **]
lisinopril 10mg qdaily
potassium 20 meq qdaily
warfarin 3mg MWF 2mg STTS
nitro tabs
[**Hospital1 **] 600mg qdaily (recently changed from tricor)
actos 30mg qdaily (recently changed from metformin [**2-28**] to CRI)
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO once a day.
4. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16).
Disp:*30 Tablet(s)* Refills:*0*
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*18 Capsule(s)* Refills:*0*
8. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed for cough.
Disp:*320 ML(s)* Refills:*0*
9. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO once
a day.
11. Outpatient Lab Work
Please check PT, INR, Creatinine, Potassium, Sodium, and BUN and
have these lab results sent to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 107357**]. Phone:
([**Telephone/Fax (1) 25201**], Fax: ([**Telephone/Fax (1) 107358**]
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
Influenza B
Hypotension
Aortic Stenosis
Elevated INR
Atrial Fibrillation
Discharge Condition:
Good, no oxygen requirement
Discharge Instructions:
You were admitted to the hospital for treatment of low blood
pressure, influenza and pneumonia. On admission it was found
that you had elevated levels of coumadin in your blood. You
were given Vitamin K and a plasma transfusion to correct the
levels. You were given fluids to treat your low blood pressure,
and you were given antibiotics to treat your pneumonia. While
in the hospital you were monitored and treated in the ICU and
then transferred to the floor for further care. With regards to
your pneumonia, it is believed that is developed as a
complication of influenza. With regards to your coumadin dose,
it is believed that [**Telephone/Fax (1) 107356**] may have interacted to cause
your dose to be too high. Please do not take [**Telephone/Fax (1) 107356**] when
you leave the hospital. Please take all other medications as
detailed below.
.
Please return to the hospital or call your physician if you
[**Name9 (PRE) 107359**] fever > 101, chest pain, shortness of breath, or any
other complaint concerning to you.
.
The following changes were made to your medications:
1. Actos - discontinued
2. [**Name9 (PRE) **] - discontinued
3. Warfarin 2mg per day only
4. Lisinopril 2.5mg daily - please discuss with your doctor
before resuming higher 10mg dose.
5. Atenolol - please do not resume taking until you discuss
with your PCP.
.
Recommended Follow-up Care:
1. Evaluation by Cardiologist for Moderate-Severe Aortic
Stenosis and possible valve replacement.
2. Please have your kidney function, and INR checked in the
next week and have the results sent to your PCP.
3. Repeat CXR in 4 weeks time to document resolution of your
pneumonia.
Followup Instructions:
1. Please follow-up in Cardiology: ([**Telephone/Fax (1) 2037**], Wednesday,
[**3-25**] at 1:20pm, Dr. [**Last Name (STitle) **], [**Hospital Ward Name 23**] [**Location (un) **], [**Hospital Ward Name 5074**] of [**Hospital1 69**].
2. Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 107357**], in [**Location (un) 2199**] for
an appointment in the next 1-2 weeks. Phone: ([**Telephone/Fax (1) 25201**],
Fax: ([**Telephone/Fax (1) 107358**].
3. Please have your Creatinine, potassium, PT, INR checked
prior to your next appointment and have the results sent to Dr.
[**Last Name (STitle) 107357**]. Pleaes have bloodwork done in next 3-5 days.
ICD9 Codes: 5849, 4280, 5859, 4241, 2449, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1136
} | Medical Text: Admission Date: [**2150-2-16**] Discharge Date: [**2150-2-19**]
Date of Birth: [**2067-8-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Hyponatremia, hypothermia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 82 year-old Spanish speaking female with a history of
CAD s/p recent BMS to RCA, type II DM, hyperlipidemia,
hypertension, paroxysmal atrial fibrillation admitted following
a fall. Pt was recently hospitalized [**Date range (1) 34801**] from the
cardiology service with NSTEMI and had a BMS to RCA and new
atrial fibrillation. She was started on antiplatelet therapy
and started on anticoagulation. Pt notes that she has been
having fatigue and lethargy dating back to this hospitalization.
This AM she woke up to use the bathroom, when she felt her
"balance was off" and fell. Fall witnessed by her husband. She
hit her head on falling. She denies prodromes of
lightheadedness, palpitations, or chest pain. No LOC. Per her
daughter, she fell 2 days prior, attributed to poor balance,
resulting in trauma to her right foot. She notes poor PO intake
for 1 week due to poor appetite. Denies nausea, vomitting, or
loose stools. Notes constipation and is currently on
"laxatives." +Increasing cold intolerance. Also with dysuria
and chills dating back to prior admission.
In the field found to have FSG 30, given 1 amp D50. FSG 51 on
arrival to ED. Given another 1 amp D50, serum glucose
subsequently 256. In the ED, hypothermic to T 32, started on
beg hugger. Also with hyponatremia to 120, given 2 L warmed NS.
Also given ceftriaxone 1 gm for concern for sepsis without
clear source given hypothermia and hypoglycemia. Imaging
notable for CT abd/pelv without acute process, CT head and neck
notable for retrolisthesis of C5-C6 of unclear acuity. Seen by
spine c/s in ED and c-spine cleared. Decadron 10 mg given for
?adrenal insufficiency.
ROS: The patient denies any fevers, weight change, nausea,
vomiting, abdominal pain, diarrhea, melena, hematochezia, chest
pain, shortness of breath, orthopnea, PND, lower extremity
edema, cough, urinary frequency, urgency, lightheadedness, focal
weakness, vision changes, headache, rash or skin changes.
Past Medical History:
1. Coronary Artery Disease s/p BMS to RCA on [**2150-2-13**]
2. Diabetes Mellitus, type 2 - on insulin
3. Hypertension
4. Hyperlipidemia
5. Cataracts s/p surgical repair x2
6. Proliferative Retinopathy
7. Diabetic Neuropathy
Social History:
Social history is significant for the absence of current or
former tobacco use. There is no history of alcohol or drug
abuse. She lives with her husband and is able to perform ADLs.
Family History:
There is no family history of premature coronary artery disease
or sudden cardiac death. Mother died of MI at age 62. Father
died of kidney disease.
Physical Exam:
On Presentation:
Vitals: T:94.1 BP:131/46 HR:53 RR: 12 O2Sat: 100% RA
GEN: Elderly female, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, +MM dry, +mild bruising of tip of tongue, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: Bradycardia, RR, distant heart sounds, normal S1 S2, radial
pulses +2
PULM: Bibasilar crackles
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E
NEURO: Alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. +Decreased sensation to light touch of lower
extremities up to ankles b/l
SKIN: No jaundice, cyanosis, or gross dermatitis. +Diffuse
echymoses of abdomen, and pelvic region. +Laceration of 4th
metatarsal.
.
.
Discharge:
VS T98 158/52 54 18 99RA
GEN: Elderly female, NAD. Non-toxic.
HEENT: EOMI, mmm.
RESP: CTA B. No WRR.
CV: Brady, regular
ABD: Soft, NT.
Ext: Small skin tear on toe R foot, no longer bleeding.
superficial.
Pertinent Results:
[**2150-2-16**] 06:40AM GLUCOSE-265* UREA N-35* CREAT-1.4*
SODIUM-120* POTASSIUM-4.0 CHLORIDE-87* TOTAL CO2-26 ANION GAP-11
[**2150-2-16**] 06:40AM CK(CPK)-423*
[**2150-2-16**] 06:40AM cTropnT-0.10*
[**2150-2-16**] 06:40AM CK-MB-9
[**2150-2-16**] 06:40AM OSMOLAL-271*
[**2150-2-16**] 06:40AM WBC-9.4 RBC-3.16* HGB-10.2* HCT-27.3* MCV-86
MCH-32.4* MCHC-37.5* RDW-13.9
[**2150-2-16**] 06:40AM NEUTS-87* BANDS-0 LYMPHS-8* MONOS-3 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2150-2-16**] 06:40AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2150-2-16**] 06:40AM PLT SMR-NORMAL PLT COUNT-274
[**2150-2-16**] 06:40AM PT-16.9* PTT-45.6* INR(PT)-1.5*
[**2150-2-16**] 06:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2150-2-16**] 06:40AM URINE RBC-0-2 WBC-[**3-26**] BACTERIA-NONE YEAST-NONE
EPI-0-2
[**2150-2-16**] 12:31PM TRIGLYCER-151* HDL CHOL-38 CHOL/HDL-3.1
LDL(CALC)-50
[**2150-2-16**] 12:31PM LIPASE-24
[**2150-2-16**] 12:31PM ALT(SGPT)-38 AST(SGOT)-44* LD(LDH)-256* ALK
PHOS-78 TOT BILI-0.5
[**2150-2-16**] 12:31PM GLUCOSE-188* UREA N-29* CREAT-1.3*
SODIUM-126* POTASSIUM-4.6 CHLORIDE-93* TOTAL CO2-23 ANION GAP-15
ECG: Sinus bradycardia to 55, LBBB, LAD, no acute ST/T changes
Imaging:
CXR ([**2-16**]): Mild volume overload, cardiomegaly, increased
pulmonary vascular prominence
CT Head ([**2-16**]):
1. Very small left parietovertex scalp subcutaneous hematoma.
2. No evidence of acute intracranial hemorrhage or mass effect.
3. No evidence of acute major territorial infarct. However, MRI
with diffusion-weighted imaging is more sensitive for evaluation
of acute ischemia.
CT C-spine ([**2-16**]):
1. No evidence of acute fracture.
2. Moderately severe degenerative changes within the cervical
spine with
grade 1 retrolisthesis of C5 on C6. Given the degenerative
findings, acuity this is likely chronic; however, there is
ventral canal narrowing at this and the C4-C5 level, and MRI of
the cervical spine is recommended if myelopathic symptoms
suggest acute cord injury.
3. Multilevel spinal stenosis secondary to disc bulges and
herniations and
spondylosis.
CT abd/pelvis ([**2-16**]):
1. No evidence of intra-abdominal infection. No acute abdominal
pathology.
2. 13 x 8 mm mural nodule along the right posterior bladder wall
which is
concerning for malignancy. Recommend further evaluation with
urine cytology and/or cystoscopy.
.
X-ray R foot:
IMPRESSION:
No fracture.
.
[**2150-2-19**] 08:00AM BLOOD WBC-11.5* RBC-3.44* Hgb-10.4* Hct-30.0*
MCV-87 MCH-30.2 MCHC-34.6 RDW-14.3 Plt Ct-427
[**2150-2-16**] 12:31PM BLOOD PT-18.5* PTT-35.4* INR(PT)-1.7*
[**2150-2-17**] 04:32AM BLOOD PT-17.6* PTT-29.9 INR(PT)-1.6*
[**2150-2-18**] 07:20AM BLOOD PT-20.1* PTT-60.0* INR(PT)-1.9*
[**2150-2-19**] 08:00AM BLOOD PT-20.4* INR(PT)-1.9*
[**2150-2-19**] 08:00AM BLOOD Glucose-93 UreaN-26* Creat-1.2* Na-132*
K-4.8 Cl-96 HCO3-26 AnGap-15
[**2150-2-19**] 08:00AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.4
[**2150-2-16**] 06:40AM BLOOD CK-MB-9
[**2150-2-16**] 06:40AM BLOOD cTropnT-0.10*
[**2150-2-16**] 05:00PM BLOOD CK-MB-7 cTropnT-0.07*
[**2150-2-18**] 07:20AM BLOOD calTIBC-358 VitB12-762 Folate-16.4
Ferritn-131 TRF-275
[**2150-2-16**] 12:31PM BLOOD Triglyc-151* HDL-38 CHOL/HD-3.1
LDLcalc-50
[**2150-2-16**] 06:40AM BLOOD Osmolal-271*
[**2150-2-16**] 06:40AM BLOOD TSH-0.55
[**2150-2-16**] 06:40AM BLOOD Free T4-1.3
[**2150-2-19**] 01:32PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.012
[**2150-2-19**] 01:32PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2150-2-16**] 06:40AM URINE RBC-0-2 WBC-[**3-26**] Bacteri-NONE Yeast-NONE
Epi-0-2
Brief Hospital Course:
MICU COURSE:
82 year-old Spanish speaking female with a history of CAD s/p
recent BMS to RCA, type II DM, hyperlipidemia, hypertension,
paroxysmal atrial fibrillation admitted with hypothermia and
hyponatremia.
# Hypothermia:
# Hypoglycemia:
# Hyponatremia:
# CAD: Recent BMS to RCA, pt was continued on home ASA, plavix,
statin.
# Hypertension: Antihypertensives initially held. She was
restarted on her BB and [**Last Name (un) **] at lower doses. They should be
titrated up as needed.
# Atrial fibrillation: Currently in NSR, on coumadin for
anticoagulation. Lovenox held (had been on lovenox bridge to
coumadin from prior hospitalization) given extensive bruising on
her abdomen. Coumadin titrated up to 5 mg at time of transfer.
# Mass Along Bladder: On her CT scan from ED, she was noted to
have a mass on the posterior aspect of her bladder concerning
for malignancy. She had a urine cytology sent which is
currently pending and should have urology follow up for possible
cystoscopy.
# Left toe laceration: Secondary to fall, per preliminary
report, cannot rule out extension into bone. As her hypothermia
has resolved and there is little suscipicion of infection and
her exam benign, further imaging deferred.
.
.
82 spanish speaking F with afib, CAD s/p recent BMS to RCA, dm2,
admitted with fall, hyponatremia, hypothermia, hypoglycemia.
Pt initially presnted with hypothermia, bradycardia and
hyponatremia, concerning for hypothyroidism. TSH however was
wnl. Sepsis unlikely given pt hemodynamic stable and no clear
source for infection (symptom of dysuria in setting of foley
catheter, clean u/a), adrenal insufficiency also unlikely. Given
negative work up and occurence with hypoglycemia, hypothermic
episode most likely [**2-23**] her hypoglycemic episode. She received
external warming and her temperature normalized on the first day
of her hospital stay. Blood and urine cultures remained
negative throughout her ICU stay.
.
1. Fall/ C5-6 retrolisthesis:
Fall sounds mechanical in nature. CT showed C5-6 retrolisthesis.
c-spine was cleared by Neurosurgery in ED. Neuro exam remains
non-focal
- PT consult
- no events on tele except bradycardia - approx 50
.
# Hypothermia:
This resolved with simple warming measures, was likely [**2-23**]
hypoglycemia. There was initial concern for possible sepsis,
though bld cx and urine cx are NGTD. TSH wnl.
.
# Hypoglycemia/Type II Diabetes, controlled with complications:
Hypoglycemia was in setting of poor PO and continued long acting
insulin, now resolved. Also, it was found that pt's husband
administer's patient's insulin, but does not have a clear method
for calculating dose of insulin, and it appears that pt does not
even check her glucose daily or even weekly. Nursing spent
significant time educating patient, husband and daughter about
the need for frequent daily glucose monitoring, and the use of a
sliding scale. Patient was discharged on NPH and sliding scale,
as used during the hospitalization.
Recommend that patient have geriatrics consult with Dr. [**Last Name (STitle) 713**]
after discharge.
.
# Hyponatremia:
Pt noted to have hypovolemic hyponatremia on admission,
corrected with hydration. She was encouraged to increase her PO
intake.
Sodium runs baseline in 130s likely [**2-23**] diuretics.
.
# Chronic diastolic heart failure, EF 50%:
currently euvolemic
- patient returned to her home dosing of cardiac medications
prior to discharge.
.
# Mass Along Bladder: On her CT scan from ED, she was noted to
have a mass on the posterior aspect of her bladder concerning
for malignancy. She had a urine cytology sent which is
currently pending and should have urology follow up for possible
cystoscopy.
**Please follow up**
.
# CAD:
Recent BMS to RCA. No active CP symptoms, trop 0.07, though
baseline mildly elevated, ECG with LBBB
- Cont home ASA, plavix, statin, BB
.
# Chronic renal failure, Stage III:
cr 1.3 at baseline
- Cr currently at baseline
.
# Atrial fibrillation:
now in SR
- c/w coumadin, INR 1.9 at discharge
- c/w metoprolol
.
# Anemia:
hct 26.3, baseline around 30, has remained stable since
admission.
- request outpatient follow-up
.
# Left toe laceration:
Secondary to fall.
- Xray toe without fracture
.
# FEN: Cardiac, diabetic diet
.
# F/u: recommend outpatient Geriatrics consult with Dr. [**Last Name (STitle) 713**]
([**Telephone/Fax (1) 6846**]
# Comm: Pt and daughters, son in law [**Telephone/Fax (1) 73293**]
Medications on Admission:
-Atorvastatin 80 mg
-Citalopram 20 mg
-Ranitidine HCl 150 mg
-Hydrochlorothiazide 50 mg
-Losartan 100 mg
-Furosemide 20 mg QMOWEFR
-Isosorbide Mononitrate 60 mg
-NPH 40/20-->as of late has been taking NPH 30/15 due to poor PO
intake
-Lovenox 60 (day #4, bridge to coumadin fro afib per prior
discharge summary, had previously planned for 5 day bridge)
-Clopidogrel 75 mg
-Coumadin 4 mg
-Aspirin 81 mg
-Toprol 75 mg
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Hydrochlorothiazide 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
6. Losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: 1.5
Tablet Sustained Release 24 hrs PO once a day. Tablet Sustained
Release 24 hr(s)
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*5 Tablet(s)* Refills:*0*
11. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
12. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig: Ten
(10) units Subcutaneous twice a day.
Disp:*1 pen* Refills:*2*
13. Humalog Pen 100 unit/mL Insulin Pen Sig: per sliding scale
units Subcutaneous Breakfast, Lunch, Dinner.
Disp:*1 pen* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Uphams Corner Health Care
Discharge Diagnosis:
# Fall, with findings of C5-6 retrolistesis
# Type 2 diabetes, controlled with complications
# Hypoglycemia
# Hypothermia
# Chronic diastolic heart failure; EF 50%
# Coronary artery disease; s/p recent BMS to RCA
# Chronic renal failure, stage III
# Atrial fibrillation
# Anemia
Discharge Condition:
stable
Discharge Instructions:
Please check your blood sugars as instructed, and follow the
instructions provided for your sliding scale insulin. Please
take your medications as prescribed. Please seek medical
attention if you develop fevers, chills, difficulty controlling
your blood sugars, or any other concerns.
Followup Instructions:
recommend outpatient Geriatrics consult with Dr. [**Last Name (STitle) 713**] ([**Telephone/Fax (1) 15260**]
.
[**Name6 (MD) **] [**Last Name (NamePattern4) 6559**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2150-3-13**]
1:00
ICD9 Codes: 2761, 4280, 3572, 2724, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1137
} | Medical Text: Admission Date: [**2164-1-23**] Discharge Date: [**2164-1-26**]
Date of Birth: [**2120-8-12**] Sex: F
Service: MEDICINE
Allergies:
Topiramate / Aripiprazole / Shellfish / Bee Pollen
Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
melena
Major Surgical or Invasive Procedure:
Upper endoscopy with enteroscope
History of Present Illness:
Ms. [**Known lastname 45209**] is a 43F with a history of alcoholic cirrhosis s/p
TIPS, active alcoholism, and prior UGIB attributed to duodenal
varix who presents with melena.
.
She had had a recent admission to the MICU Green with melena,
requiring several units of blood, and ultimately underwent an IR
guided duodenal varix coiling, balloon dilation of TIPS, and
stenting of the Rt hepatic vein, reducing portosystemic pressure
from 15 mg to 10 mg. During her most recent admission the pt was
tachycardic, hypotensive and required multiple blood
transfusions and underwent EGD that showed only mild portal
gastropathy and colonoscopy that showed a large volume of blood
in the colon and grade 1 external/internal hemorrhoids. She
subsequently underwent CTA that showed duodenal varicies that
were embolized. She was discharged from the EPT service on
[**2164-1-16**], after having received a total total of 11 U pRBC, 2 U
plt, 1 U FFP, 2 U Cryo.
She endorses tarry stools for the past month. She also endorses
[**2-23**]
black starry stools a day, with Nausea, but without any vomiting
or hematemesis. She also endorses some urinary frequency.
.
.
In the ED, initial VS were 98.6 118 123/61 14 98% room air. She
was started on Pantoprazole gtt, octreotide gtt, and Ceftriaxone
1 g IV. her labs were notable for Ca 8.3, AP 123, Tbili 4.1,
AST: 69, Alb: 3.0, and a Serum [**Month/Day (1) **] 335. Hepatology consult was
called, and the patient was started on pantoprazole and
octreotide gtt and received one dose of ceftriaxone. She also
received 1 L NS.
.
On transfer, her vitals were 98.4 97 18 114/64 96% RA. She had a
16 G and an 18G placed.
.
On arrival to the MICU, she is pleasant, talkative, and without
acute complaint.
Past Medical History:
- Alcoholic cirrhosis s/p TIPS [**9-/2162**]
- s/p cholecystectomy [**2153**]
- Gastroesophageal reflux disease
- Bipolar disorder
- Hypertension
- Depression/anxiety
- Recent burns to both hands [**11/2163**] (housefire) s/p skin
grafting from R thigh
Social History:
Lives with husband and two teenage children in [**Name (NI) 1110**]. Actively
drinking alcohol; when she does not drink she gets tremulous in
her hands, but no history of DTs/seizure. Active smoker and no
history of IVDU per OMR records.
Family History:
N-C
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: Alert, oriented, no acute distress. Appears tanned.
Smells of [**Name (NI) **].
HEENT: MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP flat, no LAD
CV: Regular rate and rhythm (borderline tachycardic), 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
Ext: Warm, well perfused, 2+ pulses, 1+ edema B
Neuro: Mild tremor
Skin: Grafting to the first and second digits of the hands
bilaterally.
DISCHARGE PHYSICAL EXAM:
Vitals: 98.8 (Tm 99.3) 122/74 (SBP 110-120s) 76 16 100%RA
General: Alert, oriented, no acute distress.
HEENT: MMM, oropharynx clear, EOMI, PERRL
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
Ext: Warm, well perfused, 2+ pulses, 1+ edema B
Neuro: Mild fine tremor
Skin: Grafting to the first and second digits of the hands
bilaterally. bruising of L arm.
Pertinent Results:
Admission labs:
[**2164-1-23**] 09:40PM GLUCOSE-108* UREA N-6 CREAT-0.5 SODIUM-138
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-23 ANION GAP-13
[**2164-1-23**] 09:40PM ALT(SGPT)-28 AST(SGOT)-69* ALK PHOS-123* TOT
BILI-4.1*
[**2164-1-23**] 09:40PM LIPASE-47
[**2164-1-23**] 09:40PM cTropnT-<0.01
[**2164-1-23**] 09:40PM ALBUMIN-3.0* CALCIUM-8.3* PHOSPHATE-3.7
MAGNESIUM-1.7
[**2164-1-23**] 09:40PM ASA-NEG ETHANOL-335* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2164-1-23**] 09:40PM WBC-2.6* RBC-3.12* HGB-9.4* HCT-26.9* MCV-86
MCH-30.1 MCHC-35.0 RDW-19.6*
[**2164-1-23**] 09:40PM NEUTS-52.5 LYMPHS-33.8 MONOS-10.5 EOS-1.5
BASOS-1.7
[**2164-1-23**] 09:40PM PLT SMR-LOW PLT COUNT-90*
[**2164-1-23**] 09:40PM PT-15.8* PTT-37.7* INR(PT)-1.5*
Hct trend:
[**2164-1-24**] 01:06AM BLOOD Hct-24.6*
[**2164-1-24**] 05:44AM BLOOD WBC-2.2* RBC-2.80* Hgb-8.8* Hct-24.3*
MCV-87 MCH-31.3 MCHC-36.0* RDW-20.0* Plt Ct-78*
[**2164-1-24**] 09:51AM BLOOD Hct-26.3*
[**2164-1-25**] 06:19AM BLOOD WBC-1.6* RBC-2.87* Hgb-8.8* Hct-25.6*
MCV-89 MCH-30.8 MCHC-34.6 RDW-19.9* Plt Ct-69*
Pertinent Interval Labs:
[**2164-1-25**] 06:19AM BLOOD PT-17.1* PTT-34.6 INR(PT)-1.6*
[**2164-1-24**] 05:44AM BLOOD Glucose-81 UreaN-6 Creat-0.5 Na-136 K-5.0
Cl-107 HCO3-21* AnGap-13
[**2164-1-26**] 09:25AM BLOOD Glucose-87 UreaN-5* Creat-0.5 Na-135
K-3.2* Cl-104 HCO3-23 AnGap-11
[**2164-1-24**] 05:44AM BLOOD ALT-31 AST-95* LD(LDH)-430* AlkPhos-100
TotBili-3.5*
[**2164-1-26**] 09:25AM BLOOD ALT-26 AST-52* LD(LDH)-210 AlkPhos-110*
TotBili-3.5*
[**2164-1-25**] 06:19AM BLOOD Calcium-7.8* Phos-3.7 Mg-1.5*
[**2164-1-26**] 09:25AM BLOOD Albumin-2.6* Calcium-8.0* Phos-3.3
Mg-1.4*
EGD: Impression:
Normal mucosa in the whole Esophagus
No evidence of varices, active bleeding, ulcers or rings
Mosaic appearance in the fundus and stomach body compatible with
Mild portal non bleeding gastropathy
Diverticulum in the fundus
No evidence of varices, ulcers, masses or active bleeding
Varices at the third part of the duodenum (injection)
No evidence of active bleeding
Otherwise normal EGD to third part of the duodenum
RUQ U/S: IMPRESSION: Patent TIPS.
Brief Hospital Course:
===================
Brief Patient Summary
===================
43F with a history of alcoholic cirrhosis (still actively
drinking), history of prior UGIB though now s/p TIPS and
duodenal varix embolization, presents with melena. The patient
was monitored briefly in the ICU, intubated for airway
protection and EGD, was hemodynamically stable, called out to
the medical floor, and discharged home, not requiring
transfusions.
===================
ACTIVE ISSUES
===================
# Gastrointestinal bleeding: Patient endorses melanotic stool.
She has known duodenal varices prior embolization. EGD on [**1-24**]
showed a large duodenal varix which was injected with glue. She
was treated with octreotide and PPI. She did not require
transfusion. She got 80mg pantoprazole, followed by 8mg/hr. Got
IV Octreotide gtt. Received Ceftriaxone 1 g Q24H with plan for 7
days of antibiotics. RUQ U/S showed a patent TIPS.
.
# PANCYTOPENIA: Likely secondary to liver cirrhosis. Plts and
WBC count are comparable to prior values; Hct baseline is upper
20s-lower 30s as above. This was stable.
.
# ALCOHOLIC CIRRHOSIS: TIPS, portal vein are patent. Current
MELD is 16 and Child-[**Doctor Last Name 14477**] class B-C (at limit depending on how
ascites s/p TIPS are considered). She remains an active drinker.
Followed by Dr. [**Last Name (STitle) 497**] though no recent visit in our system.
Transaminases, alk phos are roughly at her baseline; Tbili and
INR are higher than prior baseline. Continued Rifaximin 550 mg
[**Hospital1 **], lactulose, Folic acid 1 mg Daily, Thiamine HCl 100 mg
Daily, Multivitamin Daily.
.
# ACTIVE ALCOHOLISM: Active drinker, no known history of
DTs/seizure. Blood alcohol 335 on arrival to ED. Kept on CIWA
scale, but did not require benzodiazepenes. We urged the
patient that she needs treatment for her alcoholism, or it will
continue to cause her medical problems and likely lead to her
death.
.
====================
TRANSITIONAL ISSUES
====================
1. F/U w/ Dr. [**Last Name (STitle) 497**] in [**Hospital **] clinic
2. continue Ciprofloxacin: final day [**1-30**]
Medications on Admission:
Furosemide 60 mg Daily
Lactulose 30 ml PO QID
Rifaximin 550 mg [**Hospital1 **]
Folic acid 1 mg Daily
Thiamine HCl 100 mg Daily
Multivitamin Daily
Spironolactone 150 mg [**Hospital1 **]
Omeprazole 40 mg Daily
Lorazepam 0.5 mg Q8H PRN anxiety
Discharge Medications:
1. furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day).
3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. spironolactone 50 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
8. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for anxiety: do not drive or drink alcohol
while taking this medication.
10. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days: final day [**1-30**].
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnoses:
melena secondary to duodenal varices
alcoholic hepatitis
alcoholism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 45209**],
You were admitted to the [**Hospital1 69**]
for black, bloody stools. This was from blood vessels in the
first part of your small bowel that are bleeding. You had an
endoscopy where the gastroenterologist attempted to control this
source of bleeding.
This bleeding is from portal hypertension, which is caused by
your alcohol consumption. It is of the utmost importance that
you stop drinking alcohol, as continuing alcohol will cause more
damage to your body, and puts you at much increased risk for
death within the next year.
ADD:
ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days: final day [**1-30**].
Followup Instructions:
Department: LIVER CENTER
When: FRIDAY [**2164-5-4**] at 3:20 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
ICD9 Codes: 2851, 4019, 3051, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1138
} | Medical Text: Admission Date: [**2144-1-6**] Discharge Date: [**2144-1-24**]
Date of Birth: [**2082-5-7**] Sex: F
Service: MEDICINE
Allergies:
Ampicillin / Lidocaine / alcohol / Demerol / tobramycin /
Scopolamine
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
s/p Fall
Intracranial hemorrhage
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
Hemodialysis
History of Present Illness:
Ms. [**Known firstname 3460**] [**Known lastname 99511**] is a 61 y.o. female who was seen at [**Hospital1 2025**] for
hemorrhagic stroke hypertensive in etiology 2 weeks ago, was
subsequently discharged home and then presented to [**Hospital **]
Hospital 3 days ago for dyspnea. She was doing well but had SBP
in 200's and was refusing most BP meds and only taking Lopressor
12.5 per OSH physician. [**Name10 (NameIs) **] last evening, she was found down by
nursing after falling off the bed. She was awake but delirious
and was noted to have expressive aphasia. She dropped her sats
to
the 80's and was taken to CT for planned CTA chest and CT head.
She decompensated further in the scanner without getting either
scan, was taken to the ICU where she was intubated and then
brought back to the scanner. Per the OSH physician the CTA chest
was negative for PE. A CT head was obtained which showed a 3cm
Right temporal SDH along the temporal fossa, a Left temporal
contusion, and right sphenoid [**Doctor First Name 362**] and temporoparietal bone
fractures extending to the sphenoid [**Doctor First Name 362**].
She was transferred to [**Hospital1 18**] Neurosurgery for further
management.
Prior to arrival she continued to desaturate and required
sedation in travel.
Past Medical History:
- Diastolic heart failure (EF = 50%, 10/[**2143**]). No data at this
hospital.
- Hemorrhagic CVA 2 weeks PTA
- Polycystic kidney disease with ESRD on hemodialysis/peritoneal
dialysis
- HTN
- Anemia
- Asthma
Social History:
Current smoker at 1/2 ppd. No ETOH use.
Patient has 2 children. Daughter [**Name (NI) **] ([**Telephone/Fax (1) 99512**]) is HCP.
Family History:
She has 2 children: (1) 27, 35. No known renal disease or
polycystic kidney disease in the family, no known HTN.
Physical Exam:
On Admission:
O: T; 97 HR 82 regular BP 160/90 RR 13 O2Sat 100% on 40% FIO2
gen: intubated/sedated, moving arms and legs spontaneously
CV: RR, S1 and S2 nl, no murmurs
Pulm: crackles at the base, increase AP diameter, clear in upper
lung fields
GI: peritoneal catheter noted into the upper abdominal region, +
BS, soft, NT/ND
Extr: no c/c/e
Neuro:Intubated/sedated, + gag, + corneals
opens eyes to voice, Pupils 4-2mm bilaterally, MAEs
purposefully,
not following commands no clonus,upgoing toes bilaterally
On transfer to floor:
VS: 153/71 (24 hour range 122-179) 85 97%2L
GA: Awake and alert. Whimpering in distress but unable to
localize or provide a specific symptoms. Soft wrist restraints
in-place.
HEENT: Pupils pinpoint. EOMI. Anicteric. MMM. OP clear
Neck: No JVD
Cards: RRR, S1 and S2 appreciated, loud crescendo-decrescendo
murmur best her at sternal border with radiaition into the
carotids
Pulm: Limited exam as patient was not able to fully participate.
CTAB anteriorly.
Abd: Soft, NT/ND. BSx4. PD line in place.
Extremities: No gross deformity or edema.
Neuro/Psych: Awake and alert. Oriented only to self. Able to
follow simple commands. Moving all extremities. No clear motor
deficit.
On discharge:
Vitals - 98.4 154/72 68 20 97%RA
General - Appears well and in NAD. Sitting at table.
HEENT - PERRLA, EOMI, anicteric, MMM
CV - RRR, S1 and S2, no m/r/g
Lung - CTAB
Abdomen - Soft, NT/ND, BSx4
Neuro - Awkae and alert. Oriented. Moving all extremities.
Strength 5/5 and symmetric.
Pertinent Results:
ADMISSION LABS & STUDIES:
[**2144-1-6**] 09:27AM GLUCOSE-79 UREA N-59* CREAT-7.0* SODIUM-135
POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-22 ANION GAP-21*
[**2144-1-6**] 09:27AM CALCIUM-8.7 PHOSPHATE-5.3* MAGNESIUM-2.1
[**2144-1-6**] 09:27AM WBC-10.7 RBC-3.03* HGB-9.5* HCT-29.3* MCV-97
MCH-31.3 MCHC-32.3 RDW-16.7*
[**2144-1-6**] 09:27AM PLT COUNT-246
[**2144-1-6**] 09:27AM PT-10.6 PTT-28.5 INR(PT)-1.0
[**2144-1-6**] 09:27AM ALT(SGPT)-27 AST(SGOT)-35 CK(CPK)-129
[**2144-1-6**] 09:27AM CK-MB-6 cTropnT-0.10*
[**2144-1-6**] 11:39AM GLUCOSE-70 LACTATE-0.6 K+-4.4
[**2144-1-6**] 11:39AM TYPE-ART PO2-211* PCO2-33* PH-7.42 TOTAL
CO2-22 BASE XS--1
[**2144-1-6**] 09:00PM CK-MB-4
[**2144-1-6**] 09:00PM CK(CPK)-86
EEG ([**2144-1-6**]) -
IMPRESSION: This EEG gives evidence for what appeared initially
to be a severe encephalopathy and later seemed to have some, at
least minimum improvement. There was some focality to it in that
there were right temporal epileptiform transients but also
bicentral suggesting a more diffuse abnormality with some focal
superimposed features. No sustained seizure discharges were
identified.
CXR ([**2144-1-6**]):
The ET tube tip is 3.5 cm above the carina. The NG tube tip
passes below the diaphragm, most likely terminating in the
stomach. Hemodialysis catheter tip is at the level of the
cavoatrial junction.
Since the prior study, there has been interval progression of
pulmonary edema, asymmetric, mostly involving right lung.
Bibasal areas of atelectasis have progressed as well. Evaluation
of the patient after diuresis is highly recommended. The right
lower lobe consolidation might reflect in fact a combination of
pulmonary edema as well as additional process such as aspiration
or infection.
Esophageal temperature probe is noted.
[**2144-1-6**] CT BRAIN
Overall stable appearance of traumatic injuries from the prior
study is
demonstrated. Right temporal subgaleal hematoma with underlying
temporal bone fracture possibly involving the greater [**Doctor First Name 362**] of
the sphenoid is again demonstrated. Underlying this is
extra-axial hemorrhage overlying the inferior right temporal
lobe, most likely epidural, given its anatomic
location. The mass effect from this collection is unchanged.
A contra coup injury to the left temporal lobe has resulted in
an
intraparenchymal hemorrhagic contusion surrounded by edema, also
unchanged. Subdural hemorrage tracking along the left tentorium
is more conspicuous than on the prior study.
No new hemorrhage, mass, or infarct is seen. There is stable
fluid
opacification of the bilateral sphenoidal sinuses and several
ethmoid air
cells.
IMPRESSION:
1. Stable appearance of right temporal bone fracture with
underlying
extra-axial hematoma, most likely in the epidural space given
the location and mechanism. No marked mass effect.
2. Unchanged left temporal hemorrhagic contusion.
3. More conspicuous left subdural hematoma overlying the
temporal lobe and
tracking along tentorium.
4. No new hemorrhage.
CXR ([**2144-1-9**]):
There has been interval removal of the endotracheal and
endogastric tubes. A left-sided central venous catheter tip sits
at the mid SVC. A right-sided dialysis catheter tip sits in the
superior portion of the right atrium. The cardiomediastinal
contours are unchanged. Mild pulmonary edema is unchanged. Small
bilateral pleural effusions with basilar atelectasis persist.
The right lung base appears to demonstrate slightly more
consolidation than before, possibly representing an early
pneumonia or aspiration.
CT Head ([**2144-1-12**]):
A left temporal lobe area of hemorrhage is unchanged in size
compared to the previous examination with surrounding vasogenic
edema. The right temporal hematoma is also unchanged measuring
26 x 20 mm_. The small left subdural hematoma is unchanged as
well. No new areas of hemorrhage are noted. The ventricles and
sulci are normal in size and configuration. The visible
paranasal sinuses and mastoid air cells show opacification of
the left mastoid air cells, unchanged. The right zygomatic arch
temporal bone and sphenoid bone fractures as well as hemorrhage
in the right sphenoid cells is unchanged.
IMPRESSION:
1. Unchanged right temporal probable epidural, small left
subdural and left temporal hemorrhagic contusion. No new areas
of hemorrhage or mass effect.
2. Unchanged fractures and slight decrease in the blood in
bilateral sphenoid sinuses.
KUB ([**2144-1-12**]):
FINDINGS: The coiled end of the catheter projects over the
middle parts of
the pelvis, slightly right to the midline. Currently, there is
no evidence of free air or pathologic calcifications.
DISCHARGE LABS & STUDIES:
[**2144-1-24**] 06:27AM BLOOD WBC-6.5 RBC-3.27* Hgb-10.5* Hct-33.0*
MCV-101* MCH-32.0 MCHC-31.7 RDW-17.3* Plt Ct-352
[**2144-1-24**] 06:27AM BLOOD WBC-6.5 RBC-3.27* Hgb-10.5* Hct-33.0*
MCV-101* MCH-32.0 MCHC-31.7 RDW-17.3* Plt Ct-352
[**2144-1-24**] 06:27AM BLOOD Glucose-106* UreaN-69* Creat-4.8*# Na-133
K-5.4* Cl-94* HCO3-26 AnGap-18
[**2144-1-24**] 06:27AM BLOOD Calcium-8.4 Phos-5.0* Mg-2.0
[**2144-1-22**] 04:50PM BLOOD Phenyto-2.3*
[**2144-1-23**] 06:05AM BLOOD VitB12-480
Brief Hospital Course:
REASON FOR HOSPITALIZATION:
61 F with APKD & ESRD, recent hemorrhagic CVA and dCHF who
presented following traumatic right temporal SDH and
intraparenchymal contusions, also with respiratory
decompensation attributed to VAP.
ACUTE DIAGNOSES:
# Intracranial hemorrhage: Patient was admitted to the
Neurosurgical ICU s/p traumatic fall with left temporal
hemorrhagic contusion, left subdural hematoma overlying the
temporal lobe and tracking along tentorium, also with L temporal
contusion, and right sphenoid [**Doctor First Name 362**] and temporoparietal bone
fractures. The patient was initially admitted to the
Neurosurgical ICU, and repeat CT head was stable so the patient
was transferred to the MICU, as Neurosurgery did not feel
surgical intervention was needed. The patient was managed
conservatively with frequent neuro checks, blood pressure
control with goal SBP 140-160, and seizure prophylaxis on
Dilantin. Repeat head CT on [**1-12**] was stable and the patient
was stable from a neurologic standpoint. Given the patient's
low albumin and chronic kidney disease, both a total Dilantin
level and free Dilantin levels were checked for dosing.
Neurosurgery confirmed that given the high risk of seizures with
temporal hemorrhage, the patient should be therapeutic on
Dilantin until follow-up with Neurosurgery in 4 weeks (with a
repeat head CT prior to appointment). Dilantin was reloaded
[**1-14**] and on [**1-15**] for low phenytoin levels, and the dose was
increased per pharmacy's recommendations.
#. Encephalopathy: The patient had altered mental status
following extubation in the MICU, and EEG was performed as she
was not following commands. The EEG did not show focal
seizures, and the patient's mental status improved slightly
prior to transfer to the floor. On the floor, the patient
continued to have confusion and disorientation, although she was
alert and interactive. This was likely secondary to her acute
illness and intracranial hemorrhage. Neurosurgery was contact[**Name (NI) **]
[**1-12**] and repeat CT head was ordered to rule out worsening ICH
as a cause of persistent altered mental status. CT head [**1-12**]
showed stable right temporal epidural, small left subdural, and
left temporal hemorrhagic contusion without changes. She was on
olanzapine as needed for agitation as well as seroquel at night
for agitation. The patient's mental status slowly improved and
her family felt that she was at her baseline mental status at
the time of discharge.
#. Hypertension: The patient presented on a home
anti-hypertensive regimen of Metoprolol 25 mg [**Hospital1 **]. Given her
intracranial hemorrhage, her blood pressure goal was SBP
140-160, and she was started on labetolol, amlodipine. The
patient was noted to have fluctuating blood pressures on the
floor in the setting of agitation, and hydralazine was given as
needed. In order to keep her blood pressures within target
range, her metoprolol was increased to 75 mg TID & she was
started on amlodipine 10 mg QD.
#. Respiratory Decompensation/?VAP: The patient was admitted to
the Neurosurgical ICU on [**1-6**] for acute dyspnea and respiratory
decompensation, with possible opacity on CXR. She was intubated
and mechanically ventilated, and underwent a bronchoscopy in the
ICU that showed gram (-) rods on bronch washings with culture
showing only respiratory flora. She was initially placed on
broad spectrum coverage with Vancomycin, Ceftriaxone, and
Ciprofloxacin for VAP on [**1-7**] which was switched to gram
negative coverage with Cefepime and Ciprofloxacin following
bronchoscopy results. Her respiratory status improved and she
was successfully extubated. Antibiotics were discontinued [**1-14**]
due to lack of definitive evidence of VAP and negative
bronchoscopy culture. The patient has no fever, leukocytosis,
or other symptoms of respiratory infection throughout her course
on the medicine floor.
CHRONIC DIAGNOSES:
#. ESRD: The patient has a history of ESRD due to polycystic
kidney disease. She is on hemodialysis M/W/F through R IJ
dialysis catheter. During her hospital stay, the patient became
agitated overnight in the setting of her altered mental status,
and pulled her PD catheter. The connecter became disconnected
and there was concern for contamination, but the connecter and
catheter tip were cleaned and reconnected. Renal was aware, and
was concerned that the PD catheter may be displaced and that the
cuff may be exposed. A KUB obtained which was unremarkable.
Transplant surgery was consulted to evaluate the PD catheter and
did not find the catheter to be displaced or the cuff to be
exposed. Given the patient was not initiated on peritoneal
dialysis due to her social situation, it is unclear why she had
the PD catheter placed at OSH. However, transplant surgery did
not feel comfortable with removing the PD catheter without
approval from the patient's outpatient nephrologist, and it was
left in place to be followed up as an outpatient. She was
continued on hemodialysis through her R IJ dialysis catheter on
a M/W/F schedule with the Renal dialysis team following. She
was continued on her home renal regimen.
#. CHF: The patient has a history of chronic diastolic heart
failure. She was euvolemic on initial presentation, and had
fluid removal as needed throughout her hospital stay with M/W/F
hemodialysis.
#. Asthma/COPD: Continued duonebs per home regimen.
#. Anemia: Most likely [**2-20**] CKD, hct stable at ~29-33. Normal
iron level but ferritin elevated, likely [**2-20**] acute illness.
Should have iron studies re-drawn as an outpatient following
resolution of her acute illness for further assessment.
.
TRANSITIONAL ISSUES:
#Code: Full
#Communication: Daughter [**Name (NI) **] ([**Telephone/Fax (1) 99512**])
Medications on Admission:
- PhosLo TID with meals
- Lopressor 25mg [**Hospital1 **]
- Iron supplement
- Tylenol prn
- ASA 81mg daily
- Albuterol inhale
- Nephrocaps
- Vitamin B12
Discharge Medications:
1. PhosLo 667 mg Capsule Sig: One (1) Capsule PO three times a
day: With Meals.
Disp:*90 Capsule(s)* Refills:*2*
2. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 capsules* Refills:*2*
5. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
Disp:*1 unit* Refills:*0*
7. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day.
Disp:*30 Capsule(s)* Refills:*2*
8. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
Disp:*60 Capsule(s)* Refills:*2*
10. heparin (porcine) 1,000 unit/mL Solution Sig: One (1) flush
Injection PRN (as needed) as needed for line flush: DIALYSIS
NURSE ONLY: Withdraw 4 mL prior to flushing with 10 mL NS
followed by Heparin as above according to volume per lumen.
.
11. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) flush
Intravenous PRN (as needed) as needed for catheter.
12. phenytoin 50 mg Tablet, Chewable Sig: as directed Tablet,
Chewable PO as directed: Take 4 tablets every morning, 3 tablets
in afternoon, & 3 tablets at bedtime.
Disp:*90 Tablet, Chewable(s)* Refills:*2*
13. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
three times a day.
Disp:*270 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Right temporal subdural hematoma
- Right temporal probable epidural hematoma
- Small left subdural hemoatoma
- Left temporal hemorrhagic contusion
- Right temporal-parietal bone fracture
SECONDARY DIAGNOSES:
- Respiratory failure requiring intubation
- Adult Polycystic Kidney Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname 99511**], it was a pleasure to participate in your care while
you were at [**Hospital1 18**]. You were admitted to the hospital following
a fall from bed resulting in bleeding within your brain. When
you were initially in the hospital, you had difficulty breathing
and required mechanical support in the intensive care unit until
your breathing improved. The neurosurgeons evaluated you and
felt you did not need surgery, and your brain bleed was managed
conservatively with optimal blood pressure control and close
monitoring. A repeat CT scan of your brain showed no worsening
of your brain bleed, and this will slowly resolve over time.
Until you follow up with the neurosurgeons, you will need to be
on anti-seizure medications in addition to your new blood
pressure medications.
While in the hospital, you also had significant confusion and
disorientation, which is not suprising given your critical
medical conditions. Your confusion improved throughout your
hospital stay.
MEDICATION CHANGES:
- Medications ADDED:
----> Please START metoprolol 75 mg three times daily
----> Please START Amlodipine 10mg daily
----> Please START Phenytoin 200mg in the morning then 150 mg
twice a day (afternoon & evening). This medication should be
continued until you are seen for your neurosurgery follow-up
appointment.
- Medications STOPPED:
---> Please STOP Aspirin until otherwise instructed at your
neurosurgery follow-up appointment
- Medications CHANGED: None.
Followup Instructions:
Follow-Up Appointment Instructions:
Department: RADIOLOGY
When: WEDNESDAY [**2144-2-12**] at 8:15 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: WEDNESDAY [**2144-2-12**] at 9:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Please also make an appointment to see your primary care
provider, [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].([**Telephone/Fax (1) 4688**]) within 7 days of
discharge from your rehabilitation facility.
ICD9 Codes: 5856, 2930, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1139
} | Medical Text: Admission Date: [**2140-2-25**] Discharge Date: [**2140-3-1**]
Date of Birth: [**2084-6-2**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 55 year old gentleman
known coronary artery disease who has had multiple PCIs in
the past. He just recently relocated to the [**Location (un) 86**] area and
had an exercise treadmill test as part of a workup with a new
cardiologist. The patient does not report any symptoms of
chest pain or shortness of breath. The exercise treadmill
test was positive and he was referred to [**Hospital6 1760**] for cardiac catheterization.
PAST MEDICAL HISTORY: 1. Hypertension; 2.
Hypercholesterolemia; 3. Coronary artery disease; 4. Status
post collarbone surgery.
ALLERGIES: Altace which causes hyperkalemia.
PREOPERATIVE MEDICATIONS:
1. Aspirin 325 mg p.o. q. day.
2. Atenolol 50 mg p.o. q. day.
3. Zocor 40 mg p.o. q. day.
4. Niacin 1000 mg p.o. q. day.
HOSPITAL COURSE: The patient was transferred to Dr.
[**Last Name (STitle) 70**] for surgical treatment of his coronary artery
disease. His cardiac catheterization showed 80% ostial left
main stenosis and two patent stents in the right coronary
artery with 80% lesion proximal to the stent with a normal
left ventricular function. The patient was taken to the
Operating Room on [**2-25**] with Dr. [**Last Name (STitle) 70**] for a
coronary artery bypass graft times three with left internal
mammary artery to left anterior descending, vein graft to
right coronary artery and vein graft to diagonal, please see
operative note for further details. The patient was
transferred to the Intensive Care Unit in stable condition on
Propofol and Levophed. The patient was weaned and extubated
on his first postoperative day. On postoperative day #1 the
patient continues to require Levophed for maintaining
adequate blood pressure. The patient was seen by physical
therapy on postoperative day #2. By postoperative day #2 the
patient was able to walk 500 feet. While still in the
Intensive Care Unit the Levophed was weaned to off. Chest
tubes were removed without incident. On postoperative day
#4, the patient was able to complete a level 5 of physical
therapy ambulating 500 feet and climbing one flight of stairs
with no difficulty. The patient's pacing wires were removed
without incident and on postoperative day #5 the patient was
cleared for discharge to home.
CONDITION ON DISCHARGE: Temperature maximum 98.6, pulse 94
in sinus rhythm, blood pressure 116/62, respiratory rate 18,
room air oxygen saturation 97%. The patient's weight on
[**3-1**], is 74.7 kg. Preoperatively the patient was 74
kg. The patient is awake, alert and oriented times three,
nonfocal. Heart is regular rate and rhythm without rub or
murmur. Respiratory breath sounds are clear bilaterally.
Gastrointestinal, positive bowel sounds. Abdomen is flat,
nontender, nondistended. Extremities are warm and well
perfused with trace pedal edema. Sternal incision
Steri-Strips are intact. There is no erythema or drainage.
Sternum is stable. Left lower extremity vein prior site
Steri-Strips are intact and there is no erythema or drainage.
Laboratory data revealed white blood cell count 5.4,
hematocrit 22.8, platelet count 193, sodium 143, potassium
3.7, chloride 107, bicarbonate 31, BUN 14, creatinine 0.7,
glucose 90. The patient's hematocrit had been 22 and stable
for several days. The patient was asymptomatic with
hematocrit and it was felt the patient had not had any prior
blood transfusions and was asymptomatic with his anemia. The
patient will be discharged to home on iron and Vitamin C.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease.
2. Status post urgent coronary artery bypass graft times
three.
3. Postoperative anemia.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. q. day times seven days.
2. Potassium chloride 20 mEq p.o. q. day times seven days.
3. Atenolol 50 mg p.o. q. day.
4. Enteric coated Aspirin 325 mg p.o. q. day.
5. Plavix 75 mg p.o. q. day.
6. Colace 100 mg p.o. b.i.d.
7. Percocet 5/325 one to two p.o. q. 4-6 hours prn.
8. Zantac 150 mg p.o. b.i.d.
9. Niferex 150 mg p.o. q. day.
10. Vitamin C 500 mg p.o. b.i.d.
11. Folate 1 mg p.o. q. day.
12. Simvastatin 40 mg p.o. q. day.
13. Niacin 1000 mg p.o. q. day.
DISCHARGE DISPOSITION: The patient is to be discharged to
home in stable condition.
FOLLOW UP: The patient is to follow up with Dr. [**First Name (STitle) 2031**] in
one to two weeks. The patient is to follow up with Dr.
[**Last Name (STitle) 22889**] in one to two weeks and the patient is to follow up
with Dr. [**Last Name (STitle) 70**] in five to six weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 1541**]
MEDQUIST36
D: [**2140-3-1**] 12:42
T: [**2140-3-1**] 10:55
JOB#: [**Job Number 53441**]
ICD9 Codes: 2851, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1140
} | Medical Text: Admission Date: [**2139-2-27**] Discharge Date: [**2139-3-10**]
Service:
ADMITTING DIAGNOSIS: Barrett's esophagus with high grade
dysplasia.
DISCHARGE DIAGNOSES:
1. Barrett's esophagus with high grade dysplasia.
2. Status post trans-hiatal esophagectomy.
3. Aspiration.
4. Myocardial infarction.
5. Cardiogenic shock.
6. Anoxic encephalopathy.
7. Death.
HISTORY OF PRESENT ILLNESS: The patient is an 84 year old
male who had a long standing history of gastroesophageal
reflux disease and Barrett's esophagus and had high grade
dysplasia diagnosed on recent endoscopy. The patient elected
to have an esophagectomy performed.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Question renal insufficiency.
3. Gastroesophageal reflux disease.
MEDICATIONS:
1. Norvasc.
2. Prilosec.
3. Carafate.
PHYSICAL EXAMINATION: On admission, the patient is an
elderly man in no acute distress. Vital signs are stable.
Afebrile. Chest is clear to auscultation bilaterally.
Cardiovascular is regular rate and rhythm without murmur, rub
or gallop. Abdomen is soft, nontender, nondistended without
masses or organomegaly. Extremities are warm, not cyanotic
and not edematous times four. Neurological is grossly
intact.
HOSPITAL COURSE: The patient was taken to the Operating
Room on [**2139-2-27**], where he underwent transhiatal
esophagectomy without significant complication. In the
postoperative course, he was initially admitted under the
Intensive Care Unit care and kept in the Post Anesthesia Care
Unit overnight. The patient was seen to have a low urine
output and both metabolic and respiratory acidosis and was
given approximately 8.5 liters of Crystalloid in the
perioperative period, including OR.
The patient was briefly agitated in the Post Anesthesia Care
Unit and discontinued his nasogastric tube. On postoperative
day number one, the patient was doing well with a fairly
normalized blood gas of 7.35/43/94/25/minus 1 and was
transferred to the floor.
On postoperative day two, the patient was seen to have a
baseline oxygen requirement of 70% face mask in the morning
but was saturating well and otherwise seemed to be doing
relatively well.
The patient had a white count of 22.1 which prompted a chest
x-ray showing bilateral pleural effusion and patchy bibasilar
atelectasis but no focal infiltrates. Over the course of the
day, the patient had deteriorating in his respiratory status
and became increasingly tachypneic with wheezing and coarse
breath sounds.
An EKG was performed which showed atrial fibrillation but no
ischemic changes. A baseline arterial blood gas was obtained
at that point which was 7.37/47/86/28/zero, again on 70% face
mask.
Intravenous fluids were then stopped and the patient was
begun on 20 mg of intravenous Lasix and albuterol nebulizers.
The patient was transferred to another floor for Telemetry
purposes and cycled for myocardial infarction. His
respiratory status during transfer seemed somewhat improved.
Upon arrival to the other floor, the patient stopped
respiring briefly and went bradycardic. Upon stimulation, he
was tachycardic to the 110s with a blood pressure 130/70.
Immediately subsequent to that the patient went pulseless and
into respiratory and cardiac arrest and was down for
approximately two to three minutes. CPR was begun and the
patient intubated and 15 to 20 cc. of brownish fluid was
suctioned from the endotracheal tube post intubation.
The patient regained pulse and cardiac activity and was
transferred to the Intensive Care Unit.
Cardiac consultation at that time recommended aspirin,
cycling enzymes and agreed with probable aspiration event.
They suggested a heparin drip but not is surgically
contraindicated. A heparin drip was not started. The
patient ruled in for myocardial infarction with a troponin of
26.5.
In the patient's Intensive Care Unit stay, he was supported
with a dopamine drip and diuresed for fluid overload.
Pressors were weaned off on postoperative day number eight.
Respiratory function was supported throughout his Intensive
Care Unit course appropriately with mechanical ventilation.
The patient was noted to be unresponsive after the aspiration
event, with some slow return of responsiveness over the next
several days, but no purposeful movement. To evaluate
possible neurologic injury, a CT scan was obtained after the
patient was felt to be stable enough to be transferred.
On postoperative day six, the CT scan showed no acute
intracranial event but was consistent with chronic
microvascular infarction. EEG was also obtained which
revealed diffuse widespread encephalopathy. There was a
question of possible seizure activity involving the left
upper extremity and phenytoin was begun empirically.
A repeat EEG was obtained on postoperative day number 10 and
again showed moderately severe diffuse encephalopathy with no
seizure focus.
A Neurology consultation was obtained and assessed the
patient to have minimal chance for a meaningful recovery.
In accordance with the patient's living will, the family's
wishes and discussion with the surgical attending, the
patient was made comfort measures only and expired on
postoperative day number 11.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 6066**]
Dictated By:[**Last Name (NamePattern1) 5745**]
MEDQUIST36
D: [**2139-3-24**] 10:08
T: [**2139-3-28**] 16:18
JOB#: [**Job Number 48824**]
ICD9 Codes: 4275, 5070, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1141
} | Medical Text: Admission Date: [**2171-4-2**] Discharge Date: [**2171-4-9**]
Date of Birth: [**2125-1-16**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Upper GI bleed
Major Surgical or Invasive Procedure:
EGD [**2171-4-2**]
History of Present Illness:
46 year old male with EtOH cirrhosis, c/b severe esophagitis,
ESRD due to Hepatorenal syndrome, presenting with upper GI
bleed. Patient has longstanding history of ETOH cirrhosis,
taken off transplant list last year in setting of alcohol
relapse and loss to followup. Reportedly had recent EGD showing
gastritis, but no varices. Per ED, reported having melenous
stools for the past few days. Vomited two buckets BRB at [**Hospital 39437**] with SBP 140s, HR 140s. Trended down to SBP 80s. Hb
initially 3, 9 units PRBCs and 9 units FFP at OSH. HCt 9 with
platelets of 28. Got 9U pRBC, 9 units FFP at [**Hospital3 26615**] with
SBPs up to 140s. Repeat hgb was 9, Hct 20.
.
On arrival to ED, initial VS: HR 130. Repeat labs notable for
HCT of 23.7, Plts 28, INR 1.5, CR 2.9, T bili 7.3, AST 1600, ALT
360. Repeat HCT 29 RUQ u/s was performed with preliminary read
showingpatent portal vein and recanalized umbilical vein.
Cholelithiasis. No large ascites. Patient intubated for
aspiration risk and EGD performed at bedside in ED with no
evidence of varices, but severe esophagitis. Started on PPI and
octreotide drip. At [**Hospital1 18**], got 4 units PRBCs, 2 FFP, 1 plts and
Ca gluconate. BP stable while at [**Hospital1 18**] at 110s-120s. Patient
was subsequently admitted to the ICU for further treatment. Had
one melanotic stool.
.
On arrival to the MICU, patient is intubated and sedated.
Unable to obtain further history. Patient has two 18g
peripheral IVs and one femoral CVL.
Past Medical History:
(#) MRSA bacteremia [**10-23**] treated with vancomycin
(#) EtOH abuse with h/o seziures ? during intoxication
(#) EtOH Liver disease-- acute EtOH hepatitis in [**8-27**] (was not
started on corticosteroids due to GI bleed, UTI and [**Last Name (un) **]); was
started on pentoxyphyline to prevent HRS with a planned 4 week
course from [**2168-9-26**] (last day [**2168-10-24**]); negative hepatitis A, B
and C serologies.
(#) Hemodialysis dependent-- since last admission, dx
multifactorial with ATN +/- NSAIDs +/- HRS; HD through tunneled
line TuThSat
(#) Gastroesophageal Reflux Disease
(#) Seizures in setting of heavy alcohol consumption, seen by a
neurologist who did not feel that it was a primary seizure
disorder (first [**12-26**])
(#) MVA [**3-/2153**] - Right femur fracture with [**Male First Name (un) **] placement, pelvic
fracture
(#) Asthma
Social History:
Has never smoked. Drank [**11-22**] Vodka daily until recently, but
denies drinking in the past 4 months (last drink first week of
[**Month (only) 359**]). Never has used IV drugs. Lives with girlfriend, [**Name (NI) 5627**]
[**Name (NI) 83758**] [**Telephone/Fax (1) 83759**]. Has 2 children, daughter 17, son, 16
who live with their mother who the patient is still very close
to. Pt formerly worked at Mass Electric.
Family History:
Mother - Deceased [**12-20**] alcoholic liver disease
Father - Deceased [**12-20**] [**Name2 (NI) 499**] cancer, diagnosed in his 40s. No
other family history of [**Name2 (NI) 499**] cancer.
Physical Exam:
Vitals: T: 99.6 BP: 134/53 P: 125 R: 18 O2: 98% on CMV
General: Sedated, intubated, opens eyes on command, shakes head
yes and now, intermittently following commands
HEENT: Sclera icteric, dry blood around mouth, ETT in place
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: Distended, soft, nontender, large umbilical hernia
GU: foley in place
Ext: warm, well perfused, 2+ pulses, 2+ pitting edema
bilaterally on lower extremities up to knees with superficial
erythema bilaterally, RUE fistula with palpable thrill and
audible bruit
Neuro: moves all extremities, opens eyes on command and shakes
head yes/no, follows commands intermittently
DISCHARGE EXAM:
98.4, 134/65, 80. 20, 95% RA
Gen: AOx3, NAD
HEENT: scleral icterus
CV: RRR, referred murmur from AV fistula site across precordium
Lungs: Slight decreased breath sounds of R base consistent with
pleural effusion with partial reaccumulation
Ext: [**12-21**]+ LE edema, tense, slightly erythematous, but no signs
of infection.
Neuro: nonfocal
Pertinent Results:
Admission labs:
[**2171-4-2**] 12:40AM GLUCOSE-142* UREA N-86* CREAT-2.9*#
SODIUM-143 POTASSIUM-3.7 CHLORIDE-96 TOTAL CO2-12* ANION GAP-39*
[**2171-4-2**] 12:40AM ALT(SGPT)-365* AST(SGOT)-1615* ALK PHOS-97
TOT BILI-7.3*
[**2171-4-2**] 12:40AM LIPASE-88*
[**2171-4-2**] 12:40AM ALBUMIN-3.0*
[**2171-4-2**] 12:40AM WBC-7.5# RBC-2.54*# HGB-7.9*# HCT-23.9*#
MCV-94 MCH-31.3 MCHC-33.2 RDW-16.2*
[**2171-4-2**] 12:40AM NEUTS-89.4* LYMPHS-5.0* MONOS-5.3 EOS-0.2
BASOS-0.2
[**2171-4-2**] 12:40AM PLT COUNT-28*#
[**2171-4-2**] 12:40AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2171-4-2**] 12:40AM URINE RBC-5* WBC-3 BACTERIA-FEW YEAST-NONE
EPI-0
[**2171-4-2**] 12:40AM URINE MUCOUS-RARE
Imaging:
EGD [**4-2**]:
1. Keep patient intubated and NPO
2. Continue ocreotide gtt @ 50 mcg / hr
3. Continue Protonix gtt @ 8 mg hr
4. Ceftriaxone 1 gram IV Q24 for a total of 7 days
5. Check HCT q12 hrs
6. Transfuse to keep an HCT of 25-27
7. Try to keep plt > 50 and INR < 1.5
8. Once BP and HR stable will need a non selective beta-blocker
9. Follow hepatology recs
RUQ Ultrasound: IMPRESSION:
1. Coarsened and echogenic hepatic parenchyma with the sequelae
of portal
hypertension including splenomegaly and recanalized
paraumbilical vein with patent portal vein and no evidence of
ascites.
2. Cholelithiasis without cholecystitis
3. Large right pleural effusion
AP CXR [**4-2**]:
IMPRESSION:
1. Nasogastric tube in the distal esophagus, could be advanced
15 cm.
2. Large right pleural effusion and mild pulmonary edema with
cardiomegaly, new since [**2168**].
CXR [**4-4**]:
FINDINGS: As compared to the previous radiograph, the patient
has been
extubated and the nasogastric tube has been removed. The
extensive right
pleural effusion has minimally decreased in extent, the evidence
of moderate
pulmonary edema is still present. Unchanged size and appearance
of the
cardiac silhouette.
DISCHARGE LABS:
[**2171-4-8**] 05:25AM BLOOD WBC-1.8* RBC-3.15* Hgb-9.8* Hct-31.2*
MCV-99* MCH-31.0 MCHC-31.3 RDW-19.1* Plt Ct-37*
[**2171-4-8**] 05:25AM BLOOD Glucose-83 UreaN-58* Creat-3.1* Na-141
K-3.9 Cl-106 HCO3-23 AnGap-16
[**2171-4-8**] 05:25AM BLOOD PT-16.1* PTT-33.3 INR(PT)-1.5*
[**2171-4-8**] 05:25AM BLOOD ALT-80* AST-71* AlkPhos-119 TotBili-16.6*
[**2171-4-8**] 05:25AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.7
Brief Hospital Course:
46 year old M with ETOH cirrhosis MELD of 32, CKD, presenting
with massive upper GI bleed.
.
1. GI Bleed: patient with large volume hematememsis and coffee
ground emesis, with HCT of 9 at OSH. Transfused 9U PRBC, 8U FFP
and 10U plts. HCT up to 23 on arrival and up to 29 on repeat.
No evidence of varices on previous EGDs, but hepatology
performed EGD bedside in ED which showed severe esophagitis and
severe portal gastropathy, and still no evidence of varices.
Started on octreotide and PPI drips, which were continued for 72
hours. Started on IV ceftriaxone 1 gram IV Q24hrs, which was
switched to Cipro 500mg [**Hospital1 **] which he completed a 7 day course.
The patient's Hct remained stable around 30 on the floor. He was
transitioned to [**Hospital1 **] protonix. He was given sucrafate for
esophagitis. He will have a repeat EGD in 12 weeks after
starting PPI (already scheduled).
.
2. Narrow Complex Tachycardia: The patient's HR was sustained in
the 140s during one night of admission. EKG showed a narrow
complex tachycardia most consistent with an SVT. Vagal maneuvers
were attempted without success. The patient was given low dose
beta blockers. He spontaneously converted to NSR the next
morning. He remained in NSR during the remainder of his
hospitalization.
.
3. Pleural Effusion: The patient had a moderate to large R sided
pleural effusion seen on CXR. This was new from [**2168**], but likely
subacute and c/w hepatic hydrothorax. A thoracentesis was
performed that showed a transudate. Cytology is pending on
discharge.
4. Alcohoic Cirrhosis: Patient with alcholic cirrhosis and MELD
score of 31. No longer a candidate for transplant given alcohol
relapse and loss to followup. LFTs elevated significantly above
baseline likely secondary to GI bleed and hepatic
decompensation. These continued to trend down. The patient will
be discharged with plan for relapse prevention. The patient
understood that he risks death if he continues to consume
alcohol.
.
5. CKD: patient previously on HD in the past for hepatorenal
syndrome. CR 2.9 on admission, which is below previous baseline,
but trended up slightly. He has a right sided fistula. He had
adequate urine output and his electrolytes were stable.
FOLLOW-UP:
- The patient had a leukopenia on discharge, likely from
nutrition and medications. This should be followed as an
outpatient to ensure it is trending up.
- F/U cytology from pleural fluid
Medications on Admission:
(from d/c summary [**2168-12-24**]):
- Xifaxan 550 mg Tab 1 Tablet(s) by mouth twice a day
- omeprazole 20 mg Cap, Delayed Release2 Capsule(s) by mouth
twice a day
- Sucralfate 1 gram Tab 1 Tablet(s) by mouth four times a day
- Lasix 40 mg Tab Oral 1 Tablet(s) Twice Daily
- Celexa 20 mg Tab Oral 1 Tablet(s) Once Daily
- folic acid 1 mg Tab Oral 1 Tablet(s) Once Daily
- Mag-Oxide 400 mg Tab Oral 1 Tablet(s) Twice Daily
- thiamine 100 mg Tab Oral 1 Tablet(s) Once Daily
- metoprolol tartrate 25 mg Tab Oral 1 Tablet(s) Twice Daily
- allopurinol 100 mg Tab Oral 1 Tablet(s) Once Daily
Discharge Medications:
1. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
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 Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO DAILY
(Daily).
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Upper GI Bleed
EtOH Cirrhosis
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 a severe GI bleed that
required many blood transfusions. You underwent an EGD that
showed severe inflammation of the lower part of the esophagus
and large vessels in the stomach. You were on a ventilator
initially in order to protect your lungs. Your bleeding resolved
and your blood counts remained stable. You had lower extremity
muscle weakness. You will be discharged to rehab in order to
help regain your strength.
Please take your medications as prescribed. Please attend all of
your follow-up appointments. Please refrain from drinking any
alcohol.
MEDICATION CHANGES: These will be relayed to your facility. They
will give you a list when you leave from there.
Followup Instructions:
Department: LIVER CENTER
When: TUESDAY [**2171-4-23**] at 1:40 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: DIGESTIVE DISEASE CENTER
When: THURSDAY [**2171-4-25**] at 1:30 PM
With: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST Best Parking: Main Garage
Department: ENDO SUITES
When: THURSDAY [**2171-4-25**] at 1:30 PM
ICD9 Codes: 5789, 5856, 2760, 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1142
} | Medical Text: Admission Date: [**2119-9-24**] Discharge Date: [**2119-10-5**]
Date of Birth: [**2045-8-23**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Briefly, this is a 74-year-old
male with a history of diabetes, and hypertension, and high
cholesterol who presented to an outside hospital with
shortness of breath. He was worked up at the outside
hospital for the acute shortness of breath and was found to
be in respiratory distress. His heart rate was elevated and
has had runs of V-tach, and his blood pressure was also
elevated. He had positive jugular venous distention,
crackles, and pulmonary edema. Arterial blood gas at that
time was found to be pH 7.21, bicarb of 65, and pO2 of 105.
He was given O2, Lasix, morphine, Combivent, and metoprolol.
The patient is admitted for myocardial infarction and was
consistent with an elevation in his troponin and elevation in
his cardiac enzymes. Echocardiogram was done which showed
hypokinesis.
On hospital day four, his creatinine had elevated to 1.5 and
they stopped his diuresis. Then Mucomyst was planned for
cardiac catheterization and he was transferred to the [**Hospital1 **] for that.
PAST MEDICAL HISTORY: Patient's past medical history is
significant for diabetes type 2, hypertension, high
cholesterol, emphysema, glaucoma, metastatic prostate cancer
status post radiation.
MEDICATIONS: His medications on admission were Lipitor 10 mg
po q day, Accupril 20 mg po q day, Dyazide po q day prn,
Prandin 2 mg tid AC, metformin 500 po bid, and eyedrops for
his glaucoma.
PHYSICAL EXAMINATION: He was afebrile and his vital signs
were stable at that time. On physical exam, his neck had no
jugular venous distention. At time of presentation, his neck
was supple with good carotid, no bruits. His heart was
regular, rate, and rhythm with no murmurs, rubs, or gallops.
His lungs had decreased breath sounds bilaterally and they
were distant with no crackles. His abdomen is soft,
nontender, nondistended and bowel sounds are present. He is
obese. Extremities: There is no clubbing, cyanosis, 2+
edema bilaterally, and his distal pulses were 1+.
LABORATORIES ON ADMISSION: His white count was 11.3,
hematocrit 35.7, and platelet count of 283. Sodium 137,
potassium 4.0, chloride of 97, bicarb of 27, BUN of 55,
creatinine of 1.0, blood sugar 151.
Patient was admitted to the hospital and cardiac
catheterization was done along with EP study. The patient
was found to have multi-vessel disease. Cardiothoracic
Surgery was consulted at that time. Prior to the operating
room, the patient had pulmonary function tests in order to
assess his pulmonary status. It was felt at that time that
his pulmonary status is capable of handling the operation.
The patient was taken to the operating room on [**2119-9-29**],
where a CABG x3 was performed: LIMA to left anterior
descending artery, saphenous vein graft to OM-3, saphenous
vein graft to diagonal. The patient was transferred to the
CSIU postoperatively.
Patient was attempted to be weaned, however, had some
difficulty. It was felt at this time due to his pulmonary
status, it is important to wean his ventilator quickly. On
secondary attempts, the patient was able to be weaned and
extubated from the ventilator. He was started on beta
blockers and diuresis with Lasix. He continued to diurese
well. His laboratories were stable and he is out of bed and
walking around in the Intensive Care Unit, and he was
transferred to the floor. Patient's chest tubes were removed
for low output as well his Foley was removed.
Physical therapy was consulted while in the Intensive Care
Unit to assess ambulation and mobility. They felt he would
be able to progress to such a point that he can be discharged
home safely.
Patient was transferred to the floor and continued to improve
on [**2119-10-2**]. At that time on postoperative day #4, he
continued to improve, however, his heart rate and blood
pressure continued to be elevated, though his beta blocker
was increased and he continued to have aggressive pulmonary
toilet with nebulizer treatments, chest PT, and diuresis.
Physical therapy continued to follow along and he continued
to do well, however, he was found to have desaturations while
ambulating.
He was able to be weaned off of his oxygen on postoperative
day #5, however, required oxygen while ambulating. At that
time, it was felt that with continued diuresis, he could
improve and be discharged home.
On [**2119-10-5**], it was found that he was able to walk around and
ambulate without requiring O2 and patient was discharged
home.
MEDICATIONS UPON DISCHARGE: Lopressor 50 mg po bid,
ipratropium nebulizer one nebulizer q6 hours prn, albuterol
one nebulizer q4h prn, Leukine glutamate 250 po bid,
dipivefrin 0.1% one drop q8 hours to the left eye, Lasix 20
mg po bid, Zantac 150 po bid, pilocarpine 0.5% one drop to
infected eye q6h, Glucophage 500 mg po bid, Repaglinide 2 mg
po tid AC, Percocet 1-2 tablets po q4h prn, [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq
po bid, EC-ASA 325 po q day.
The patient's discharging diagnoses are coronary artery
disease, status post coronary artery bypass graft x3,
diabetes type 2, hypertension, high cholesterol, emphysema,
glaucoma, and metastatic prostate cancer status post
radiation.
The patient is discharged home in stable condition.
Instructed to followup with Dr. [**Last Name (STitle) 70**] in four weeks and
his primary care physician [**Last Name (NamePattern4) **] [**1-11**] weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern4) 7148**]
MEDQUIST36
D: [**2119-10-4**] 14:46
T: [**2119-10-10**] 07:16
JOB#: [**Job Number 45024**]
ICD9 Codes: 4280, 9971, 4271, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1143
} | Medical Text: Admission Date: [**2188-11-5**] Discharge Date: [**2188-11-11**]
Date of Birth: [**2121-2-19**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old
male who presented to outside hospital on [**2188-11-4**]
complaining of chest pain. He said he has a history of chest
pain for approximately the past 9 months with exertion.
However, on [**2188-11-4**] he had chest pain at rest. He was ruled
out for myocardial infarction by enzymes, had a stress
echocardiogram 1 month ago, which showed some wall motion
abnormalities of the septum in distal lateral wall. The
patient was started on beta-blocker and aspirin at that time,
and referred for cardiac catheterization. Cardiac
catheterization today revealed 3-vessel disease. His
catheterization report is as follows: He had an EF of 45
percent, severe inferior hypokinesis, left main 30 percent,
LAD 90 percent proximal and 80 percent mid, 100 percent
diagonal, left circumflex or LCA, he had a 60 percent OM1, 60
percent OM2, RCA was 99 percent mid-stenosed.
PAST MEDICAL HISTORY: Hypertension.
Hypercholesterolemia.
Diverticulosis.
Skin cancer.
Status post tonsillectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS AT HOME:
1. ASA 325 mg daily.
2. Lipitor 10 mg daily.
3. Norvasc 10 mg daily.
4. Lopressor 25 mg b.i.d.
5. Magnesium oxide 400 mg daily.
REVIEW OF SYSTEMS: He denies palpitations, orthopnea, PND,
lower extremity edema, claudication, melena, GI bleed,
history of TIA, CVA, seizures or dyspnea on exertion.
PREOPERATIVE PHYSICAL EXAMINATION: His height was 5 feet 11
inches, and weight 170 lbs. Vital signs, temperature of
98.3, blood pressure 124/88, heart rate between 50 and 70
sinus rhythm, respiratory rate of 16 and his oxygen
saturation was 95 percent on room air. The patient was flat
lying in bed in no acute distress. He was alert and oriented
x 3, responding appropriately to all commands and questions.
His heart rate was in regular rate and rhythm, positive S1,
S2 without clicks, rubs, murmurs or gallops. His lungs were
clear to auscultation bilaterally. His abdomen was soft,
flat, nondistended, nontender with positive bowel sounds. He
had no carotid bruits. His extremities were warm, well
perfused, without cyanosis, clubbing or edema. There were no
varicosities and he had a dressing in his right groin
catheterization site without a hematoma.
PREOPERATIVE LABORATORY DATA: His preoperative chest x-ray
revealed no cardiomegaly or any acute cardiopulmonary
process.
His EKG was, he had a sinus rhythm at 84 with normal axis and
intervals, and he had an isolated Q-wave in lead III and T-
wave flattening inferiorly.
His preoperative labs: He had a white blood count of 10.5,
hematocrit of 43.3, platelet count of 192, PT 13.2, PTT 30.2,
and INR 1.1. His UA was negative. His sodium was 137,
potassium 3.7, chloride 102, bicarbonate 24, BUN 12,
creatinine 0.8, and a glucose of 107. His ALT was 18, AST
15, alkaline phosphatase 80, amylase 39, total bilirubin 0.7
and albumin 4.2.
Cardiac catheterization report was already presented.
HOSPITAL COURSE: The patient was prepared for surgery and
NPO overnight and on [**2188-11-6**], he went to the operating room
and underwent a coronary artery bypass graft x 4. The grafts
were as follows: LIMA to LAD, saphenous vein graft to ramus,
saphenous vein graft to OM, saphenous vein graft to PLV.
Attending surgeon was Dr. [**First Name (STitle) **] [**Name (STitle) **]. The patient
tolerated the procedure well. His cardiopulmonary bypass
time was 112 minutes, cross-clamp time was 97 minutes. The
patient was transferred to CSRU in stable condition with a
heart rate of 88 beats per minute and a-paced. His mean
arterial pressure was 70, CVP of 5, PA diastolic of 10, PA
mean of 15. He was on a Neo-Synephrine drip of 0.2, which
was also being titrated and a propofol drip of 15.
On postoperative day 1, the patient was hemodynamically
stable. T-max of 98.6, sinus rhythm 78, blood pressure
103/50, respiratory rate 20, oxygen saturation was 99 percent
on 4 liters nasal cannula, which means the patient was
extubated following surgery yesterday. His physical
examination was unremarkable. He is currently on a Neo-
Synephrine of 1 and the plan was to wean his Neo-Synephrine
and remove his Swan and his chest tubes and transfer him to
FAR-2, which is the inpatient telemetry floor.
On postoperative day 2, on the floor, the patient went into
rapid atrial fibrillation, which was converted with Lopressor
5 four doses and an amiodarone bolus. The patient was then
started on amiodarone 400 mg p.o. b.i.d. Otherwise, the
patient appeared to be doing very well. His blood pressure
was 122/70 and T-max 99.3. He was in no acute distress. His
lungs were clear to auscultation and his incisions were
clean, dry and intact. So his atrial fibrillation was
converted and he received 2 grams of magnesium sulfate and
would just plan to follow his postoperative atrial
fibrillation.
On postoperative day 3, after he was converted at nighttime,
he also then underwent another series of rapid atrial
fibrillation on [**2188-11-8**], which converted with a dose of
Lopressor of 5 times 2.
So now it is postoperative day 4. The patient was
hemodynamically stable. His heart rate was in normal sinus
rhythm at 81 and hemodynamically, he otherwise appeared to be
doing well. The plan was to check his labs continually, to
get the patient out of bed and ambulate and continue PT. The
patient was receiving amiodarone dose of 400 t.i.d.,
Lopressor 25 b.i.d. and would receive Coumadin if the patient
went into atrial fibrillation again. The patient's
epicardial wires were also removed today following his normal
sinus rhythm.
On postoperative day 4, the patient appeared to be doing
well. His heart rate was in normal sinus at 86, blood
pressure of 106/68. Physical examination was unremarkable.
His chest was stable. His incisions were clean and dry and
intact. The patient was at level 5 and the patient remained
free from arrhythmias overnight. The plan was to discharge
him home tomorrow in the morning. His Lasix was decreased to
20 mg q.d. today.
On postoperative day 5, the patient appeared to be doing
well. He had been receiving physical therapy throughout his
stay and was currently at level 5. He was hemodynamically
stable. His physical examination today, which is his
discharge day, is as follows: He was alert and oriented x 3,
following all commands. His lungs were clear to auscultation
bilaterally. His heart rate was regular rate and rhythm. No
clicks, rubs, murmurs or gallops. His sternum was stable.
His incision was healing well. His bowel sounds were
positive. His abdomen was soft, nontender, nondistended.
His extremities were warm and well perfused without edema.
His left saphenous vein graft incision site was clean and dry
with Steri-Strips intact.
DISCHARGE STATUS: On [**2188-11-11**], which is his postoperative
day 5, the patient was discharged to home with VNA in good
condition.
DISCHARGE DIAGNOSES: Status post coronary artery bypass
graft.
Postoperative atrial fibrillation.
Hypertension.
Hypercholesterolemia.
FOLLOW UP: The patient is recommended to follow up with Dr.
[**Last Name (STitle) 3321**] in [**4-17**] weeks, Dr. [**Last Name (STitle) 5057**] in [**4-17**] weeks and Dr.
[**Last Name (STitle) **] in 4 weeks and to follow up with [**Hospital 409**] Clinic in 2
weeks.
DISCHARGE MEDICATIONS:
1. Colace 100 mg p.o. b.i.d.
2. Aspirin 325 mg p.o. q.d.
3. Oxycodone/acetaminophen 5-325 p.o. 1-2 tablets q.4-6h.
p.r.n.
4. Amiodarone 20 mg 2 tablets p.o. t.i.d.
5. Lasix 20 mg p.o. q.d.
6. Lopressor 50 mg p.o. b.i.d.
7. Potassium chloride 10 mEq 2 tablets p.o. q.d.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern1) 25060**]
MEDQUIST36
D: [**2188-12-9**] 10:04:39
T: [**2188-12-9**] 23:11:01
Job#: [**Job Number 104512**]
ICD9 Codes: 4111, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1144
} | Medical Text: Admission Date: [**2130-3-5**] Discharge Date: [**2130-3-6**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
stab wounds to R chest neck and face s/p assult
Major Surgical or Invasive Procedure:
OR with plastic surgery for repair of R facial nerve and closure
of multiple stab wounds
History of Present Illness:
85M stabbed multiple times by intruder. Lacerations include R
neck, R chestx2, L chest and R lower face. +moderate pain, but
controlled with meds. No difficulty opening or closing mouth.
No changes in vision/hearing. No nausea, vomiting, headache.
Initial trauma workup including CTA of neck and chest had ruled
out need for emergent OR. He received ancef and tetanus. NO
difficulty swallowing.
Past Medical History:
hypertension, peptic ulcer disease
Physical Exam:
PE: T-98.2 BP-129/39 HR-96 RR-18 O2sat-100%2L
gen: thin, elderly man, with large bulky dressing to face.
face: R mandibular laceration, 8 cm, gaping with large flap.
+exposed bone. bleeding controlled. sensation to chin intact.
dog eared lac just inferior to nose. bleeding controlled
mouth: no teeth (wears dentures at baseline) No intraoral
lesions.
R neck: 2cm superficial laceration
R clavicular area: 2cm superficial lac, 3cm superficial lac,
abrasion over sternal notch
Left upper chest: 3cm wound
neuro: alert and oriented x 3
Brief Hospital Course:
Plastic Reconstructive surgery was consulted to manage patients
facial lacerations. Was found to have a severed R facial nerve.
Patient taken to OR for repair of nerve and closure of stab
wounds. Postoperative course was uncomplicated. Observed in the
TICU overnight for neuro checks. On day of discharge, physical
therapy worked with patient and deemed him safe for discharge to
home without any need for additional services.
Medications on Admission:
atenolol
HCTZ
protonix
MVI
Discharge Medications:
atenolol
HCTZ
protonix
MVI
Discharge Disposition:
Home
Discharge Diagnosis:
stabbing victim
Discharge Condition:
stable
Discharge Instructions:
1)Return to Plastic Surgery clinic on Friday for suture removal;
call [**Telephone/Fax (1) 4652**] to make an appt
2)If you have increased pain, swelling, bleeding or expanding
pulsatile mass in your neck, go to nearest ED immediately
Followup Instructions:
Plastic Surgery clinic on Friday [**2130-3-10**] Call [**Telephone/Fax (1) 4652**] to
schedule appointment
ICD9 Codes: 2851, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1145
} | Medical Text: Admission Date: [**2128-6-21**] Discharge Date: [**2128-7-10**]
Date of Birth: [**2128-6-21**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 1794**] is the former 3.49
kilogram product of a 40-1/7 week gestation pregnancy, born
to a 31-year-old, gravida 2, para 1 now 2, Hispanic woman.
Prenatal screens: Blood type O+, antibody negative, rubella
immune, RPR nonreactive, hepatitis B surface antigen
negative, Group Beta Strep status negative. The pregnancy
was notable for an elevated quadruple screen, estimated Down
syndrome risk at about 1:180. An amniocentesis was not
performed. A full fetal survey was reportedly normal. There
was spontaneous onset of labor leading to spontaneous vaginal
delivery under epidural and spinal anesthesia. There was no
intrapartum fever or other clinical evidence of
chorioamnionitis. Rupture of membranes occurred 1-1/2 hours
prior to delivery and yielded meconium stained amniotic
fluid. The infant was born by spontaneous vaginal delivery.
He had Apgars of 8 at one minute and 8 at five minutes. His
initial examination raised suspicion for Down syndrome and
the infant was admitted to the neonatal intensive care unit
for evaluation. He was noted to have an oxygen saturation of
80% on room air without evidence of respiratory distress.
Anthropometric measurements upon admission to the neonatal
intensive care unit: Weight 3.49 kilograms (75th
percentile), length 50.5 cm (75th percentile) and head
circumference 34.5 cm (50th to 75th percentile).
PHYSICAL EXAMINATION AT DISCHARGE: Weight 3.475 kilograms
(50th to 75th percentile), length 53.5 cm (90th percentile)
and head circumference 36 cm (90th percentile). General:
Alert, active, term male in no acute distress. Head, eyes,
ears, nose and throat: Anterior fontanelle open and flat.
Up slanting palpebral fissures. Eyes clear. Positive red
reflex bilaterally. Chest: Breath sounds clear and equal,
well aerated, easy respirations. Cardiovascular: Regular
rate and rhythm, no murmur, normal S1 and S2. Femoral pulses
2+. Abdomen: Soft, nontender, no hepatosplenomegaly, no
masses, positive bowel sounds, cord off umbilical stump and
moist. GU: Circumcised male, healing without drainage.
Testes descended bilaterally. Spine: Straight, normal
sacrum. Extremities: Moving all. Hips: Stable. Skin:
Warm and dry. Color: Pink. Mongolian spot over sacrum.
Neurological: Positive suck, positive grasp, follows voice,
low normal tone.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
1. Respiratory: [**Known lastname **] required oxygen for hypoxemia. His
respiratory rate and work at breathing were always within
normal limits. He weaned to room air on [**2128-7-8**].
At the time of discharge, he was breathing comfortably
with a respiratory rate of 30 to 50 breaths per minute.
Chest X-ray showed normal lungs and pulmonary blood flow.
2. Cardiovascular: Due to his presentation with
symptomatology consistent with Trisomy-21, [**Known lastname **] had an
echocardiogram performed on the date of birth, [**2128-6-21**], which showed a large, 9 mm patent ductus
arteriosus, a patent foramen ovale and pulmonary
hypertension with right ventricular pressures greater
than one-half systemic. A repeat echocardiogram on [**7-5**], [**2128**] showed a tiny PDA with right ventricular
pressures less than 58% systemic pressures. The patent
foramen ovale persisted. [**Known lastname **] will be followed by
Pediatric Cardiology at [**Hospital3 1810**]. He has an
appointment with Dr. [**Last Name (STitle) 15852**] in the cardiology clinic on
[**2128-8-12**] at 1 p.m. At the time of discharge, no
murmur was noted. Baseline heart rate is 140 to 160
beats per minute with a recent blood pressure of 73/50 mm
Hg, mean arterial pressure of 60 mm Hg.
3. Fluids, electrolytes and nutrition: [**Known lastname **] was initially
treated with intravenous fluids due to his polycythemia.
He was made NPO until day of life #3. He has been all
p.o. feedings since that time. He takes 110 to 130 mL
per kilo per day. He is being discharged on Similac
formula fortified to 26 calories per ounce by
concentration. Weight on the day of discharge is 3.475
kilograms. Serum electrolytes were checked in the first
week of life and were within normal limits.
4. Infectious disease: [**Known lastname **] had a complete blood count and
blood culture drawn upon admission to the neonatal
intensive care unit. He received a 72 hour course of
ampicillin and gentamicin. Blood culture was no growth.
5. Hematological: Hematocrit at birth was 64.8%. His
hematocrit rose to 66% and due to the persistent
hypoxemia and hypoglycemia, a partial volume exchange
transfusion was performed on day of life #2. [**Known lastname **] also
had thrombocytopenia. Initial platelet count was 38,000.
He received a platelet transfusion on day of life #2.
His thrombocytopenia resolved. His most recent
hematocrit and platelet count are from [**2128-7-5**] with
a hematocrit of 54.5 and a platelet count of 203,000.
[**Known lastname **] is blood type O+ and is direct antibody test
negative.
6. Gastrointestinal: [**Known lastname **] required treatment for
unconjugated hyperbilirubinemia with phototherapy. Peak
serum bilirubin occurred on day of life #2 with a total
of 15.4 mg per dl. He was treated with phototherapy for
approximately 72 hours. Rebound serum bilirubin on day
of life #6 was a total of 10.6 mg per dl.
7. Neurology: [**Known lastname **] has maintained a normal neurological
exam except for below normal tone associated with Trisomy-
21. He will be referred for early intervention program
at home discharge.
8. Genetics: Chromosomes were sent for SISH for chromosome
#21. This was positive for Trisomy-21. His karyotype is
47XY plus 21. [**Known lastname **] was evaluated by the pediatric
genetics service from [**Hospital3 1810**]. He was also
referred to the Down Syndrome Clinic at [**Hospital1 62374**]. The contact person is [**Name (NI) **] [**Name (NI) **].
9. Sensory/audiology: Hearing screening was performed with
automatic auditory brain stem responses. [**Known lastname **] passed in
both ears.
10. Psychosocial: Mother and father are [**Name (NI) 8003**] speaking.
They have been very involved in [**Known lastname 73676**] care during
admission.
CONDITION AT DISCHARGE: Good.
DISCHARGE DISPOSITION: Home with parents.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 38896**], 391 [**Location (un) **], [**Apartment Address(1) 73677**], [**Location (un) 2251**], [**Numeric Identifier 73678**], telephone number [**Telephone/Fax (1) 73679**], fax number [**Telephone/Fax (1) 46299**].
CARE AND RECOMMENDATIONS AT TIME OF DISCHARGE:
1. Ad lib p.o. feeding, Similac 26 calories per ounce.
2. No medications.
3. Iron and vitamin D supplementation. Iron supplementation
is recommended for preterm and low birth weight infants
until 12 months corrected age. All infants that
predominantly breast milk should received vitamin D
supplementation at 200 international units (may be
provided as a multivitamin preparation) daily until 12
months corrected age.
4. Car seat position screening was performed. [**Known lastname **] was
observed in his car seat for 90 minutes without any
episodes of oxygen desaturation or bradycardia.
5. State newborn screens were sent on [**2128-6-24**] and [**7-5**], [**2128**]. No notification of abnormal results to date.
6. Immunizations: Hepatitis B vaccine was administered on
[**2128-7-5**].
7. Immunizations recommended: Synagis RSV prophylaxis
should be considered from [**Month (only) **] through [**Month (only) 958**] for
infants who meet any of the following 4 criteria: Born
at less than 32 weeks; born between 32 and 35 weeks with
2 of the following: Daycare during RSV season, a smoker
in the household, neuromuscular disease, airway
abnormalities or school age siblings; chronic lung
disease; or hemodynamically significant congenital heart
disease. Influenza immunization is recommended annually
in the fall for all infants once they reach 6 months age.
Before this age and for the first 24 months of the
child's life, immunization again influenza is recommended
for household contacts and out of home caregivers. This
infant has not received rotavirus vaccine. The American
Academy of Pediatrics recommends initial vaccination of
preterm infants at or following discharge from the
hospital if they are clinically stable and at least 6
weeks but fewer than 12 weeks of age.
8. Followup appointments scheduled or recommended:
Appointment with Dr. [**Last Name (STitle) 38896**], primary pediatrician,
within 3 days of discharge. Pediatric cardiology at
[**Hospital3 1810**] Cardiology Clinic, Dr. [**Last Name (STitle) 15852**], on
[**2128-8-12**] at 1 p.m.
DISCHARGE DIAGNOSES:
1. Term newborn male.
2. Trisomy-21.
3. Polycythemia, status post partial volume exchange
transfusion.
4. Thrombocytopenia.
5. Unconjugated hyperbilirubinemia.
6. Patent ductus arteriosus.
7. Pulmonary hypertension.
8. Status post circumcision.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) 73680**]
MEDQUIST36
D: [**2128-7-10**] 03:17:40
T: [**2128-7-10**] 07:12:10
Job#: [**Job Number **]
ICD9 Codes: V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1146
} | Medical Text: Admission Date: [**2183-5-27**] Discharge Date: [**2183-6-1**]
Date of Birth: [**2108-12-7**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Abdominal pain.
Major Surgical or Invasive Procedure:
Exploratory laparotomy, right
hemicolectomy with takedown of hepatic flexure, and
construction of an end ileostomy and mucous fistula.
History of Present Illness:
Mr. [**Known lastname 11333**] is a 74-year-old male
who previously underwent a kidney transplant that was
complicated by allograft rejection and shock resulting in
loss of his kidney and return to dialysis. The patient has
had multiple vascular complications and recently underwent an
fem distal bypass on the right side. He remains hospitalized
in the skilled nursing facility when he developed abdominal
pain over the last several days. He presented to the
emergency room where on evaluation he was found to have
obvious peritonitis. A CT scan did not demonstrate any intra-
abdominal pathology.
Past Medical History:
1) ESRD s/p cadaveric renal transplant [**6-4**], on PD (catheter
placed '[**82**])
2) CAD s/p CABG X 3 [**2176**]
- s/p angioplaty OM graft [**2-6**]; s/p angioplasty of native LAD
[**11-4**]
3) HTN
4) Hyperlipidemia
5) Type II DM
6) anemia of chronic disease
7) h/o bladder carcinoma status post resection.
8) s/p TURP ('[**76**]) and TURBT
9) s/p hernia repair
10) Peripheral vascular disease: s/p Right femoral-to-posterior
tibial artery bypass with nonreversed right cephalic arm vein
graft
Social History:
Pt is a retired truck driver, lives with wife, son and
grandchildren. Smoked for 40 years, quit smoking 20 years ago.
Denies EtOH and illicit drugs.
Family History:
Mother- died MI ([**2157**]'s)
Father- died Ca ([**2127**]'s)
Physical Exam:
On admission:
97.1 82 91/41 16 95% 2L O2
Appears in pain, A&Ox3
PEARL, NC/AT
Irreg
rhonchi diffusely
soft, diffusely tender w/ gaurding
Ext: R groin incision w/ staples, RLE incision w/ staples, small
serous drainage
Dry gangrene 1st and 3rd toes. RUE incision intact
Pulses: RLE Fem-palp, graft-palp, DP/PT-dop
LLE Fem-palp, [**Doctor Last Name **]-dop, DP/PT-dop
Pertinent Results:
[**2183-5-27**] 01:40PM BLOOD WBC-4.5# RBC-3.94* Hgb-12.3* Hct-39.4*#
MCV-100*# MCH-31.3 MCHC-31.3 RDW-23.1* Plt Ct-54*#
[**2183-5-27**] 10:02PM BLOOD WBC-5.2 RBC-3.04* Hgb-9.8* Hct-30.6*
MCV-101* MCH-32.1* MCHC-31.8 RDW-22.7* Plt Ct-56*
[**2183-5-28**] 02:47AM BLOOD WBC-8.0# RBC-3.11* Hgb-9.9* Hct-31.7*
MCV-102* MCH-31.9 MCHC-31.4 RDW-22.7* Plt Ct-58*
[**2183-6-1**] 03:16AM BLOOD WBC-8.5 RBC-3.72* Hgb-11.4* Hct-35.9*
MCV-96 MCH-30.7 MCHC-31.9 RDW-22.2* Plt Ct-47*
[**2183-6-1**] 08:51AM BLOOD WBC-10.0 RBC-3.59* Hgb-11.2* Hct-33.9*
MCV-95 MCH-31.1 MCHC-32.9 RDW-22.4* Plt Ct-55*
[**2183-5-27**] 01:40PM BLOOD PT-14.1* PTT-28.2 INR(PT)-1.2*
[**2183-5-27**] 01:40PM BLOOD Plt Smr-VERY LOW Plt Ct-54*#
[**2183-5-27**] 10:02PM BLOOD PT-14.8* PTT-29.6 INR(PT)-1.3*
[**2183-5-27**] 10:02PM BLOOD Plt Ct-56*
[**2183-6-1**] 03:16AM BLOOD Plt Ct-47*
[**2183-6-1**] 08:51AM BLOOD PT-33.1* PTT-39.9* INR(PT)-3.6*
[**2183-6-1**] 08:51AM BLOOD Plt Ct-55*
[**2183-5-27**] 01:40PM BLOOD Fibrino-559* D-Dimer-2837*
[**2183-6-1**] 08:51AM BLOOD Fibrino-203#
[**2183-5-27**] 01:40PM BLOOD Glucose-218* UreaN-50* Creat-5.3*#
Na-131* K-3.2* Cl-88* HCO3-26 AnGap-20
[**2183-5-27**] 10:02PM BLOOD Glucose-204* UreaN-47* Creat-4.8* Na-131*
K-3.4 Cl-96 HCO3-20* AnGap-18
[**2183-5-28**] 02:47AM BLOOD Glucose-222* UreaN-50* Creat-5.0* Na-130*
K-3.6 Cl-95* HCO3-20* AnGap-19
[**2183-6-1**] 03:16AM BLOOD Glucose-91 UreaN-32* Creat-2.8* Na-136
K-4.5 Cl-97 HCO3-13* AnGap-31*
[**2183-6-1**] 08:51AM BLOOD Glucose-66* UreaN-29* Creat-2.4* Na-144
K-4.4 Cl-100 HCO3-16* AnGap-32*
[**2183-5-27**] 01:40PM BLOOD ALT-22 AST-17 AlkPhos-75 Amylase-19
TotBili-0.4
[**2183-5-27**] 10:02PM BLOOD ALT-17 AST-17 LD(LDH)-285* CK(CPK)-39
AlkPhos-64 Amylase-16 TotBili-0.5
[**2183-5-28**] 05:37AM BLOOD CK(CPK)-41
[**2183-5-31**] 09:00PM BLOOD ALT-417* AST-568* CK(CPK)-62 AlkPhos-80
Amylase-44 TotBili-1.8*
[**2183-6-1**] 08:51AM BLOOD ALT-643* AST-948* LD(LDH)-1398*
CK(CPK)-96 AlkPhos-74 Amylase-47 TotBili-3.0*
[**2183-5-27**] 01:40PM BLOOD Lipase-15
[**2183-5-27**] 10:02PM BLOOD Lipase-13
[**2183-5-31**] 09:00PM BLOOD Lipase-37
[**2183-6-1**] 08:51AM BLOOD Lipase-49
[**2183-5-27**] 10:02PM BLOOD CK-MB-6 cTropnT-0.67*
[**2183-5-28**] 05:37AM BLOOD CK-MB-NotDone cTropnT-0.72*
[**2183-5-28**] 01:59PM BLOOD CK-MB-6 cTropnT-0.85*
[**2183-5-31**] 09:00PM BLOOD CK-MB-NotDone cTropnT-0.41*
[**2183-6-1**] 08:51AM BLOOD CK-MB-NotDone cTropnT-0.38*
[**2183-5-27**] 01:40PM BLOOD Albumin-2.6* Calcium-8.2* Phos-5.3*
Mg-1.6
[**2183-5-27**] 10:02PM BLOOD Albumin-2.1* Calcium-8.1* Phos-6.4*
Mg-1.4*
[**2183-5-28**] 02:47AM BLOOD Phos-6.8* Mg-2.0
[**2183-5-31**] 09:00PM BLOOD Calcium-11.2* Phos-5.6* Mg-2.2
[**2183-6-1**] 03:16AM BLOOD Calcium-11.5* Phos-6.1* Mg-2.1
[**2183-6-1**] 08:51AM BLOOD Albumin-2.5* Calcium-10.9* Phos-5.5*
Mg-2.0
[**2183-5-29**] 05:47AM BLOOD Hapto-171
[**2183-5-31**] 03:32PM BLOOD Vanco-3.2*
[**2183-6-1**] 08:55AM BLOOD Type-ART pO2-43* pCO2-35 pH-7.38
calHCO3-22 Base XS--3
[**2183-6-1**] 03:33AM BLOOD Type-ART pO2-83* pCO2-28* pH-7.33*
calHCO3-15* Base XS--9
[**2183-6-1**] 01:12AM BLOOD Type-ART pO2-105 pCO2-28* pH-7.32*
calHCO3-15* Base XS--10
[**2183-6-1**] 03:33AM BLOOD freeCa-1.09*
Brief Hospital Course:
Pt transferred from [**Hospital1 **] with acute intermittant
abdominal pain. CT in ED showed:
1. 3 cm anterior abdominal wall inflammatory changes with foci
of air in rectus sheath and subcutaneous tissue, above
umbilicus. In the absence of recent instrumentation, this is
suspicious for infection, and a focus clinical exam at this site
is advised. If indeed of infectious etiology, diagnostic
considerations should include gas forming organisms.
2. Multiple foci of free intraabdominal air in nondependent
portions of the abdomen. This air is likely secondary to
peritoneal catheter. However, if clinical service suspicion is
high, we can reimage the patient in the left down lateral
decubitus position after the administration of more oral
contrast.
.
Pt was admitted [**2183-5-27**] and was taken to the SICU. Pressors
were started in the setting of new onset Afib. Pt intubated,
NGT, foley, a-line, CVL, PA. Solumedrol 24'. Linezolid,
Levoflox and flagyl started. Peritoneal fluid sent for
analysis, and grew 3 isolates of Enterococcus. Pt underwent
operation on day of admission. Post-op Dx: Gangrenous cecum
without perforation. Final path showed:
Ileocolectomy specimen:
1. Focally transmural necrosis and acute inflammation, colon,
see note.
2. Proximal and distal resection margins free of necrosis and
acute inflammation.
3. Unremarkable appendix.
.
Renal and GI were consulted, Vascular surgery followed. CVVH
was initiated. Pt continued on vent, pressors (levophed) and
propofol.
POD 2- platelets decreased and HIT screen was sent. Was found
to be negative. Hct dropped 30->24 and was transfused 2 units.
Cards consulted: plan for TEE, cardioversion once
anticoagulation can be started.
POD 3- pt extubated and off pressors. Platelets transfused x2.
POD 4- transfused pRBC x2 and plts x3, CVVH continued
POD 5- During AM rounds (approx 0805) pt found to be in
respiratory distress w/ [**Month (only) **]. O2 sats. Pt intubated. Neo
started with SBP to 90's, increased with little effect. Pt
continued to acutely decompensate despite pressors and fluids.
ACLS protocol, CPR initiated. Vfib arrest. Time of death 0900,
[**2183-6-1**]. Family notified by primary team.
Medications on Admission:
Iron 325 mg PO daily
Nephrocaps
Prednisone 20 mg PO daily
Cipro 250 mg PO BID
Metoprolol 125 mg PO BID
atorvastatin 80 mg PO daily
Colace 100 mg PO BID
Finasteride 5 mg PO daily
Prevacid 30 mg PO BID
Imdur 30 mg PO daily
Hydralazine 25 mg PO q6h
Glipizide 5 mg PO BID
Metamucil
epo
Percocet prn
Discharge Medications:
deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: Colon Ischemia
Secondary: CAD, ESRD, CHF
Discharge Condition:
Expired
Discharge Instructions:
Pt Expired
Followup Instructions:
none
ICD9 Codes: 5185, 5856, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1147
} | Medical Text: Admission Date: [**2195-5-31**] Discharge Date: [**2195-6-5**]
Date of Birth: [**2195-5-31**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: [**Known lastname 449**] [**Known lastname 1024**] was born with a
birthweight of 3.41 kg and a gestational age of 35-5/7 week
born to a 34-year-old G2 P1-2 woman.
Prenatal screens: Blood type O+, antibody negative, rubella
immune, RPR nonreactive, hepatitis B surface antigen negative,
group beta Strep status unknown. The pregnancy was
uncomplicated. EDC was [**2195-7-1**].
The mother presented with ruptured membranes at 12 am on
[**2195-5-31**] five hours prior to delivery. There was no
maternal fever. Labor progressed rapidly and there was no
precipitous vaginal delivery. Apgars were 7 at one minute
and 8 at five minutes. The baby was noted to have prominent
facial bruising and respiratory distress at delivery. He was
admitted to the Neonatal Intensive Care Unit for treatment of
respiratory distress.
PHYSICAL EXAM UPON ADMISSION TO THE NEONATAL INTENSIVE CARE
UNIT: Weight 3.41 kg, length 51 cm, head circumference 35
cm. General: Nondysmorphic infant with grunting and
retracting. Head, eyes, ears, nose, and throat: Anterior
fontanel is soft and flat, normal faces. Palate intact.
Chest: Initial grunting. Breath sounds equal and clear,
improved after starting on continuous positive airway
pressure. Cardiovascular: Normal S1, S2, no murmur.
Femoral pulses normal. Abdomen is soft without organomegaly.
Genitourinary normal. Appropriate for gestational age male
with testes palpable bilaterally.
Neurological: Tone excellent. Cry vigorous.
Symmetrical examination. Hips: Slightly increased laxity,
but stable. Skin: Facial bruising as previously noted.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
1. Continuous positive airway pressure was initiated shortly
after admission to the Neonatal Intensive Care Unit. [**Known lastname 449**]
required a maximum of 30% inspired oxygen. An arterial blood
gas was a pH of 7.33, pCO2 of 43, a pO2 of 58. His
respiratory distress gradually resolved over the next few
hours, and by day of life #1, he was on room air with normal
respiratory rates. A chest x-ray showed bilateral mild
strict densities with normal lung volumes, normal
situs and normal heart size. His respiratory
distress was thought to be due to retained fetal lung fluid.
2. Cardiovascular: [**Known lastname 449**] maintained normal heart rates and
blood pressures. There were no murmurs noted during
admission.
3. Fluids, electrolytes, and nutrition: [**Known lastname 449**] was initially
NPO and maintained on intravenous fluids. Enteral feeds were
started on day of life #1, and gradually advanced to full
volume. At the time of discharge, he is breastfeeding well
or taking Enfamil 20. Discharge weight is 3.285 kg.
4. Infectious Disease: Due to an unknown group B Strep
status and the respiratory distress, [**Known lastname 449**] is evaluated for
sepsis. A white blood cell count was 23,000 with a
differential of 35% polys, 0% bands. A blood culture was
obtained prior to starting intravenous ampicillin and
gentamicin. Blood culture was no growth at 48 hours and the
antibiotics were discontinued.
5. Hematological: Hematocrit at birth is 55.4%. [**Known lastname 449**] did
not receive any transfusions of blood products.
6. Gastrointestinal: Peak serum bilirubin occurred on day of
life five, a total of 15.0/0.3 mg/dl direct.
7. Neurological: [**Known lastname 449**] has maintained a normal neurological
examination during admission, and there were no neurological
concerns at the time of discharge.
8. Sensory: Audiology hearing screening was performed with
automated auditory brain stem responses. [**Known lastname 449**] passed in
both ears.
CONDITION ON DISCHARGE: Good.
DISCHARGE/DISPOSITION: Home with parents.
PRIMARY PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1728**], [**Last Name (NamePattern1) 40688**],
[**Location (un) 620**], [**Numeric Identifier 52283**], phone [**Telephone/Fax (1) 37814**].
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Adlib feeding breast feeding or Enfamil 20.
2. Medications none.
3. Car seat position screening was performed with oxygen
saturations greater than 95% for 90 minutes without any
episodes of apnea.
4. State Newborn Screen was sent on [**2195-6-4**] with no
notification of abnormal results to date.
5. Immunizations received: Initial hepatitis B vaccine was
administered on [**2195-6-4**].
6. Follow-up bilirubin should be checked on Saturday [**2195-6-6**]
at [**Hospital1 18**]. Results should be called into Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1728**] prior
to the family's leaving.
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet
any of the following three criteria: 1) Born at less than 32
weeks, 2) born between 32 and 35 weeks with plans for daycare
during RSV season, with a smoker in the household, or with
preschool siblings, 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.
FOLLOW-UP APPOINTMENTS:
1. Pediatrician on Tuesday [**2195-6-9**]
2. VNA - Monday [**2195-6-8**]
DISCHARGE DIAGNOSES:
1. Prematurity at 35-4/7 weeks gestation.
2. Transitional respiratory distress due to retained fetal
lung fluid.
3. Suspicion for sepsis ruled out.
4. Unconjugated hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D. [**MD Number(1) 37238**]
Dictated By:[**Last Name (Titles) 37548**]
MEDQUIST36
D: [**2195-6-5**] 04:32
T: [**2195-6-5**] 05:20
JOB#: [**Job Number 52284**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1148
} | Medical Text: Admission Date: [**2197-9-8**] Discharge Date: [**2197-9-21**]
Date of Birth: [**2135-2-23**] Sex: M
Service: CT Surgery
HISTORY OF PRESENT ILLNESS: The patient was referred in by
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8173**], who evaluated him on the day of
admission for symptoms with congestive heart failure. In
early [**Month (only) 216**], he started to feel, as he stated, lousy. He
became short of breath, which became progressively worse. He
sleeps on two pillows and describes paroxysmal nocturnal
dyspnea. He had some increased abdominal girth.
The patient was admitted to the hospital about one week ago
for 24 hours and only received some intravenous Lasix. He
did not have any testing at that time. He has never had any
chest pressure and denies a history of prior myocardial
infarction. He also denies dizziness, lightheadedness or
syncope. He has had hypertension and was a smoker but quit
five years ago.
MEDICATIONS ON ADMISSION: Paxil 30 mg p.o.q.d., oxazepam 15
mg p.o.q.d., Univasc 15 mg p.o.q.d., Lasix 40 mg p.o.q.d.,
insulin, Pravachol 20 mg p.o.q.d., aspirin, Centrum Silver,
vitamin E and garlic.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION: On physical examination, the patient
appeared to be in moderate respiratory distress. His weight
was 238 pounds. He had a good blood pressure at 110/80 but
his pulse was 120 beats per minute. Jugular venous pressure
could not be assessed. He had 1+ carotids bilaterally. On
chest examination, there were bibasilar rales. On cardiac
examination, apical impulse was diffuse, heart sounds were
normal, there was a loud summation gallop. Abdomen was
distended. There was peripheral edema of the right leg to
the mid-calf level. Pulses were not easily palpable.
LABORATORY DATA: Electrocardiogram showed sinus tachycardia
and left bundle branch block. Echocardiogram showed an
enlarged left atrium, dilated left ventricle with a left
ventricular ejection fraction of less than 20%. The right
ventricle was also hypokinetic. There was moderate pulmonary
hypertension.
On the day of admission, hematocrit was 38.1, white blood
cell count 9.6, platelet count 337,000, prothrombin time
19.2, INR 2.4, blood sugar 166, BUN 27, creatinine 1.1,
sodium 132 and chloride 94.
IMPRESSION ON ADMISSION: Dr.[**Name (NI) 31768**] impression was
that the patient was in congestive heart failure and she
admitted him to the hospital.
PAST MEDICAL HISTORY: 1. Insulin dependent diabetes
mellitus. 2. Congestive heart failure. 3. Peripheral
vascular disease, status post right femoral-popliteal bypass,
status post left femoral-popliteal bypass and status post
below the knee amputation in [**2196-2-17**]. 4. Hypertension.
5. Anxiety.
ALLERGIES: The patient has no known drug allergies.
HOSPITAL COURSE: The patient was followed by Dr. [**Last Name (STitle) **] and
was seen by cardiology for his episodes of nonsustained
ventricular tachycardia and ventricular bigeminy. He ruled
out for a myocardial infarction by CKs, but the plan was to
take him for a cardiac catheterization when he was more
stable and had been diuresed significantly. He was followed
by Dr. [**Last Name (STitle) 8173**] with a left below the knee amputation and
he was followed by cardiology and case management, as was
diuresed for his congestive heart failure. He continued on
aspirin and Univasc and remained on the cardiology floor.
On [**2197-9-12**], the patient underwent a cardiac
catheterization and was referred to cardiothoracic surgery
for evaluation. On [**2197-9-12**], his white blood cell
count was 8.2 with a hematocrit of 38.7, platelet count
288,000, prothrombin time 15.4, partial thromboplastin time
28.7, INR 1.6, sodium 132, potassium 4.1, chloride 93,
bicarbonate 29, BUN 41, creatinine 1.4, and blood sugar 163.
The patient was examined again by cardiothoracic surgery. He
had had an intra-aortic balloon pump placed in the
catheterization laboratory in his right femoral artery. His
right foot was warm and perfused. He is status post left
lower leg amputation. He was seen by Dr. [**First Name (STitle) 10102**] of cardiac
surgery, who again examined, and also noted venous stasis
changes of his right leg. He also noted a thick panniculus
on his obese abdomen but no hepatosplenomegaly or masses
detected. A Foley catheter was in place. He had questions
about conduit availability in the right leg and recommended
that vein mapping be done. He also noted that the left hand
had an intact palmar arch on examination of the left radial
artery, the patient is left handed, but there was a question
of the intactness of his right palmar arch, as decisions for
conduits needed to be made.
Cardiac catheterization on [**2197-9-14**]: Left
ventricular ejection fraction not calculated as no
ventriculogram was done; left main had a 50% lesion, left
anterior descending artery had a 90% lesion; circumflex 100%
lesion and right coronary artery 100% occluded. Index was
only 1.7 at the time of examination, with pulmonary artery
pressure of 57/34. Dr. [**First Name (STitle) 10102**] recommended right leg vein
mapping and getting a transthoracic echocardiogram to
evaluate for mitral regurgitation and left ventricular
ejection fraction, and agreed to re-evaluate the patient when
the studies were done.
The patient remained in the Coronary Care Unit with an
intra-aortic balloon pump, with a tentative plan to go to the
Operating Room on [**Last Name (LF) 2974**], [**2197-9-15**]. He continued
to have occasional premature ventricular contractions on
telemetry. His magnesium was repleted. He continued his
diuresis. Vein mapping showed below the knee lesser
saphenous and greater saphenous to be patent. Echocardiogram
showed a left ventricular ejection fraction of less than 15%
with left ventricular dilatation, 2+ mitral regurgitation, 2+
tricuspid regurgitation, right ventricle with also dilated
and depressed function.
Diagnosis of severe ischemic cardiomyopathy was made. The
patient was also started on a beta blocker and ACE inhibitors
were continued, as well as aspirin and the heparin drip. He
continued diuresis. Dr. [**First Name (STitle) 10102**] again explained the risks
to the patient, who consented to surgery. He was also seen
by case management for placement issues postoperatively.
On [**2197-9-15**], the patient underwent coronary artery
bypass grafting times three with a left internal mammary
artery to the left anterior descending artery, saphenous vein
graft to obtuse marginal and saphenous vein graft to
posterior descending artery.
The patient was transferred to the Cardiothoracic Intensive
Care Unit on milrinone and Levophed as well as continued
mechanical support with his intra-aortic balloon pump that
had been placed preoperatively. Of note, his saphenous vein
grafts were obtained from the lesser saphenous area as well
as distal greater saphenous, distal to the femoral-poplitea
graft in the left lower extremity due to his prior peripheral
vascular surgery. Please refer to the operative note in the
chart. Of note, the patient had been transferred to the
Intensive Care Unit on the following additional medications:
Epinephrine drip, amiodarone drip and propofol.
On postoperative day number one, Amicar and epinephrine drips
were off. The patient had received 14 units of fresh frozen
plasma, ten units of packed red blood cells, one unit of
cryoprecipitate and four units platelets for continuing
bleeding postoperatively. He was on an amiodarone drip at 1,
insulin at 12, Levophed at 0.24, milrinone 0.375, propofol 25
and cisatracurium at 1. He was up 13.9 liters in fluid. He
had put 4.9 liters out from his chest tubes.
The patient remained paralyzed, with bilateral rhonchi. His
white blood cell count was 6.2, hematocrit 27, potassium 4.2,
BUN 35, creatinine 1.6, blood sugar 236 and INR 1.5. He was
kept sedated with orders to continue transfusing him to a
platelet count of about 100,000. He was on levofloxacin and
vancomycin for perioperative antibiotics.
The patient was returned to the Operating Room for
postoperative bleeding on the evening of the operative day,
[**2197-9-15**]. He was explored for mediastinal bleeding
and returned to the Cardiothoracic Intensive Care Unit with
his chest open. He was back on a Neo-Synephrine drip and a
Dopamine drip was started and then discontinued. His blood
pressure was 95/65 with decreased urine output. His balloon
remained at 1 to 2. He had an output of 4.79 with an index
of 2 on the following drips: Amiodarone, Ativan, insulin,
Levophed, milrinone, morphine and Neo-Synephrine at 3.5. His
creatinine rose to 2.2, his potassium was 5, BUN 14, white
blood cell count 11, hematocrit 27.8, while he remained
intubated and sedated on his drips, with attempts to wean his
PEEP. He remained critically ill in the Intensive Care Unit.
On postoperative day number two, the patient continued in the
Intensive Care Unit, with an open chest. He was
hemodynamically stable on his continued multiple drip
supports and remained paralyzed and sedated. His hematocrit
rose to 30 with a white blood cell count of 12 and he
remained on drug support in the Intensive Care Unit. He
continued on levofloxacin and vancomycin also as his support.
He got good diuresis with a Lasix drip. There was some
evidence of acidosis. Dr. [**First Name (STitle) 10102**] planned to close the
chest on the following day and discussed this plan with the
family. The patient also remained on vasoconstrictors to
help maintain tone.
On postoperative day number four, a repeat echocardiogram
showed a left ventricular ejection fraction of 10% to 20%
with poor wall motion. There was a question of whether or
not the patient was a transplant candidate and was scheduled
to return back to the Operating Room to close his chest. He
was somewhat hypotensive, with a blood pressure of 84 to 100
range. Vasopressin was also started to help maintain his
tone. His hematocrit was 29.6 but his white blood cell count
rose to 13.1. He remained on amiodarone, Ativan, dobutamine,
insulin, Levophed, morphine, Neo-Synephrine and cisatracurium
for paralyzation in the Intensive Care Unit.
A renal consult was obtained on [**2197-9-19**] and they
attributed the patient's sluggish renal function, which had
now risen from 2.1 to 3.1 creatinine and BUN of 57, to
cardiogenic shock and hypoperfusion of his kidneys. They
recommended some CVVH but only if there was a possibility
that his heart would recover from his cardiogenic shock.
On [**0-0-0**], the patient remained on maximal
medical and mechanical support but he continued to move
downhill, with multi-organ failure. All the issues were
explained to the family by Dr. [**First Name (STitle) 10102**], but they requested
continued intervention and refused comfort measures only.
The patient was seen by the clinical nutrition team and
followed by renal. As the patient continued to deteriorate,
renal thought that dialysis would be impossible with his low
cardiac index and attempted to consult the family again
regarding these issues.
The patient continued to be aneuric and his oxygenation was
becoming more difficult. The patient became acidotic and his
systemic vascular resistance was only 487 with a blood
pressure of 90/50. He remained on dobutamine,
Neo-Synephrine, vasopressin, morphine, vancomycin, insulin
and Ativan drips.
The patient's creatinine on [**2197-9-20**] was 3.1 to 4.8
with continuing acute renal failure. His chest x-ray showed
increased pleural effusion with a question of a pericardial
effusion. He remained in cardiogenic shock. His balloon
remained at 1:1. His potassium rose from 5 the day prior to
6.4. Renal continued to follow him but were unable to
recommend dialysis as his prognosis was extremely poor and
was due to lack of perfusion from his heart.
Dr. [**First Name (STitle) 10102**] spoke with the patient's family on the morning
of [**2197-9-20**], and they agreed to comfort measures only
and "Do Not Resuscitate" status, and the patient expired on
[**2197-9-21**] in the Intensive Care Unit.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass grafting time three.
2. Insulin dependent diabetes mellitus.
3. Hypertension.
4. Peripheral vascular disease, status post left and right
femoral-popliteal bypasses and status post left below the
knee amputation.
5. Congestive heart failure.
6. Cardiogenic shock.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 13625**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2197-12-20**] 10:41
T: [**2197-12-26**] 11:13
JOB#: [**Job Number **]
ICD9 Codes: 4280, 5849, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1149
} | Medical Text: Admission Date: [**2195-7-27**] Discharge Date: [**2195-8-7**]
Date of Birth: [**2141-8-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3127**]
Chief Complaint:
OLT on [**2195-7-28**] for Hep C and alcoholic cirrhosis
Major Surgical or Invasive Procedure:
liver transplant [**2195-7-28**]
clot evacuation and biliary reconstruction [**2195-7-29**]
History of Present Illness:
Patient in his usual state of health on liver transplant waiting
list for HCV and ETOH cirrhosis when he was called in for OLT.
Pt denies fever/chills or any recent illnesses.
Past Medical History:
DM on PO meds
HCV
ETOH cirrhosis
Social History:
Lives in single family home with 2 floors.
Has a female friend who will be helping post transplant, not
currently residing with him.
One child
Denies recent ETOH use
Still smoking
Family History:
Non-Contrib
Physical Exam:
A+Ox3 in NAD
eyes anicteric, no jaundice of skin
Card: RRR, no M/R/G
Resp: Lungs CTA bilaterally
Abd: Distended, soft, NT, no scars
Extremeties: [**2-6**]+ bilateral pitting edema of LE
+ pedal pulses
Pertinent Results:
[**2195-7-27**] 02:00PM GLUCOSE-156* UREA N-24* CREAT-1.2 SODIUM-137
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-25 ANION GAP-13
[**2195-7-27**] 02:00PM ALT(SGPT)-96* AST(SGOT)-104* ALK PHOS-123*
TOT BILI-3.0*
[**2195-7-27**] 02:00PM CALCIUM-8.3* PHOSPHATE-2.3* MAGNESIUM-1.9
[**2195-7-27**] 02:00PM WBC-3.7* RBC-3.35* HGB-11.7* HCT-32.8* MCV-98
MCH-34.9* MCHC-35.7* RDW-16.2*
[**2195-7-27**] 02:00PM PLT COUNT-51*
[**2195-7-27**] 02:00PM PT-17.2* PTT-28.2 INR(PT)-1.6*
[**2195-7-27**] 02:00PM FIBRINOGE-212
Brief Hospital Course:
Pt admitted on [**7-27**] for OLT for ETOH cirrhosis and HCV. There
was concern pre-op that the patient might have a thrombosed
portal Vein. During the procedure, when the liver was excised,
the patient had a period of instability, with his blood pressure
dropping to the high 70s low 80s systolic range, with some
arrhythmias.
This responded to fluid resuscitation. There was some clot and
thickening in the lateral wall on the left side of the recipient
portal vein, and this was removed. There was excellent portal
flow upon release of clamp. The caval
anastomosis was hemostatic. This was quickly followed by release
of the portal clamp. There was excellent flow through the
portal vein, and the liver perfused nicely. Patient had a
diffuse coagulopathy, and required aggressive resuscitation
with both packed RBCs and clotting factors. Once hemostasis was
achieved, the artery was reperfused and there was excellent flow
and thrill in the hepatic artery.
Again, the patient had diffuse ooze from several areas,
including the raw surface on the right diaphragm, an area around
the portal vein, and several measures were taken to achieve
hemostasis, including direct cautery with both [**Last Name (un) 4161**] and Argon
beam and topical application of hemostatic agents, such as
Surgicel and Surginette. He also continued to receive
aggressive blood product resuscitation. He did remain
hemodynamically stable during this period.
Both ducts were of equal and good caliber.
After the completion of all the anastomoses, at least an hour
was spent securing hemostasis. During course of the case,
the patient received 9 liters of crystalloid, 23 units of
FFP, 15 units of packed RBCs, and 7 units of platelets, and 4
units of cryoprecipitate. He received 3800 cc by cell [**Doctor Last Name 10105**].
He remained hemodynamically stable. The patient was transferred,
still intubated, in stable condition to the intensive care unit.
Post op, coagulopathy complicated the immediate post op course
and the patient was taken back to the OR. There was no
hemorrhage from the gallbladder fossa or hilar area. Near the
hilum, ongoing bile staining was noted that presumably was
coming from the common duct anastomosis. The hematoma was
evacuated in the pelvis and the abdomen was irrigated thoroughly
with crystalloid solution. Active hemorrhage was not identified.
A moderate amount of blood was also identified behind the spleen
but
there was no active bleeding. Once hemostatis was established,
the patient underwent a takedown choledochocholedochostomy,
conversion to a Roux-en-Y and hepaticojejunostomy.
On [**7-29**], an US was done and the main, right and left portal
veins are patent and demonstrate normal hepatopetal flow with
normal arterial waveforms, including extensive diastolic flow.
The hepatic veins are patent. The common bile duct was not
dilated, measuring 4 mm.
LFTs were initially elevated with AST and ALT peaking on POD1
and trending to normal by POD 9. Alk phos was always less than
200 and T bili peaked at 4.7 on POD 5. Patient remained afebrile
throughout the post op period.
Patient was extubated on POD 2 and remained in ICU until POD 5.
Cholangiogram performed on POD 6 was negative with no evidence
of leak, stricture or biliary duct dilatation.
Fluid volume status in the form of edema was an issue throughout
the hospitalization and lasix was initiated on POD 5 with very
good results. Weight on D/C was 3 kg above admission weight.
Patient was to acquire [**Last Name (un) 10289**] stockings on D/C and was encouraged
to use TEDS and ACE wraps while hospitalized.
Immunosuppresion was per protocol, however there was a mild
elevation of the Prograf level and adjustments were implemented
to a final discharge dose of [**1-4**]. Creatinine slightly above
baseline at 1.5 on discharge.
[**Doctor Last Name 406**] drain was still having high output, so it was left in at
discharge. Pt remained afebrile throughout, BP stable and well
controlled. Blood sugar well controlled on home dose Glipizide.
SS Insulin used in hospital but not required for home as usage
minimal to none while hospitalized.
Pt discharged to home with VNA services and hospital bed for
[**Location (un) 448**] while in the post op period. This was per patient
request as home has narrow stairways.
Pt to follow up in clinic and blood draws per routine.
Medications on Admission:
Lasix 40", Aldactone 25', Glipizide 5'
Discharge Medications:
1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
tab PO DAILY (Daily).
3. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Valcyte 450 mg Tablet Sig: One (1) Tablet PO once a day.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
7. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*28 Patch 24HR(s)* Refills:*0*
8. Glipizide 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
9. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed: Continue as long as you are on pain
medications.
11. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*30 Tablet(s)* Refills:*0*
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
14. Miconazole Nitrate-Zinc Oxide 0.25 % Ointment Sig: One (1)
tube Topical twice a day for 14 days: Wash area and pat dry
gently. Apply twice a day.
Disp:*1 tube* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
Caregroup VNA
Discharge Diagnosis:
liver transplant [**2195-7-28**] for HCV
DMII
Discharge Condition:
stable
Discharge Instructions:
Call[**Telephone/Fax (1) 673**] if fevers, chills, nausea, vomiting, increased
leg swelling, abdominal pain, jaundice or
redness/bleeding/drainage from incision or capped bile tube.
Empty JP drain when half full, record output from JP. bring
Labs every Monday & Thursday for cbc, chem 10, ast, alt, alk
phos, tbili, albumin and trough prograf level. Results fax'd to
[**Telephone/Fax (1) 697**]
Followup Instructions:
Provider: [**Name10 (NameIs) 1344**] [**Last Name (NamePattern4) 3125**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2195-8-13**] 9:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2195-8-13**]
10:00
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2195-8-20**]
7:45
Completed by:[**2195-8-17**]
ICD9 Codes: 5845, 2875, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1150
} | Medical Text: Admission Date: [**2180-10-6**] Discharge Date: [**2180-11-8**]
Date of Birth: [**2104-2-15**] Sex: F
Service: MEDICINE
Allergies:
Naproxen
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
urosepsis; metabolic acidosis
Major Surgical or Invasive Procedure:
endotracheal intubation
placement of PICC
placement of tunneled catheter for hemodialysis
removal of tunneled catheter
History of Present Illness:
76 y/o F with DM, HTN, PVD, afib not on coumadin due to hx of
SDH, CRI who was taken to [**Hospital 6687**] Hosp today for worsening
mental status. +N/V x3 days, + diarrhea on questioning. Initial
VS at scene nml. Here denies any CP, SOB, dyspnea, orthopnea.
Denies any abd pain, CP, HA, visual changes. Not able to relate
any further hx. Denies any new meds, but does not have accurate
history of her meds.
.
On transfer to our ED, her VS were 97.9, HR 93, Bp 143/63, RR
22, 94% on 4L NC. Her RR increased progressively to the 30s, and
she was placed on a NRB for hypoxia. She was given 2 amps
bicarb, 1gram of tylenol and admitted to the MICU in the setting
of her profound acidosis.
Past Medical History:
1. DM II with neuropathy
2. PVD
3. Hypertension
4. Dyslipidemia
5. Atrial fibrillation
6. h/o TB s/p LUL resection [**2129**]
7. h/o Diverticulosis s/p bowel resection [**2169**]
8. Osteoarthritis
9. h/o arrythmia s/p AV node ablation
[**82**]. s/p TAH, s/p c-section
11. s/p spinal surgery
[**84**]. s/p rt. hip surgery
[**85**]. s/p rt. EIA endartectomy with patch angioplasty w dacron
14. s/p b/l foot surgeries
15. SDH s/p mechanical fall
16. Suspected diastolic dysfunction
17. CRI likely due to HTN/DM; baseline 1.6-1.8
18. COPD on home oxygen (no PFTs in OMR)
Social History:
Married and lives with spouse of 26 years; has 2 kids. Reports
smoking (quit 20 years ago), admits to drinking [**12-7**] glasses of
wine with dinner daily.
Family History:
non-contributory
Physical Exam:
Admission exam:
VS: Temp:97.1 BP:111/53 HR:75 RR:16 O2sat: 97% 2L NC
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions
NECK: No jvd
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl. IV/VI systolic murmur at RUSB that
radiates to carotids
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: +LE chronic ulcers with some granulation tissue; some areas
of pus formation. +charcot joints bilaterally. Wrist joints with
arthritis.
NEURO: AAOx2. Moves all ext spont.
discharge exam:
Neuro: LUE 4/5 strength at proximal and distal muscles, [**4-8**]
strength at RUE, 1-2/5 strength in LLE, 3/5 strength in RLE.
Pertinent Results:
labs on admission:
[**2180-10-6**] 05:01PM BLOOD WBC-11.3* RBC-3.46* Hgb-9.8* Hct-31.7*
MCV-92 MCH-28.3 MCHC-30.9* RDW-18.0* Plt Ct-115*#
[**2180-10-6**] 05:01PM BLOOD Neuts-85.8* Lymphs-5.2* Monos-3.7
Eos-5.2* Baso-0.1
[**2180-10-6**] 05:01PM BLOOD PT-13.8* PTT-42.1* INR(PT)-1.2*
[**2180-10-6**] 05:01PM BLOOD Glucose-84 UreaN-86* Creat-6.4*# Na-143
K-3.7 Cl-115* HCO3-7* AnGap-25*
[**2180-10-7**] 05:30PM BLOOD ALT-8 AST-15 LD(LDH)-368* CK(CPK)-363*
AlkPhos-103 TotBili-0.7
[**2180-10-7**] 05:30PM BLOOD CK-MB-12* MB Indx-3.3 cTropnT-0.15*
[**2180-10-7**] 10:59PM BLOOD CK-MB-11* MB Indx-3.7 cTropnT-0.15*
[**2180-10-8**] 05:44AM BLOOD CK-MB-10 MB Indx-4.5 cTropnT-0.16*
[**2180-10-6**] 05:01PM BLOOD Albumin-3.2* Calcium-7.7* Phos-9.2*#
Mg-1.8
[**2180-10-7**] 05:13AM BLOOD calTIBC-156* Ferritn-721* TRF-120*
[**2180-10-6**] 05:01PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
labs on discharge:
[**2180-11-8**]: Na: 142 K: 4.8 Cl: 113 CO2: 18 BUN: 53 Cr: 2.4 glu: 78
Ca: 8.8 Mg: 2.2 P: 5.0
[**2180-11-8**]: WBC: 6.1 Hct: 33.8 Plt: 147
[**2180-11-8**]: PT: 14.8 PTT: 53.1 INR: 1.3
.
CT Head without contrast [**2180-11-4**]: IMPRESSION: No acute
intracranial pathology. Please note that MRI is more sensitive
for the detection of early CVA. If clinically indicated, MRI
with diffusion images could be performed.
.
CT abdomen/pelvis [**2180-10-25**]: IMPRESSION:
1. Large left retroperitoneal hematoma involving the iliopsoas
extends down into the left groin.
2. Unchanged nodular enlargement of the left adrenal gland is
incompletely characterized on this non-contrast CT.
3. Interstitial thickening of the dependent lung bases suggest
volume overload.
.
Portable Abdomen [**2180-10-24**]:IMPRESSION: Right-sided 7 mm renal
stone located overlying the right transverse process of the L4
vertebral body corresponding closely to the right renal stone
identified in the [**2180-6-30**] CT.
.
MRI Brain/Head/Neck [**2180-10-14**]:
FINDINGS: BRAIN MRI:
There are several areas of slow diffusion identified in both
cerebral hemispheres. In the right cerebral hemisphere,
prominent approximately 1-cm area of slow diffusion seen in the
right basal ganglia periventricular region. In addition, several
small subcortical areas of hyperintensity seen, one in the right
periatrial region and the second in right parietal subcortical
region. In addition, small areas of slow diffusion are seen in
the left basal ganglia periventricular region and left parietal
subcortical region. Findings are indicative of multiple acute
infarct, probably from embolic source. There is no midline
shift, mass effect or hydrocephalus. Moderate brain atrophy and
mild-to-moderate changes of small vessel disease are identified.
The suprasellar and craniocervical regions are normal.
.
IMPRESSION: Multiple small acute infarcts in the subcortical
region as described above. Moderate brain atrophy and mild
changes of small vessel disease.
.
MRA OF THE NECK:
Neck MRA somewhat limited by motion demonstrates mild
atherosclerotic disease at both internal carotid origin. No
evidence of high-grade stenosis seen in the internal carotid
carotids. Stenosis is also seen at the origin of the right
external carotid. Both vertebral arteries demonstrate
tortuosity, which could be secondary to cervical spondylosis.
.
IMPRESSION: Mild atherosclerotic at the origin of both internal
carotid arteries. The evaluation is somewhat limited by motion.
.
MRA OF THE HEAD:
The head MRA demonstrates normal flow signal in the arteries of
anterior and posterior circulation. Both middle cerebral artery
bifurcation regions are not visualized on projection images. In
addition, both posterior cerebral arteries are not well
visualized on projection images. However, these vessels are well
visualized on the source images.
IMPRESSION: No significant abnormalities on MRA of the head.
.
Bilateral Duplex LE [**2180-10-14**]: IMPRESSION: No evidence of DVT
involving the right or left lower extremities.
.
CT Head [**2180-10-13**]: IMPRESSION: Evidemce of sinusitis invloving
bilateral sphenoid, left ethmoid sinuses. Opacification of right
mastoid air cells. No acute intracranial pathology, hemorrhage
or masses.
.
ECHO [**2180-10-9**]: The left atrium is dilated. The right atrium is
moderately dilated. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is normal (LVEF>55%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The ascending aorta is mildly dilated.
The aortic valve leaflets are moderately thickened. There is
severe aortic valve stenosis (area <0.8cm2). The left
ventricular inflow pattern suggests impaired relaxation. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2180-1-21**],
the ejection fraction now appears normal. Moderate symmetric
LVH, severe AS and moderate pulmonary artery systolic
hypertension are similar to prior.
.
CT without contrast [**2180-10-8**]:
IMPRESSION:
1. Severe upper lobe predominant interstitial and ground-glass
opacities, with a small simple right pleural effusion and
scattered pathologically enlarged mediastinal lymph nodes.
Differential considerations include hemorrhage, interstitial
pneumonia (either infectious or acute, idiopathic) and
noncardiac edema.
2. Probable calcific aortic stenosis. Severe coronary, aortic
and branch atherosclerosis.
3. Nodular enlargement of the left adrenal gland, which cannot
be further characterized on this study. If clinically indicated,
an MRI or adrenal protocol CT may be considered.
4. Subcentimeter splenic hypodensity, which is also incompletely
characterized.
5. Nasogastric tube terminating in the distal esophagus.
.
Renal U/S [**10-6**]: No hydronephrosis
.
CXR [**10-6**]: Upright AP and lateral views of the chest are
obtained. There is persistent cardiomegaly. Improved aeration at
the left lung base is noted. Mild interstitial prominence is
again noted, which may represent interstitial edema. Mediastinal
contour is unremarkable. Atherosclerotic calcification of the
aortic knob is again noted. No large effusions are present.
Visualized osseous structures are intact. Clips are noted in the
left upper quadrant.
Brief Hospital Course:
76 y/o F with DM, HTN, PVD, afib, hx of SDH, CRI who was taken
to [**Hospital 6687**] Hosp for worsening mental status found to be in ARF
with severe acidosis. Transferred to [**Hospital1 18**] MICU for management.
Hosp course by problem:
.
# Acute respiratory distress: She initially was tachypneic to
compensate for her metabolic acidosis. She then developed
hypoxia and increased work of breathing. She was intubated for
hypoxic respiratory failure. CT chest without contrast showed
bilat infiltrates. Initially, concerning for infectious vs CHF
vs interstitial lung disease. She was started on vanco,
ceftriaxone (also for UTI), and azithro to cover broadly for
infectious causes. She briefly was treated with steroids given
possibility of interstitial pneumonitis however bronch only
showed 1 eosinophil thus this was stopped. She then was
aggressively diuresed and improved dramatically. Thus, much of
her distress was thought secondary to fluid overload given 1)
aggressive IVF resusc in OSH and 2) likely CHF. However, her
sputum grew GNR and ceftriaxone was switched to Zosyn and vanc
was started on [**10-12**] for VAP. Pt was also diuresed with lasix
gtt and iv lasix for pulmonary edema. Vanc was stopped after 8
days as sputum only grew pseudomonas. Zosyn was switched to
Cefepime on [**10-18**] when GNR was identified as pseudomonas (Later,
sensitivities returned sensitive to Zosyn and Cefepime/[**Last Name (un) 2830**]).
Pt was extubated on [**10-17**] and did well. Pt is to have 14 day
course of abx for pseudomonas and last day of Cefepime is [**10-25**].
Pt continued to diurese intermittently with IV lasix which was
switched to po lasix to keep her I/O even. Lasix was temporarily
discontinued when the patient began dialysis, but she was
restarted on lasix when dialysis was stopped. Her oxygen
saturations remained in the mid-90s on room air.
.
# Severe acidosis and acute on chronic renal failure: Acute
onset not entirely clear. She had had poor PO intake, N/V for
several days prior to admit. Her Cr though increased
dramatically from baseline. She also had pH of 7.03 on
presentation. Delta-delta suggested AG (renal failure) and
nonAG (? IVF) acidosis. She received HCO3 in ED and gradually
stabilized. Her Creatinine peaked at 6.8 and trended down once
she diuresed. Acidosis resolved as creatinine improved. The
patient had a tunnelled catheter placed for hemodialysis by
Interventional Radiology and hemodialysis was started for
uremia. She was followed by the renal service, and the decision
was made to stop dialysis, given a return of her creatinine to a
new baseline of 2.5. Her hemodialysis catheter was removed on
[**11-7**] without incident. Following discontinuation of her
hemodialysis, she was started on renagel 1600 tid, and sodium
bicarb 600 mg tid. She has an appointment scheduled with Dr.
[**Last Name (STitle) 4883**] on [**12-28**] at 10:00 AM. Her creatinine remained
stable off dialysis.
.
# Atrial fibrillation: Pt was in sinus at admission and while
intubated. However, post-extubation, pt went into atrial
fibrillation with rapid ventricular response to 140-150s. Pt
was continued on home dose amiodarone which was intermittently
held for ?pulmonary fibrosis and a couple of bradycardia
episodes but was started when AF with RVR occurred. Pt
initially responded to IV/po metoprolol, but later there wasn't
a good rate response. Thus, diltiazem drip and po dilt was
started with HR in 90-100s. EP was consulted and recommended
increasing amiodarone to 400mg [**Hospital1 **] and switching to metoprolol.
Pt was not anticoagulated at home and anticoagulation was not
continued until she suffered a stroke (see below for details)
and then anticoagulation was started.Her amiodarone was
decreased back to 400 mg qd and her diltiazem was titrated up to
60 mg qid. Her heart rate was better controlled on this regimen
in the 60s-80s, with occasional return to sinus rhythm; however,
she continued to have bursts up to the 120s. Anticoagulation is
discussed below regarding her retroperitoneal bleed. Her
amiodarone will have to be reduced to 200 mg qd in 1 week.
.
# Embolic stroke: On [**10-13**], pt was noted to have L sided weakness
with L facial droop. Stat head CT was obtained and neuro was
consulted. CT did not reveal acute processes, but MRI later
recommended by neuro whose suspicious was high for R MCA stroke
showed R caudate stroke. Pt was started on Argatroban initially
as there was a concern for HIT as plts were trending down and
with new stroke in the setting of NSR. HIT came back negative,
and argatroban was switched to heparin and plts continued to
rise. Patient's strength continued to improve during her
hospital stay. Neuro exam on discharge revealed 4/5 strength in
the LUE, 5/5 strength in the RUE, 2/5 strength in LLE, [**2-7**]
strength in RLE.
.
#. Retroperitoneal bleed: Patient had acute RP bleed, with a Hct
drop of 15 points, while on heparin gtt for acute embolic stroke
during her course in the ICU. Since RP bleed, the patient had
been off of anticoagulation. She was monitored closely for back
and flank pain, and her hematocrit was monitored closely,
without subsequent drops. Heparin gtt was restarted on [**11-3**],
with a goal PTT of 40-60, until patient proved stable (had
retroperitoneal bleed as below) her PTT goal was then increased
to 60-80. She was started on coumadin 2.5 on [**11-7**]. Her INR on
day of discharge was 1.3, and she will need to continue on the
heparin gtt until her INR is therapeutic. She will need INR
levels closely monitored. She will need to be monitored for
back/flank pain and hematocrit drop to watch for recurrence of
her RP bleed. Also, patient has been transiently guaiac positive
with brown stools, now resolved. Also, anemia due to chronic
renal insufficiency treated with procrit.
.
# Thrombocytopenia: Likely due to marrow suppression in setting
of ARF and UTI. When pt suffered a stroke, HIT was sent and
argatroban was started. Later, HIT came back negative. Her
platelets were closely monitored.
.
# Cards CHF: Echo showed no diastolic or systolic function.
However, she was thought profoundly fluid overloaded. She
responded to diurel and lasix 80 then was placed on lasix gtt
for 1 day. Good UOP then auto-diuresed well. The patient was
restarted on lasix 40 qd after her hemodialysis was
discontinued.
.
# Cards vessels: trop leak thought [**1-7**] demand ischemia. No new
wall motion abnl. Pt was started on lipitor when stroke was
found. The patient wsa maintained on telemetry, and denied chest
pain.
.
# UTI: [**Last Name (un) 36**] to ceftriaxone. received 7 d course. Yeast was
found in her urine and she completed a 14 day course of
fluconazole.
.
# LE Ulcers: The patient has bilateral lower extremity ulcers on
her feet.
Unclear etiology; per old notes has ? hx of paraproteinuria vs
diabetic neuropathy, Wound care was consulted, and dressed her
ulcers. Podiatry also came to see her ulcer, and indicated that
no new acute surgery was necessary. Nutrition was encouraged to
promote wound healing. She will need qod dressing changes on
her feet, and her ulcers should be considered if she an increase
in her temperature.
.
#. Urinary yeast infection: many yeast on UA. UCx [**10-21**] no
growth. Fluconazole was completed with a 14 day course.
.
#. s/p Pseudomonas pneumonia: Patient afebrile, leukocytosis
resolving, good sat on room air, no dyspnea. s/p 2 week course
of cefepime. Follow up chest x-ray shows pulmonary vascular
congestion without obvious infiltrate.
.
#. DM: Her diabetes mellitus was managed with a sliding scale
insulin regimen with fingersticks 4 times daily.
.
#. Hypernatremia: The patient was found to be hypernatremic and
fluid boluses were initiated. With the start of hemodialysis,
hypernatremia resolved and fluid boluses were stopped; however,
when hemodialysis was discontinued, fluid was gently restarted.
.
FEN: TF started [**10-9**]. When it was felt that the patient could
take adequate PO, tube feeds were stopped andd she was seen by
the speech and swallow team. Her diet was slowly advanced to
thin liquids and soft foods. Pt's intake towards the end of her
hospital course was improved, however not entirely adequate. She
refused an NG tube or PEG tube.
.
Access: PICC
.
Prophylaxis: The patient was started on subcutaneous heparin for
prophylaxis initially, then, heparin gtt was started when it was
felt that her retroperitoneal bleed was stable. She was started
on a proton pump inhibitor for ulcer prophylaxis.
.
Code: Full Code confirmed on multiple occasions during the
[**Hospital 228**] hospital stay.
Medications on Admission:
Amio 200 qD
Calcitriol 0.25
Zoloft 100
Senna [**Hospital1 **]
Synthroid 25mcg
Zyprexa 2.5 qD
Folic Acid/Thiamine/MVI
Ambien qhs
Percocet prn
Toprol XL 50
Norvasc 5
PPI 40
Humalog SS
Coumadin 5
Lasix 20 qOD
.
Allergies: Naproxen --> renal toxicity
Discharge Medications:
1. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed. Tablet(s)
2. Insulin Lispro 100 unit/mL Solution [**Hospital1 **]: One (1) insulin per
sliding scale Subcutaneous ASDIR (AS DIRECTED).
3. Sertraline 50 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
4. Levothyroxine 25 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
5. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
6. Thiamine HCl 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
8. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
9. Hexavitamin Tablet [**Hospital1 **]: One (1) Cap PO DAILY (Daily).
10. Atorvastatin 40 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
11. Miconazole Nitrate 2 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
12. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) nebulizer
inhalation Inhalation Q6H (every 6 hours) as needed.
13. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID
(3 times a day) as needed.
14. Olanzapine 5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily).
15. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
16. Sevelamer 800 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID W/MEALS
(3 TIMES A DAY WITH MEALS).
17. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: Two (2) Tablet PO QID
(4 times a day): hold for sbp <90 or HR <55.
18. Amiodarone 200 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
19. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
20. Diltiazem HCl 60 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4
times a day): hold for sbp <100 .
21. Zolpidem 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
22. Epoetin Alfa 4,000 unit/mL Solution [**Last Name (STitle) **]: One (1) injection
4000 units/mL Injection QMOWEFR (Monday -Wednesday-Friday).
23. Furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
24. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
25. Sodium Bicarbonate 650 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID
(2 times a day).
26. Calcium Acetate 667 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
27. Warfarin 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
28. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
[**Last Name (STitle) **]: One (1) sliding scale asdir Intravenous ASDIR (AS
DIRECTED): until INR therapeutic. please titrate ptt to target
60-80.
29. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands
Discharge Diagnosis:
Primary diagnoses:
Ventilator associated pneumonia
Acute on chronic renal failure
Metabolic acidosis
Atrial fibrillation with rapid ventricular response
Valvular and acute diastolic heart failure
Cardioembolic right basal ganglia stroke - left hemiparesis.
Retroperitoneal bleed
Blood loss anemia
Anemia of chronic kidney disease
[**Female First Name (un) 564**] UTI
Rectal bleeding
Secondary diagnoses:
Chronic kidney disease stage IV
COPD on home oxygen
Diabetes mellitus type II
Hypertension
Hypercholesterolemia
Atrial fibrillation
SDH s/p mechanical fall
Mod/Severe aortic stenosis
Osteoarthritis
AV node ablation
s/p TAH, s/p c-section
s/p spinal surgery
s/p right hip surgery
s/p b/l foot surgeries
h/o TB s/p LUL resection [**2129**]
h/o Diverticulosis s/p bowel resection [**2169**]
Right CFA below-knee popliteal artery bypass graft
Endarterectomy of right internal iliac artery and Dacron patch
Severe peripheral neuropathy and PVD s/p bilateral foot
reconstruction
Discharge Condition:
fair
Discharge Instructions:
You were admitted to the hospital and had a long hospital stay.
You were initially placed in the ICU. You had a stroke, and
blood thinners were started initially, but after developing a
bleed, the blood thinners wre temporarily stopped. They were
restarted when it was felt that it was stable. You also had a
pneumonia and you were given antibiotics. Furthermore, your
kidneys had failure, and you were followed by the renal team and
started on hemodialysis, which was discontinued when your renal
function remained stable. Your medications were monitored
carefully and you will need assistance with your medications.
You will remain on the heparin drip until you are appropriately
anticoagulated. Then, you will only have to take warfarin
(coumadin) for anticoagulation.
.
You should call your primary care doctor, or return to the
emergency room with any new symptoms of chest pain, shortness of
breath, fever >101.4 F, any new weakness, or any other symptoms
which are concerning to yuo.
Followup Instructions:
You have an appointment with Dr. [**Last Name (STitle) 4883**] (renal). Provider:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2180-12-27**] 10:00.
Please call if you are unable to keep this appointment.
Completed by:[**2180-11-8**]
ICD9 Codes: 5849, 2762, 4280, 4241, 4168, 3572, 496, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1151
} | Medical Text: Admission Date: [**2127-12-23**] Discharge Date: [**2127-12-26**]
Date of Birth: [**2073-7-26**] Sex: M
Service: MEDICINE
Allergies:
Vicodin / Erythromycin Base
Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
chest pain, STEMI
Major Surgical or Invasive Procedure:
left heart catheterization and balloon angioplasty
History of Present Illness:
54yo male with past medical history significant for coronary
artery disease s/p multiple interventions including CABG in
[**2118**], htn, hld who is presenting with STEMI. The patient reports
that he was standing in his kitchen at rest this afternoon
around 4pm and he had sudden onset of chest pressure, which is
how his angina always presents. He took nitroglycerin x4 and the
chest pain did not improve, so he called EMS.
.
Upon arrival of EMS, the patient was given nitro and aspirin. He
was taken to OSH, where EKGs were done and the decision was made
to transfer to [**Hospital1 18**]. On arrival to the cath lab, he reported
his pain as [**4-13**]. In the cath lab, the patient had balloon
angioplasty of the TCA but no placement of stent. There was
thrombosis of the distal RCA that was refractory to balloon
angioplasty, despite IV heparin, IV integrillin and prasugrel.
The final injection showed TIMI 1 flow into the distal vessel
and ST segment elevation consistent with continued inferior wall
STEMI. His CP was [**6-13**].
.
The patient reports that he has been in his baseline state of
health since [**Month (only) 116**], when he was experiencing increasing anginal
symptoms and so he had repeat coronary angiography, done as an
outpatient, where he was found to have severe in stent
restenosis of the RCA and had DES placed. Since that time, he
has had much improved symptoms and has been able to keep up with
his exercise regimen of walking 2miles 5 days a week at a speed
of [**3-7**] miles per hour. On Friday, 4 days prior to presentation,
the patient noted that he was "at the edge of his exertion"
while he was doing his 2 mile walk. By this he means that if he
had increased his speed, he would have had angina, but since he
maintained his speed, he was not having angina. On Sunday, 2
days prior to presentation, the patient had acute onset of chest
pain and realized he had forgotten to take his am meds, so he
took them and he took one nitroglycerin and felt resolution of
the pain.
.
In the CCU, the patient reports 2/10 chest pain, denies dyspnea.
.
On review of systems, he denies any prior history of stroke,
deep venous thrombosis, pulmonary embolism, bleeding at the time
of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CABG: [**2118-4-6**]: LIMA -> LAD, SVG -> rPDA, SVG -> diagonal, SVG
-> ramus, left radial -> OM
[**2118-9-16**] PTCA and beta-brachytherapy of VG -> PDA
[**2-6**] s/p PTCA/beta-brachytherapy of the SVG->PDA
- PERCUTANEOUS CORONARY INTERVENTIONS:
-[**2117**]: IMI treated with retavase and overlapping proximal RCA
stents and distal RCA stent
-[**6-/2120**] s/p rotational atherectomy of the mid RCA and stenting
with two Taxus DES 3.0 x 12mm in the distal RCA with an
overlapping
3.0 x 24mm Taxus.
- [**5-/2127**] focal severe in-stent restenosis in the right coronary;
Drug-eluting stent (3.5 x 12 mm dilated to 3.75 mm).
- PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Anxiety/depression
Low back pain (resolved)
Left ankle fracture with surgery
Elbow fracture with surgery
? TIA word finding difficulty, micrographia after receiving
retavase.
Social History:
Divorced, has 3 kids- son, 22 has substance abuse issues;
daughter, 20, is at [**Hospital1 498**] [**Location (un) 5169**]; son, 17 is honors high school
student.
Occupation: Electrical Engineer; went out on disability several
years ago.
Tobacco: Quit [**2100**] (smoked 1-2ppd x7 years)
ETOH: quit 20 yrs
Recreational drug use: denies
Family History:
mother died at age 85 [**2-5**] Parkinson's disease. Dad died in his
40's from liver disease. Brother- died in his 60s from chronic
inflammatory demyelinating polyneuropathy. Sister- breast
cancer, obesity. Sister-depression.
3 children healthy.
Physical Exam:
ADMISSION EXAM:
.
VS: T=AF BP= 92/54 HR=65 RR=14 O2 sat= 98% 2L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP at clavicle.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
.
[**2127-12-23**] 07:50PM BLOOD WBC-8.7# RBC-3.86* Hgb-11.6* Hct-34.3*
MCV-89 MCH-30.0 MCHC-33.8 RDW-12.8 Plt Ct-187
[**2127-12-23**] 07:50PM BLOOD PT-12.3 INR(PT)-1.1
[**2127-12-23**] 07:50PM BLOOD Glucose-107* UreaN-14 Creat-0.9 Na-138
K-4.0 Cl-110* HCO3-21* AnGap-11
.
PERTINENT LABS AND STUDIES:
.
[**2127-12-23**] 07:50PM BLOOD CK(CPK)-84
[**2127-12-24**] 03:07AM BLOOD CK(CPK)-364*
[**2127-12-24**] 04:45PM BLOOD CK(CPK)-1084*
[**2127-12-24**] 03:07AM BLOOD CK-MB-44* MB Indx-12.1* cTropnT-0.27*
[**2127-12-24**] 08:50AM BLOOD CK-MB-90* cTropnT-0.68*
[**2127-12-24**] 04:45PM BLOOD CK-MB-105* MB Indx-9.7* cTropnT-1.28*
.
[**2127-12-24**] ECHOCARDIOGRAM The left atrium is elongated. Left
ventricular wall thickness, cavity size, and global systolic
function are normal. There is mild regional left ventricular
systolic dysfunction with mild hypokinesis of the basal to mid
inferior wall. The remaining segments contract normally (LVEF =
55 %). 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 structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
.
IMPRESSION: Mild regional left ventricular systolic function
with preserved left ventricular ejection fraction. Mild mitral
regurgitation. Mild pulmonary hypertension.
Brief Hospital Course:
This is a 53 year-old Male with past medical history significant
for CAD s/p CABG and multiple PCIs, p/w STEMI s/p DES to RCA
with poor flow after stenting ho presented with ST-elevation
myocardial infarction and underwent cardiac catheterization.
.
ACUTE CARE:
.
# CORONARY ARTERY DISEASE - The patient has had multiple PCIs
and is s/p CABG. He had a left heart catheterization with
balloon angioplasty of the RCA at the time of admission without
placement of stent, he was medically managed. He was treated
with Heparin gtt, Integrillin gtt, Pprasugrel and Aspirin. His
integrillin and heparin infusions were discontinued following
his catheterization. A 2D-Echo showed mild regional left
ventricular systolic dysfunction with mild hypokinesis of the
basal to mid inferior wall (LVEF 55%). We did decreased his
Lisinopril from home dose of 40 mg to 10 mg this admission and
stopped his Plavix and decided to utilize Prasugrel.
.
CHRONIC CARE:
.
# HYEPRTENSION - We continued home Lisinopril but at 10 mg daily
and resumed his Metoprolol medication.
.
# HYPERLIPIDEMIA - Continued Atorvastatin 80 mg PO daily.
.
ISSUES OF TRANSITIONS IN CARE:
1. Exchanged Plavix for Prasugrel for anti-platelet therapy.
2. Will follow-up with outpatient Cardiologist and primary care
physician.
3. At the time of discharge, the patient had no pending
radiologic studies, labroatory studies, or microbiologic data.
Medications on Admission:
1. NTG 0.4mg tablet SL prn chest pain
2. aspirin 325mg daily,
3. Plavix 75 mg daily,
4. lisinopril 40 mg daily,
5. Atorvastatin 80mg daily
6. Toprol-XL 200 mg daily.
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual as directed as needed for chest pain: Take 1 capsule
x3, separated by 5 minutes.
3. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. prasugrel 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. metoprolol succinate 200 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:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
1. Acute ST-elevation myocardial infarction
.
Secondary Diagnoses:
1. Hypertension
2. Hyperlipidemia
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 [**Hospital1 18**] for a heart attack that was caused by
a blockage in your right coronary artery. As you know, you did
not have placement of another stent in your coronary artery but
the artery was opened with a balloon. Your chest pain improved
with medical management and you will continue to follow with
your cardiologist and to take medications for your heart.
Please note the following changes to your medications:
1. STOP taking plavix, take prasugrel instead to prevent
blockages in your heart arteries
2. Decrease lisinopril to 10 mg daily instead of 40 mg.
Please be sure to follow up with your physicians.
Followup Instructions:
.
Department: CARDIAC SERVICES
When: MONDAY [**2128-3-15**] at 10:20 AM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Name: [**Last Name (LF) 28295**], [**First Name3 (LF) **] PA.
Location: [**Hospital1 **] PRIMARY CARE
Address: [**Street Address(2) 25171**], [**Location (un) **],[**Numeric Identifier 3862**]
Phone: [**Telephone/Fax (1) 25161**]
When: Tuesday, [**2126-1-6**]:15 AM
*[**Doctor First Name **] is covering for Dr. [**Last Name (STitle) **].
Department: CARDIAC SERVICES
When: MONDAY [**2128-2-9**] at 2:20 PM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4019, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1152
} | Medical Text: Admission Date: [**2168-7-2**] Discharge Date: [**2168-7-5**]
Date of Birth: [**2105-6-4**] Sex: F
Service: [**Year (4 digits) 662**]
Allergies:
Haldol / Darvon
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Patient is a 63 y/o F with history of hep C/ETOH cirrhosis with
multiple admissions for AMS who presents here with altered
mental status. At nursing home, she was found to have altered
mental status and was sent to an outside hospital where a UA was
positive, chest xray and head CT were negative. She was given 1
dose of levaquin at the outside hospital. She was transferred
here and her UA was positive and a CXR shows mild pulmonary
edema.
She has had several recent admissions for altered mental status.
Most recently [**Date range (1) 99384**] she was here with AMS and underwent
an infectious workup with negative results. CT of the head was
performed which was unremarkable. She underwent abdominal
ultrasound which did show patent TIPS. During hospital course,
she had no signs of active GI bleeding. Her hematocrit was
stable and she was not transfused. The patient was continued on
Lactulose and Rifaximin, as well as Zyprexa. She was also
admitted [**Date range (1) 99382**] for mental status
changes requiring intubation for airway protection. She was
treated for hepatic encephalopathy with increased lactulose
doses w/ improvement in her mental status.
In the ED, her vitals signs were Tm 100 BP 100/49 HR 79 sat97%
2LNC RR14. No ascites to tap for dxtic. She was given nalaxone,
as her tox screen was positive opiods and a mild improvement in
her mental status. UA was positive. Received a dose of
Vancomycin 1gm IV.
While in the MICU she was treated with Ciprofloxacin for urinary
tract infection, and lactulose/rifaximin for hepatic
encephalopathy. She remained hemodynamically stable upon
transfer to the floor.
Past Medical History:
1) Iron deficiency anemia
2) GI bleed - hemorrhoids, s/p TIPS; also w/ known portal
gastropathy
3) Sigmoid diverticulosis
4) Schatzki's ring
5) Duodenal polyps and duodenitis
6) MGUS
7) ?Etoh/ HCV cirrhosis with recurrent hepatic encephalopathy
8) Psychotic disorder on olanzapine
9) polysubstance abuse - etoh, cocaine, marijuana
10) COPD
11) temporal lobe epilepsy (per daughter no seizure in 30 yrs)
12) subcutaneous variceal rupture s/p hematoma exploration in
LLQ
13) Chronic kidney disease (baseline Cr ~1.4)
14) Fractures: clavicle and pubic rami
Social History:
Lives in nursing home. History of tobacco, EtOH and drug abuse.
She is originally from [**State 3908**]. She worked as an administrative
assistant when she was younger, but is now on SSDI (for
?schizophrenia and seizure disorder). Patient's daughter,
[**Name (NI) 4850**], is involved in care.
Family History:
Mother: asthma, grandmother with diabetes, HTN. No family
history of liver disease or bleeding disorders. Great aunt with
epilepsy.
Physical Exam:
Vitals - T: BP:137/57 HR:84 RR: 02 sat: 96 2L
GENERAL: laying in bed, NAD, tangential in thought
SKIN: no jaundice
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no m/r/g
LUNG: CTAB
ABDOMEN: patient refused exam
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
NEURO: CN II-XII intact
Pertinent Results:
Admission Labs:
[**2168-7-2**] 07:44PM LACTATE-1.4
[**2168-7-2**] 04:25PM GLUCOSE-94 UREA N-36* CREAT-2.2* SODIUM-139
POTASSIUM-4.8 CHLORIDE-109* TOTAL CO2-14* ANION GAP-21*
[**2168-7-2**] 04:25PM estGFR-Using this
[**2168-7-2**] 04:25PM CK(CPK)-229*
[**2168-7-2**] 04:25PM cTropnT-0.11*
[**2168-7-2**] 04:25PM CK-MB-13* MB INDX-5.7
[**2168-7-2**] 04:25PM WBC-7.2 RBC-3.63*# HGB-11.1*# HCT-35.8*#
MCV-99* MCH-30.5 MCHC-30.9* RDW-15.9*
[**2168-7-2**] 04:25PM NEUTS-75.1* LYMPHS-16.0* MONOS-7.0 EOS-1.7
BASOS-0.2
[**2168-7-2**] 04:25PM PLT COUNT-140*
[**2168-7-2**] 04:25PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2168-7-2**] 04:25PM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-4* PH-5.0 LEUK-MOD
[**2168-7-2**] 04:25PM URINE RBC-21-50* WBC-[**6-21**]* BACTERIA-MOD
YEAST-NONE EPI-[**3-16**]
[**2168-7-2**] 04:25PM URINE HYALINE-[**3-16**]*
Pertinent Labs/Studies:
Trop: .11 -> .2 -> .13
CK: 229 -> 505 -> 192
Cr: 2.2 -> 2.4 -> 1.8 -> 1.1
Radiology:
ECG ([**7-2**]): Sinus tachycardia. Delayed R wave transition.
Compared to tracing #1 there is now an R wave in lead V2. This
may represent altered lead placement. Clinical correlation is
suggested
CXR ([**7-2**]): Mild pulmonary edema, similar to that seen on
[**2168-6-1**].
CXR ([**7-4**]): Mild worsening of pulmonary edema is seen, mainly
in the periphery of both lungs, left more than right.
U/S Abd/Pelvis ([**7-2**]): Patent TIPS. Velocities appear
appropriate although accuracy is diminished due to patient
motion. No evidence of ascites. Gallbladder sludge and stones.
No ultrasonic evidence of cholecystitis.
.
Micriobiology:
Urine cultures: [**2168-7-2**] : <10,000 organisms/ml.
Blood cultures: [**2168-7-2**] + [**2168-7-3**]: No growth
Discharge Labs:
[**2168-7-5**] 09:00AM BLOOD WBC-3.8* RBC-3.27* Hgb-10.0* Hct-30.6*
MCV-94 MCH-30.6 MCHC-32.7 RDW-16.3* Plt Ct-151
[**2168-7-5**] 09:00AM BLOOD Glucose-130* UreaN-26* Creat-1.1 Na-135
K-4.7 Cl-110* HCO3-17* AnGap-13
[**2168-7-4**] 05:05AM BLOOD CK(CPK)-192*
[**2168-7-5**] 09:00AM BLOOD Mg-1.3*
Brief Hospital Course:
Mrs. [**Known lastname **] is a 63 yo female with history of HepC/ETOH
cirrhosis, history of prior substance abuse, and recurrent
hepatic encephalopathy, who presents with altered mental status.
.
#. Altered Mental Status: Patient was found by nursing home to
have altered mental status on [**2168-7-2**]. On admission to OSH,
patient's U/A had large blood, moderate leukocytes, and moderate
bacteria. Patient also had a toxicology screen which was
positive for opioids. Review of med list from extended care
facility does not reveal opiod use, it is not clear where or
when patient received narcotics prior to admission to [**Hospital1 18**]. At
OSH, the patient was given one dose of Levoquin and naloxone,
after which she had some improvement in her mental status. On
admission to [**Hospital1 18**], patient received three doses of
Ciprofloxacin, was restarted on her home dose of lactulose and
rifaximin, and received IV hydration for treatment of acute
renal failure as the team thought her mental status change could
be related to dehydration, hepatic encephalopathy, or her UTI.
With above interventions the patient's mental status improved
and she is currently back to her baseline, oriented x 2, often
tangential in thought.
.
#. Acute Renal Failure: Patient's Cr was elevated from baseline
of 1.2 to 2.4 on admission. The patient appeared hypovolemic and
received two boluses of IV fluids, as the team believed her ARF
was caused by dehydration in the setting of lactulose
administration, diuresis and poor PO intake. The patient's Cr
returned to her baseline of 1.1 with volume resuscitation and
holding diuretics. On discharge the patient's diuretics have
been held. Would recommend daily weights with the reinitiation
of Lasix 10 mg daily if the patient has a weight gain of [**2-14**]
pounds or clinical evidence of fluid overload.
.
#. Urinary Tract Infection: Patient was found to have a positive
urine analysis upon admission to the OSH. She was given one
dose of Levoquin before transfer to [**Hospital1 18**]. Upon admission at
[**Hospital1 18**], patient completed a course of 500 mg of Ciprofloxacin PO
q24h (i.e. 3 days) although of note her urine culture <10,000
bacteria.
.
#. Cirrhosis: Patient has a history of HCV cirrhosis with
history of recurrent hepatic encephalopathy. She is s/p TIPS
for GI bleeding and portal gastropathy. Patient was continued
on her previous regimen of lactulose, rifaximin, and ursodiol.
Her LFTs remained stable throughout this admission and was
treated for encaphalopathy as above.
.
#. Iron deficiency anemia: On review of her records, patient is
known to have a history of iron deficiency anemia, most likely
secondary to known portal hypertensive gastropathy and internal
hemorrhoids on recent EGD/Colonoscopy. On this admission, her
Hct remained stable and she did not require any blood
transfusions.
.
#. Seizure disorder: On review of her records, patient has a
history of a seizure disorder, which has been well controlled on
her outpatient medications. Patient was continued on
Levetiracetam and had no acute events while in the hospital.
.
#. Psychiatry: Patient has a history of psychosis, possibly due
to schitzophrenia per chart review. She was continued on her
outpatient regimen of olanzapine with return to baseline mental
status as above
.
#. Code Status: FULL CODE
Patient was previously listed as DNR/DNI last admission after
discussion with attending on record. This admission the
patient's daughter/HCP wished to readdress this decision and
after discussion with family members made decision that she
would like the patient's code status to be changed to FULL CODE
at this time. This was discussed extensively with the patient's
daughter including current health status, chronic disease and
prognosis. After conversation the patient's daughter still
reported she wanted to maintain full code status
Medications on Admission:
1. Acetaminophen 325 mg 1-2 Tablets PO Q8 PRN Not to exceed
2gm/day.
2. Milk of Magnesia Oral
3. Bisacodyl 5 mg once a day as needed for constipation.
4. Levetiracetam 500 mg PO twice daily.
5. Metoprolol Tartrate 100 PO 2 times a day
6. Ursodiol 300 mg PO 2 times daily
7. Olanzapine 5 mg PO BID
8. Ferrous Sulfate 325 mg DAILY
9. Rifaximin 600 mg 2 times a day
10. Hexavitamin Daily
11. Omeprazole 20 mg daily
12. Diphenhydramine HCl 12.5 mg/5 mL q6h as needed for pruritis
13. Menthol-Cetylpyridinium 3 mg as needed
14. Aranesp (Polysorbate) 25 mcg/mL one injection weekly
15. Ipratropium Bromide 0.02 % q6h as needed for shortness of
breath
16. Lactulose 10 gram/15 mL 60 ML PO four times a day: Titrate
to maintain 4-6BMs per day.
17. Calcium Carbonate 500 mg twice daily
18. Cholecalciferol (Vitamin D3) 400 unit Twice daily
19. Furosemide 10mg daily
20. Olanzapine 5 mg Tablet, Rapid Dissolve q6h for agitation
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Milk of Magnesia 400 mg/5 mL Suspension [**Hospital1 **]: Five (5) PO
once a day as needed for constipation.
3. Bisacodyl 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day as
needed for constipation.
4. Levetiracetam 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
5. Metoprolol Tartrate 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO
twice a day.
6. Ursodiol 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times
a day).
7. Olanzapine 2.5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times
a day).
8. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained
Release [**Hospital1 **]: One (1) Capsule, Sustained Release PO once a day.
9. Rifaximin 200 mg Tablet [**Hospital1 **]: Three (3) Tablet PO BID (2 times
a day).
10. Multivitamin Capsule [**Hospital1 **]: One (1) Capsule PO once a day.
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. Aranesp (Polysorbate) 25 mcg/mL Solution [**Hospital1 **]: One (1) ml
Injection once a week: Please continue as previous.
13. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1)
nebulization Inhalation every six (6) hours as needed for
shortness of breath or wheezing.
14. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO TID (3
times a day): Please titrate for [**3-15**] BMs/day.
15. Calcium Carbonate 500 mg Tablet, Chewable [**Month/Day (3) **]: One (1)
Tablet, Chewable PO TID (3 times a day).
16. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Month/Day (3) **]: One (1)
Tablet PO twice a day.
17. Olanzapine 5 mg Tablet, Rapid Dissolve [**Month/Day (3) **]: One (1) Tablet,
Rapid Dissolve PO every six (6) hours as needed for agitation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care - [**Hospital1 **]
Discharge Diagnosis:
Primary:
Altered mental status
Hepatic Encephalopathy
Acute Renal Failure
Urinary Tract Infection
.
Secondary Diagnoses:
Iron deficiency anemia
H/o recurrent GI bleed - grade 4 rectal varices, s/p TIPS [**11-18**];
also w/ known portal gastropathy
Sigmoid diverticulosis
Schatzki's ring
Duodenal polyps and duodenitis
MGUS
Etoh/ HCV cirrhosis
Psychotic disorder on olanzapine
Polysubstance abuse - etoh, cocaine, marijuana
COPD
Temporal lobe epilepsy (per daughter no seizure in 30 yrs)
Discharge Condition:
Good. Patient's mental status is currently at baseline. Her
acute renal failure has resolved.
Discharge Instructions:
Please take all medications as prescribed.
.
Please keep all outpatient appointments as scheduled.
.
Please return to the hospital if you experience any increase in
confusion, fevers, chills, difficulty breathing, or any other
concerning symptoms.
Followup Instructions:
Please keep following scheduled appointments:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2168-8-2**] 1:10
Provider: [**Name10 (NameIs) **] GATES, RNC MSN Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2168-8-2**] 1:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2168-8-19**] 9:00
Completed by:[**2168-7-5**]
ICD9 Codes: 5849, 5990, 2762, 5859, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1153
} | Medical Text: Admission Date: [**2141-4-6**] Discharge Date: [**2141-4-11**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
86 yo Iranian (farsi speaking) male with h/o COPD (on home o2
(uses 2-3h qdaily of home o2 overall), HTN, restless leg
syndrome, h/o anemia (prior studies showing thalesemia) and BPH
presenting today with 2 days symptoms of SOB and AMS. Per
daughter and pt - pt was in his USOH till 2 days prior - started
having increasing SOB along with new cough with increasing
sputum production, no f/c, no cp, no HA, ab pain, n/v, but +
constipation - along with sob sx - pt with decreasing po intake
- noted decreased urinary production yesterday with darker urine
- today in ED with increased intake has finally increased
production. Pt denies any recent changes in urination prior -
BPH controlled without sx of dribbing, urgency, change of
frequency till just yesterday. In terms of mentation - pt also
has been having mild increased confusion - usually AA0x3 - only
x2 now with process as above.
<br>
In [**Name (NI) **] pt initially 91% on RA - noted pt usually uses o2 3h/day -
but using more frequency past couple days without response.
Also noted pt having increased fatigue and generalized weakness
past couple days without ambulation - at baseline can ambulate
(+/- can/walker at times). Pt noted afebrile in ED - given
nebs, IV solumedrol and dose of levoquin IV and admitted for
copd exacerbation.
<br>
Review of systems:
.
Constitutional: No weight loss/gain, +fatigue, malaise, fevers,
chills, rigors, night sweats, anorexia.
HEENT: +chronic loss of vision, no photophobia. No dry motuh,
oral ulcers, bleeding nose or [**Male First Name (un) **], tinnitus, or sinus pain.
Cardiac: No chest pain, palpitations, LE edema, orthopnea, PND,
but + DOE.
Respiratory: +SOB, NO pleuritic pain, no hemoptysis, + cough.
GI: No nausea, vomiting, abdominal pain, abdominal swelling,
diarrhea, but notable for + constiatpion, no hematemesis,
hematochezia, or melena.
Heme: No bleeding, bruising.
Lymph: No lymphadenopathy.
GU: +per HPI.
Skin: No rashes, pruritius.
Endocrine: No change in skin or hair, no heat or cold
intolerance.
MS: No myalgias, arthralgias, back or nec pain.
Neuro: No numbness, weakness or parasthesias. No dizziness,
lightheadedness, vertigo. No confusion or headache. but
positive pains in LE from restless leg - controlled with home
meds
Psychiatric: No active depression or anxiety.
Past Medical History:
COPD - uses prn home o2
Restless Leg Syndrome
HTN
CKD Stage III based on review of labs this admission (baseline
1.8-2.0)
Depression
Knee Replacement
Macular Degeneration
BPH
Thalasemia
Social History:
Lives at home with wife, daughter lives on floor below.
Heavy Tobacco history, 70 years smoking, quit few years ago.
no etoh, no drugs
Family History:
NC - no CAD, but + h/o COPD in family.
Physical Exam:
Exam
VS T current 99.2 BP 120/59 HR 105 RR 20 O2sat: 96% 4L
o2nc
Gen: In NAD.
HEENT: PERRL, EOMI. No scleral icterus. No conjunctival
injection. Mucous membranes moist. No oral ulcers.
Neck: Supple, no LAD, no JVP elevation.
Lungs: +prolonged exp phase with end exp wheezing - mild-mod
tight airflow
CV: RRR, +[**2-24**] HSM at apex, no r/g
Abdomen: soft, NT, ND, NABS
Extremities: warm and well perfused, no cyanosis, clubbing,
+trace pedal edema
Neurological: alert and oriented X 2 - baseline aa0x3 of note
per daughter in room, CN [**Name (NI) 12428**] intact. Notable that pt well
alert - no evidence of somnulance
Psychiatric: Appropriate.
GU: deferred.
Pertinent Results:
[**2141-4-6**] 09:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
<br>
[**2141-4-6**] 10:00AM LACTATE-1.1
[**2141-4-6**] 09:50AM BLOOD WBC-11.6* RBC-4.79 Hgb-9.1* Hct-32.0*
MCV-67* MCH-19.1* MCHC-28.6* RDW-16.5* Plt Ct-209
[**2141-4-6**] 09:50AM BLOOD Neuts-79.6* Lymphs-13.3* Monos-5.1
Eos-1.8 Baso-0.2
[**2141-4-9**] 05:00AM BLOOD WBC-8.4 RBC-4.45* Hgb-8.9* Hct-28.8*
MCV-65* MCH-20.0* MCHC-30.9* RDW-17.5* Plt Ct-176
[**2141-4-7**] 02:00PM BLOOD Type-ART pO2-69* pCO2-105* pH-7.16*
calTCO2-40* Base XS-4 Intubat-NOT INTUBA
[**2141-4-8**] 12:15PM BLOOD Type-ART pO2-69* pCO2-70* pH-7.31*
calTCO2-37* Base XS-5
Admisson CXR:
PA AND LATERAL CHEST RADIOGRAPH: Lungs are clear. There is no
consolidation, effusion or pneumothorax. Trace pleural
thickening is seen in the major fissure on lateral film, likely
right sided. A small calcified nodule in the right mid lung
likely reflects a granuloma. Hilar and cardiomediastinal
contours are unchanged. The aorta is tortuous. There is no
evidence for volume overload. There is degenerative change in
the thoracic spine, with unchanged wedge deformity of a mid
thoracic vertebral body. There are no suspicious lytic or
sclerotic osseous lesions.
.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Unchanged degenerative change with wedge deformity of a mid
thoracic
vertebral body.
<br>
.
EKG: reviewed - sinus tach - no acute ST/TW changes, old LAD,
poor r-wave progression, possible LAE
<br>
Brief Hospital Course:
86 yo Iranian (farsi speaking) male with h/o COPD (on home o2
(uses 2-3h qdaily of home o2 overall), HTN, restless leg
syndrome, BPH transferred for hypercarbic respiratory failure.
# Acute on Chronic Hypercarbic repiratory failure:
# Acute COPD exacerbation
He presented to the ED with shortness of breath and change in
mental status. He was admitted to the floor for ARF and COPD
exacerbation. He then develooped AMS and and decreased
respiratory rate with a gas of 7.16/105/69. This was thought to
be secondary to methadone overdose due to taking 30mg [**Hospital1 **]
rather than 15mg [**Hospital1 **] when he received 10mg tabs rather than 5mg
tabs from his pharmacy. He required BiPAP the first day in the
ICU given that his PCO2 was 105 on the floor. He was started on
a narcan gtt with improvement of his respiratory status. His
narcan gtt was discontinued on [**4-8**] in the AM as he was alert
and speaking farsi. He was given fentanyl boluses and ativan
while in the ICU to help with withdrawal and to tx his restless
leg syndrome. He was started on Solumedrol 125mg IV q6hrs which
was continued x2 days, then transitioned to prednisone. He was
also started on azithromycin. [**4-9**] his home dose of methadone
was restarted 15mg PO BID. Pt is on 2L oxygen at home but taken
off oxygen this AM with goal O2 sat 88-92% as likely is chronic
CO2 retainer. Patient??????s mental status is at baseline now
oriented to self and yr by his calendar, confirmed with family
that his mental status is good.
He was given Rx for albuterol MDI and is to continue his home
inhalers as well.
# Acute on Chronic Renal Failure ?????? appeared pre renal in
etiology, now resolved.
He is to continue his home Tamsulosin and Finasteride, lasix.
# Restless Leg syndrome ?????? See above patient may have
accidentally overdosed on his methadone. His mental status
responded to a narcan gtt. He was given prn fentanyl until [**4-9**]
at which point he was restarted on his home methadone 15mg PO
BID. Emphasized appropriate dosing to pt, family, and have set
up VNA services to ensure he understands his medication.
# Anemia, microcytic - has h/o thalessemia. HCT stable during
admission.
# Code status: he did not require intubation and family reports
he does not have any history of COPD hospitalizations. Code
status is full, but his providers did discuss with family the
possibility of a comfort-focused, noninvasive approach when he
was very ill in the unit. Recommend that further goals of care
discussion continue with his PCP.
Medications on Admission:
Below medications confirmed with family with pill boxes:
.
lasix 40mg qdaily
atrovent tid
methadone 15 mg [**Hospital1 **]
flomax 0.4mg qdaily
finasteride 5mg qdaily
ocuvite 150-30-6-150 cap qdaily
vit b12 1000mcg [**Hospital1 **]
cranberry-vit c -vit E 140 -100-3- cap tid
Discharge Medications:
1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Methadone 10 mg Tablet Sig: one and a half Tablet PO twice a
day: Please look carefully at your bottle at home. Your family
reports that the pharmacy recently gave you 10 mg tablets. You
should take 15 mg per dose, twice a day.
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puff
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Disp:*1 1* Refills:*0*
5. Atrovent HFA 17 mcg/Actuation Aerosol Sig: 1-2 puffs
Inhalation three times a day: please continue to take this
medication as you were at home. I have not made any deliberate
changes.
6. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO BID (2
times a day): Continue taking this medication (vitamin B12) as
you were at home.
7. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Ocuvite 150-30-6-150 mg-unit-mg-mg Capsule Sig: One (1)
Capsule PO daily (): Continue as you have been taking at home.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Hypercarbic respiratory failure
Acute COPD exacerbation
Restless legs syndrome
Chronic kidney disease
Anxiety
Discharge Condition:
stable
Discharge Instructions:
Please seek medical attention if you develop new shortness of
breath, fever, coughing
Review your medication list carefully and compare to your
bottles at home. Your methadone should be 15 mg twice daily.
If you do not already have an albuterol inhaler, you should fill
out the prescription we have given you. If you already have one
at home, you can continue taking it as prescribed by your
primary care physician. [**Name Initial (NameIs) **] have not changed any of your other
medications.
Followup Instructions:
Please contact your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2903**] for a
follow-up appointment [**Telephone/Fax (1) 18651**] in the next 1-2 weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2141-4-11**]
ICD9 Codes: 5849, 2762, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1154
} | Medical Text: Admission Date: [**2179-2-7**] Discharge Date: [**2179-2-10**]
Date of Birth: [**2097-1-18**] Sex: F
Service: MEDICINE
Allergies:
Ativan
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
[**Hospital Unit Name 196**]/[**Doctor Last Name **] TRANSFER FOR PREHYDRATION ON SUNDAY [**2-7**]
Major Surgical or Invasive Procedure:
Thoracic aorta and carotid (with cerebral) angiography,
PTA/stent x1 to left internal carotid artery. [**2179-2-8**] by Dr.
[**First Name (STitle) **]
History of Present Illness:
82 yo female with history of cellulitis, CAD, diabetes who
recently presented to [**Hospital 1474**] Hospital [**2178-1-19**] with right and
left sided tingling x 1-1.5hr. Dx as TIA. Carotid US
demonstrated critical 80-99% stenosis of the left internal
carotid artery. She declined MRI [**2-12**] claustrophobia, but head CT
was reportedly normal. As per neurology, the symptoms were
compatible with [**Doctor First Name 3098**] lesion. She was discharged to Life Center
Rehab/Nursing home where she is currently residing. She is now
referred for prehydration in preparation for a carotid angiogram
with Dr. [**First Name (STitle) **] tomorrow. She reports having difficulty walking
due to persistence of LE weakness and spends most of her time in
a wheelchair.
.
ROS:
(+) LE swelling unchanged, R LE weakness, tingling sensation
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
1. PAD with recently documented TIA with the carotid duplex
suggesting the critical left ICA lesion.
2. Coronary artery disease: MI [**12/2173**] with stent to LCX. Also
with AMI [**2174**] with instent restenosis in LCx, s/p restenting and
brachytherapy. Also with residual 70% ostial stenosis of LAD,
70% mid vessel stenosis of the LAD with an 80% mid vessel
stenosis of the D1, medically managed. (note: only "baseline
ECG" available predates [**2174**] in-stent restenosis and PCI)
3. Hypertension.
4. Poor mobility due to multiple factors.
5. Recurrent urinary tract infections due to chronic
catheterization.
6. Chronic leg cellulitis/bilateral.
7. Bilateral pedal edema - multifactorial.
8. CRI - baseline Cr 2.0
9. Bipolar disease
10. COPD
11. DM
12. Psoriasis
13. CHF
Social History:
Nonsmoker, nondrinker, lives independently at senior high rise,
[**Doctor Last Name **] Towers.
Family History:
Unknown.
Physical Exam:
Vitals: T: 98.0 P: 70 BP: 154/61 R: SaO2:99% on RA
General: Obese talkative elderly female in no acute distress
HEENT: PERRL, cataracts, non elevated JVP. OP clear.
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted. Obese
Extremities: 2+ edema to knee. Warm, erythematous distally.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
though tangential in thought
-cranial nerves: II-XII intact
-motor: Normal grasp, Normal strength and tone bilaterally.
-sensory: reports altered sensation on right aspect of face
V2,V3 and R UE, RLE diffusely.
2+ DP and PT pulses.
Pertinent Results:
Admission Labs:
137 106 76
-----------<204
5.3 19 2.4
estGFR: 19/23 (click for details)
Ca: 8.8 Mg: 2.1 P: 4.6
.
10.4
6.7>--<207
31.4
.
PT: 12.7 PTT: 30.1 INR: 1.1
.
EKG: NSR, nl axis and intervals, Qs in II, III, AVF (not present
on [**5-12**] ECG, which was done prior to in-stent restenosis and
revascularization)
.
Radiologic Data:
[**2179-1-19**] Carotid U/S:
Grossly abnormal study: On the left side there is soft
heterogeneous plaque which is irregular. It is present in the
carotid bulb and extends into the proximal left internal carotid
artery. Spectrum analysis shows markely accelerated flow
velocities and spectral broadening consistent with an 80-99%
stenosis of the left internal carotid artery. Would strongly
recommend patient undergo CT angiography or MRA.
.
On the right side there is heterogeneous calcific plaque in the
bulb which involves the right internal carotid artery. Spectrum
analysis is wnl, not suggesting any evidence of hemodynamically
significant stenosis present in the right internal carotid
artery. There is antegrade flow present in both vertebral
arteries.
.
Conclusion: Grossly abnormal study
1) Evidence of critical 80-99% stenosis of the left internal
carotid artery. Would strongly recommend further imaging studies
as described above.
2) No evidence of hemodynamically significant stenosis present
in the right internal carotid artery.
3) Antegrade flow present in the vertebral artery bilaterally.
.
Thoracic aorta and carotid angiography [**2179-2-8**]: stent to [**Doctor First Name 3098**].
Brief Hospital Course:
Assessment and Plan:
Ms. [**Known lastname **] is a 82 year old female with severe carotid stenosis
and hx of recent TIA, suggesting [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3098**] lesion, who had a stent
placed in the [**Doctor First Name 3098**] with uncontrolled hypertension.
.
1) Carotid stenosis: She was admitted for pre cath hydration.
One episode of syncope 4 yrs prior to admission. Pt denies
symptoms of orthopnea, chest pain, shortness of breath, syncope
and no amaurosis fugax. She was prehydrated with bicarb and
given periprocedural n-acetylcysteine for renal protection. She
had uncomplicated placement of [**Doctor First Name 3098**] stent with residual 10%
normal flow. She was continued on aspirin and plavix post
procedure. She was notably hypertensive pre and post procedure
requiring nitroprusside gtt with goal SBP 100-150 for adequate
cerebral perfussion. Her antihypertensive regimen was increased
to hydralazine 100mg po q8, imdur 90mg po qd, lisinopril 20mg po
qd, and metoprolol 100mg po bid.
.
2) HCT drop: Following the procedure her hct decreased from
32.1-->25.8-->now 26.2. She had reported a headache/neck pain
immeadiately following the procedure but those resolved and the
decrease hct was thought to be dilutional. She had no
hypotension or tachycardia.
.
3) DM: She was maintained with ISS and had fingersticks QID.
.
4) CKD- Creatinine remained stable. Likely due to diabetic
nephropathy. She received hydration with bicarb and mucomyst for
renal protection.
.
5) Prophylaxis: PPI, sc heparin, bowel regimen
.
6) Code Status: Full
Medications on Admission:
Allergies: Ativan
.
Home Medications (Per Life-Care Center of [**Location 15289**] (meds
given [**2-7**]):
Hydralazine 50mg PO tid
Plavix 75mg PO qD
Lisinopril 10mg PO qD
Protonix 40mg PO qD
Folic acid 1mg PO qD
Imdur 60mg PO qD
Lasix 60mg PO qD
Plaquenil 200mg PO bid
Metoprolol 100mg PO bid
Glyburide 5mg PO bid
Colace 100mg PO bid
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
7. Plaquenil 200 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
Disp:*30 Tablet(s)* Refills:*2*
9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
11. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
12. Lasix 40 mg Tablet Sig: One (1) Tablet PO qam.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Primary diagnosis:
- Carotid stenosis
Secondary diagnosis:
- Coronary artery disease
- Hypertension
- Chronic renal insufficiency
- Diabetes mellitus
- Psoriasis
- Chronic obstructive pulmonary disease
- Chongestive heart failure
Discharge Condition:
Good, respiratory status stable
Discharge Instructions:
Please take all your medications as prescribed.
.
If you develop dizziness, visual changes, leg or arm or facial
weakness or numbness, chest pain, or shortness of breath, seek
medical attention immediately.
Followup Instructions:
Follow-up appointment with Dr. [**Last Name (STitle) 17025**] on [**2-18**] at
11am. Phone number [**Telephone/Fax (1) 3183**]. Office address [**Street Address(2) 42096**]; [**Location 15289**], MA
.
Follow up with Dr. [**First Name (STitle) **], phone ([**Telephone/Fax (1) 7236**]
ICD9 Codes: 5856, 496, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1155
} | Medical Text: Admission Date: [**2175-12-1**] Discharge Date: [**2175-12-24**]
Date of Birth: [**2175-11-30**] Sex: M
Service: NBB
HISTORY: [**First Name4 (NamePattern1) 56977**] [**Last Name (NamePattern1) **] [**Known lastname 62656**] is a 34-1/7 weeks 1,890 gram
male delivered on [**2175-11-30**] delivered by C-section at
[**Hospital1 69**] [**Hospital Ward Name **] due to
maternal medical issues. Mom is a 43-year-old gravida 6, para
2 now 3 mother with history of stroke during this pregnancy.
This pregnancy was complicated by a left ACA stroke on
[**2175-11-20**] which was thought to be due to mitral valve
vegetations. Blood cultures on mom were negative.
Mother's medical history is also notable for hypercoagulable
condition (1 copy of CGTT mutation, normal homocysteine
levels, normal factor V Leiden, normal protein-C and protein-
S, [**Doctor First Name **] negative). Mother's prenatal screens: Blood type A-
positive, antibody negative, RPR nonreactive, GC negative,
chlamydia negative, hepatitis B surface antigen negative. Mom
was betamethasone complete. At delivery, infant was vigorous
and crying. He received blow-by O2 and suctioning. Apgar
scores were 8 at 1 minute and 9 at 5 minutes.
Infant was initially admitted to [**Hospital3 1810**] newborn
ICU and transferred to [**Hospital1 69**]
[**Hospital Ward Name **] on [**12-1**] for continuation of neonatal
intensive care. Course at [**Hospital1 **] notable for respiratory
distress consistent with mild immaturity and RDS. At
[**Hospital3 1810**], the infant progressed from nasal cannula
oxygen to nasal prongs CPAP. Infant returned to [**Hospital1 346**] [**Hospital Ward Name **] where CPAP was
continued.
PHYSICAL EXAM ON ADMISSION: Weight 1,890 grams (25th-50th
percentile), head circumference 31 cm (25th-50th percentile),
length 44.5 cm (25th-50th percentile). Vital signs on
admission: Temperature 97.6, heart rate 160, respiratory rate
44, blood pressure 78/50 with mean arterial pressure of 64,
oxygen saturation 92%, and blood glucose 83. Infant on nasal
cannula CPAP, FIO2 40-45%. Infant pink, active, well perfused
with mild jaundice. Head, eyes, ears, nose, and throat:
Normal by external exam. Red reflex exam: Deferred. Chest:
Diminished breath sounds bilaterally. Cardiovascular: Normal
heart sounds, no murmur, pulses normal. Abdomen: Within
normal limits, no masses, no hepatosplenomegaly. Umbilical
cord: Normal. GU: Normal preterm male. Anus patent. Spine:
Within normal limits. Extremities: Within normal limits. Mild
jaundice. Neuro: Normal tone and movements. Normal cry.
Chest x-ray: Consistent with mild RDS.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: Infant
arrived at [**Hospital1 69**] [**Hospital Ward Name **]
NICU on [**12-1**] on continuous positive airway pressure
with FIO2 40-44%. The infant weaned to nasal cannula O2 on
day of life 3 requiring 400 cc with a FIO2 of 25-30%. Infant
was weaned off nasal cannula to room air on day of life 7.
[**Doctor First Name 56977**] has remained in room air for the rest of his
hospitalization. Has not required any supplemental oxygen. He
has not had any issues with apnea of prematurity and has not
required methylxanthine.
Cardiovascular: [**Doctor First Name 62657**] blood pressure has been stable
throughout his hospitalization. A soft intermittent murmur
was heard on day of life 5. He continues to have a soft
murmur felt to be PPS murmur.
Fluid, electrolytes, and nutrition: Upon admission to the
NICU, infant was on IV fluids of D10W infusing at 80 cc per
kilogram per day. Initial set of electrolytes were sodium of
143, potassium of 5, chloride of 111, and bicarbonate of 21.
Enteral feeds were started on day of life 3 and then stopped
on day of life 4 for a bilious aspirate. KUB at that time was
found to be normal and feeds were resumed on day of life 5.
The infant progressed successfully to full volume feeds of
breast milk at 150 cc per kilogram per day by day of life 11.
Caloric density was increased to a maximum of 26 calories per
ounce, and the infant has shown steady consistent growth and
has not shown any further signs of feeding intolerance.
Infant to be discharged home on 26 calorie breast milk
enriched to 26 calories with 4 calories per ounce of Enfamil
powder and 2 calories per ounce of corn oil. Discharge weight
2300 g. Discharge length 45.1 cm. Discharge head
circumference 33 cm. His last set of electrolytes were on
day of life 9 with a sodium of 139, potassium of 5.3, a
chloride of 103, and a bicarbonate of 23.
GI: Phototherapy was initiated on day of life 2 for a
bilirubin of 11.4. Phototherapy was discontinued on day of
life 14 for a bilirubin of 7.2. A rebound bilirubin on day of
life 15 was 8.3/0.3.
Hematology: Infant's hematocrit upon admission to the NICU
was 55. He did not receive any blood products during his
hospitalization. Blood type is not known at this time.
Infectious disease: CBC with differential and blood cultures
were drawn upon admission to the NICU at [**Hospital3 1810**].
That blood culture was negative and CBC benign. [**Doctor First Name 56977**] did
receive 48 hours of ampicillin and gentamicin. Follow-up CBC
on day of life 2 showed a white count of 14,000, hematocrit
of 58, platelet count of 170,000 with 84% polys and 0% bands. A
small pustule was noted on the left cheek on the day prior to
discharge. Gram stain revealed no organisms. Topicl antibiotic
is being applied to the lesion. No other lesions noted on day of
discharge. There have been no other issues regarding infection.
Neurology: Head ultrasound not indicated on this 34-1/7
weeker.
Sensory: A hearing screen was performed with automated
auditory brainstem responses. Results: Passed in both ears.
GU: Circumcision pending on [**12-23**].
Ophthalmology: Eye exam not indicated for this 34-1/7 weeker.
Psychosocial: [**Hospital1 69**] social
worker has been involved with the family who has been
stressed by mom's repeated admissions regarding her stroke.
Dad is involved and supportive.
CONDITION AT DISCHARGE: Infant stable in open crib, taking
p.o. feeds without difficulty, showing steady growth and
comfortable respiratory pattern in room air.
DISCHARGE DISPOSITION: To home with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 449**], phone #[**Telephone/Fax (1) 62658**]. Fax #[**Telephone/Fax (1) 51113**].
CARE AND RECOMMENDATIONS: Feeds at discharge: Ad-lib demand
feeds of breast milk enriched to 26 calories with 4 calories
per ounce of Enfamil powder and 2 calories per ounce of corn
oil.
Medications: Iron supplements 0.4 cc daily and multivitamins
1 cc daily.
Car seat position screening results: passed.
State newborn screening status: Last state newborn screen was
sent on [**12-18**]. No abnormal results have been reported.
Immunizations received: [**Doctor First Name 56977**] received his 1st hepatitis B
vaccine on [**12-20**]. No other immunizations have been
given.
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: Daycare during the 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 household
contacts and out-of-home caregivers.
A follow-up appointment has been arranged with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 449**]
([**Hospital1 8**], [**Telephone/Fax (1) 62659**]) for [**2175-12-25**] at 2 p.m. VNA
appointment set for [**12-26**].
DISCHARGE DIAGNOSIS LIST:
1. Prematurity at 34-1/7 weeks gestation.
2. Respiratory distress syndrome.
3.
Rule out sepsis.
4. Hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**]
Dictated By:[**Last Name (NamePattern1) 59783**]
MEDQUIST36
D: [**2175-12-23**] 00:32:18
T: [**2175-12-23**] 06:25:00
Job#: [**Job Number 62660**]
ICD9 Codes: 769, 7742, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1156
} | Medical Text: Admission Date: [**2149-10-23**] Discharge Date: [**2149-11-3**]
Date of Birth: [**2085-6-21**] Sex: M
Service: CARDIOTHORACIC
CHIEF COMPLAINT: The patient is transferred to [**Hospital **] [**Hospital **]
[**First Name (Titles) **] [**Last Name (Titles) **] from an outside hospital after being admitted
there for new onset of chest pain. At the outside hospital
he ruled in for a non Q wave myocardial infarction, which was
associated with one episode of ventricular tachycardia and
ventricular fibrillation, which was easily reversed to normal
sinus rhythm with direct shock cardioversion followed by
lidocaine bolus and drip after which the patient was
transferred to [**Hospital **] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **].
HISTORY OF PRESENT ILLNESS: The patient is a 64 year-old man
with known oligo symptomatic three vessel disease developed
his first episode of chest pain the day prior to admission
while working on building a garage. The chest pain was
accompanied by shortness of breath, which is his usual
anginal equivalent and was unrelieved by sublingual
nitroglycerin, so he went to a local hospital in [**State 1727**] where
his symptoms were improved with treatment of oxygen and
nitroglycerin. The pain had peaked at an 8 over 10 level and
improved to a 4 over 10 by arrival to the Emergency Room.
His vital signs upon arrival in the Emergency Room at the
outside hospital were a heart rate of 102, blood pressure
167/89. Respiratory rate 18. O2 sat 88% on room air. Once
at the hospital his CPK and troponin levels were found to be
elevated. He was started on nitroglycerin and heparin drips.
He was also diuresed and reportedly was fine until about
5:00 in the morning when his monitor alarmed for a
ventricular tachycardia. He was thumped without response and
then cardioverted with 200 jewels to normal sinus rhythm.
Lidocaine drip was started at that time. He was med flighted
to [**Hospital **] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] later on that morning.
PAST MEDICAL HISTORY: Significant for diabetes mellitus,
status post laser eye surgery, probable neuropathy,
hypercholesterolemia on a lipid lower placebo controlled
study currently. Hypertension, coronary artery disease. He
had a stress test in [**2149-1-20**] during which he became
hypotensive. There were 3 mm horizontal down sloping ST
depressions. His EF at that time was 40% and he was found to
have moderate reversible perfusion defects in the inferior
wall extending to the apex. He had a catheterization done
also in [**2149-1-20**] and was found to have an EF of 65%
and three vessel disease. Carotid ultrasound in [**2149-6-20**]
showed 40% bilateral ICA stenosis.
MEDICATIONS AT HOME: Isordil 60 mg q.a.m., Trental 400 mg
q.a.m., Diovan 160 mg q.a.m., Hydrochlorothiazide 12.5 mg
q.a.m., Prilosec 20 mg q.a.m., aspirin 161 mg q.d.. Lipid
study pills, Toprol XL 25 mg q.h.s., insulin NPH 30 units
q.a.m. and 13 units q.p.m. and sliding scale Humalog.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He lives in [**Location 1468**], but also has a house in
[**State 1727**]. He is married. He quit tobacco fifteen years ago.
He is not currently drinking, but formerly drank six to eight
beers per week.
PHYSICAL EXAMINATION ON ADMISSION TO [**Hospital **] [**Hospital **] MEDICAL
CENTER: Temperature 98.9. Heart rate 69. Blood pressure
118/55. Respiratory rate 14. O2 sat 95% on 2 liters. HEENT
extraocular muscles are intact. Pupils are equal, round and
reactive to light. Mucous membranes are moist Neck, JVP is
7 cm. Cor heart sounds regular without gallops, 2 over 6
left lower sternal border, systolic nonradiating murmur.
Pulmonary, crackles half way up on the right, a quarter of
the way up on the left. No signs of consolidation. Abdomen
is soft, nontender, nondistended with positive bowel sounds.
Extremities no edema. Pulses not palpable. Chronic stasis
changes. Groin 2+ femoral bruits. Neurologically, cranial
nerves II through XII functionally intact. Strength is 5
over 5 bilaterally. Sensation is intact to light touch.
LABORATORY: White blood cell count 11.6, hematocrit 35,
platelets 210, sodium 141, potassium 3.5, chloride 108, CO2
30, BUN 21, creatinine 1.0, glucose 276. CPK from the
outside hospital initially 386, peaked at 720. Troponin
initially 0.83, peaked at 22.9. Electrocardiogram, normal
sinus rhythm at a rate of 100 with a normal axis, normal R
wave progression, normal intervals, scooped ST depressions in
1L and 1 to [**Street Address(2) 30305**] depressions in V3 through 5.
HOSPITAL COURSE: After arrival to the [**Hospital **] [**Hospital **] [**First Name (Titles) **]
[**Last Name (Titles) **] the patient underwent cardiac catheterization. Please
see catheterization report for full details. In summary, the
catheterization showed an ejection fraction of 55% with
trivial mitral regurgitation, left main 50%, left anterior
descending coronary artery 90%, left circumflex diffusely
diseased and right coronary artery diffusely diseased. The
Cardiothoracic Service was consulted and the patient was seen
and accepted for coronary artery bypass grafting. On [**10-27**] he was brought to the Operating Room where he underwent
coronary artery bypass grafting times five. Please see the
Operating Room report for full details.
In summary, he had a coronary artery bypass graft times five
with a left internal mammary coronary artery to the left
anterior descending coronary artery and saphenous vein graft
to obtuse marginal one and ramus sequentially. Saphenous
vein graft to diagonal and saphenous vein graft to posterior
descending coronary artery. He tolerated the operation well
and was transferred from the Operating Room to the
Cardiothoracic Intensive Care Unit. At the time of transfer
the patient had an arterial line, a Swans-Ganz catheter, two
ventricular and two apical pacing wires, two mediastinal
chest tubes and one left pleural chest tube. He was A paced
at a rate of 90 beats per minute. He had a mean arterial
pressure of 75, SVP of 19. He was on Propofol at 30 mics per
kilogram per minute and nitroglycerin at 1 mcg per kilogram
per minute.
The patient's postoperative course was initially complicated
by rapid atrial fibrillation with a heart rate into the 150s
for which he was cardioverted into a normal sinus rhythm and
an Amiodarone drip was begun. He also had depressed cardiac
index for which Dopamine was started at 3 micrograms per
kilogram per minute. He remained hemodynamically stable with
good cardiac performance throughout the remainder of
operative day one. On the morning of postoperative day one
he was weaned from the ventilator and extubated successfully.
He also had an increase in his creatinine and potassium
levels on postoperative day one for which nephrology was
consulted. Over the next two days the patient remained in
the Intensive Care Unit, he was weaned from his cardio active
drugs. His renal function improved and he remained
hemodynamically stable. On postoperative day three he was
deemed safe and ready for transfer to Floor Six for
continuing postoperative care and cardiac rehabilitation.
The patient remained on postoperative cardiac surgery floor
for the next four days where he was monitored for his
hemodynamic and his renal status. His activity level was
increased over the next four days with the assistance of the
Physical Therapy Department and on postoperative day seven it
was decided that he was ready to be discharged to home.
At the time of discharge the patient's physical examination,
vital signs temperature 98.5. Heart rate 65 sinus rhythm.
Blood pressure 140/76. Respiratory rate 20. O2 sat 92% on
room air. Weight preoperatively is 86 kilograms. At
discharge is 91.2 kilograms. Laboratory data, white blood
cell count 15, hematocrit 26.9, platelets 213, sodium 136,
potassium 5.1, chloride 103, CO2 27, BUN 30, creatinine 1.0,
glucose 124. On physical examination, he was alert and
oriented times three. He moves all extremities. He follows
commands. Respiratory, breath sounds clear to auscultation
bilaterally. Heart sounds regular rate and rhythm. S1 and
S2 with no murmur. Sternum is stable and incision with
staples is open to air, clean and dry. Abdomen is soft,
nontender, nondistended with normoactive bowel sounds.
Extremities are warm and perfuse. No pulses appreciated. No
edema. Right lower extremity incision with Steri-Strips,
open to air, clean and dry.
DISCHARGE MEDICATIONS: Amiodarone 400 mg q.d., aspirin 81 mg
q.d., Ciprofloxacin 500 mg b.i.d. times five days. Lipid
study drugs as previously prescribed. Prilosec 20 mg q.d.,
Lasix 40 mg q.d., times ten days, potassium chloride 20
milliequivalents q.d. times ten days, NPH insulin 35 units
q.a.m. and 18 units q.p.m., Humalog insulin sliding scale,
Percocet 5/325 one to two tabs q 4 hours prn.
CONDITION ON DISCHARGE: Stable.
FOLLOW UP: His follow up is with his primary care physician
in one month. Follow up with the Renal Service in two to
three weeks and with Dr. [**Last Name (STitle) 1537**] in three to four weeks. Also
with the [**Hospital 409**] Clinic in two to three weeks.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery
bypass grafting times five.
2. Hypertension.
3. Hypercholesterolemia.
4. Diabetes mellitus.
5. Renal insufficiency.
6. Carotid stenosis.
7. Dyspepsia.
8. Peripheral vascular disease.
9. Right knee repair.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2149-11-3**] 09:09
T: [**2149-11-3**] 09:29
JOB#: [**Job Number 30306**]
ICD9 Codes: 4271, 9971, 5849, 2767, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1157
} | Medical Text: Admission Date: [**2137-10-7**] Discharge Date: [**2137-10-31**]
Date of Birth: [**2061-8-17**] Sex: F
Service: MEDICINE
Allergies:
Lasix / Diuril / Keflex / Iodine
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
Dyspnea, Renal Failure, anemia, fluid overload
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
76 year old female with h/o IPF on chronic prednisone, COPD with
trach, CHF, mechanical mitral valve, pacemaker, and anemia who
presents with several days of worsening dysypnea, peripheral
edema, and fatigue. She reports difficulty walking very short
distances due to SOB and lightheadness frequently. She reports
[**2-28**] pillow orthopnea that remains unchanged from baseline. She
reports frequent productive cough that occasionally is bloody,
last bloody sputum was this morning. She reports frequency of
cough and sputum production is same as baseline. She believes
she has had an unknown amount of weight gain. Peripheral edema
fluctuates in severity. She denies changes in bowel habits and
denies changes in urination. She denies changes in appetite,
denies fever, chills, chest pain, nausea, vomiting, abdominal
pain, melena, and BRBPR.She denies sick contacts and recent
travel.
In the ED, labs were significant for Hct 14, INR 10, creatinine
2.1. Had peripheral edema on exam. She was ordered for 2 units
PRBCs (not given due to difficult crossmatch), crossmatched 4
units. Also given 5mg po vitamin K. She was not given lasix or
FFP. Most recent vitals 85 113/49 23 100% 5L.
.
In the MICU, she was noted to be short of breath and had brown,
guaiac positive stool.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats,denies headache, sinus
tenderness, rhinorrhea or congestion.Denies chest pain, chest
pressure, palpitations, or weakness. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias.
Past Medical History:
- s/p mechanical mitral valve repair [**2125**]
-sinus node dysfunction s/p DDD pacemaker placement [**2125**]
- atrial flutter s/p ablation [**2-/2132**] and cardioversion [**11-3**]
- congestive heart failure, Last echo [**2137-9-12**] LVEF= 40-45%
Moderate to severe [3+] tricuspid regurgitation
- chronic obstructive pulmonary disease: 4LO2 trach at home at
rest
- idiopathic pulmonary fibrosis on chronic prednisone
- chronic kidney disease; baseline creatinine 1.3-1.6 on [**2137-9-18**]
UreaN-40* Creat-1.1
- anemia due to mechanical valve and chronic kidney disease
- hypertension
- hypercholesterolemia
- hypothyroidism
- meniere??????s disease (HOH)
- spinal arthritis
- breast cancer radical mastectomy right breast [**2095**]. Partial
left [**2097**].
- s/p hysterectomy [**2101**]
- s/p nasal embolization for refractory epistaxis [**6-30**]
Social History:
-smoked 36 years, quit in [**2111**].
-denies alcohol use.
-no IVDU.
-requires assistance with all ADLs and IADLs
-uses walker at baseline.
-housekeeper 2x /week in past.
-peapod for groceries.
-HHA twice a week and for assitance with showers.
-husband does [**Name2 (NI) 14994**].
-Husband [**Name (NI) 9102**] [**Name (NI) **] [**Telephone/Fax (1) 15153**]
Family History:
Father had polymyositis and coronary artery disease; mother had
metastatic bone cancer. She has several cousins with breast
cancer.
Physical Exam:
Vitals: T:98.3 BP:119/51 P:86 R:13 SpO2:100%
General: Alert, oriented, short of breath, difficulty finishing
sentences
HEENT: Sclera anicteric,pale conjuctiva, no tenderness,
increased pigmentation bilateral cheeks, dry oral mucosa,
oropharynx clear, PERRL
Neck: supple, JVP not elevated, no LAD
CV: tachycardia, normal S1 loud mechanical S2, no rubs,no
gallops
Lungs: slight use of accessory muscles,decreased breath sounds
bilaterally L>R, crackles in R Lung, large healed scar on R
chest in mammary region from radical mastectomy
Abdomen:refused
GU: foley
Rectal: refused
Ext: cap refill <2 sec, +2 pitting edema upper and lower
extremities
Pertinent Results:
[**2137-10-7**] 02:24PM WBC-13.6*# RBC-1.49*# HGB-4.6*# HCT-14.2*#
MCV-95 MCH-30.6 MCHC-32.1 RDW-17.5*
[**2137-10-7**] 02:24PM PLT COUNT-240#
[**2137-10-7**] 02:24PM NEUTS-92.1* LYMPHS-4.3* MONOS-2.0 EOS-1.4
BASOS-0.1
[**2137-10-7**] 02:24PM PT-86.1* PTT-53.0* INR(PT)-10.0*
[**2137-10-7**] 02:24PM GLUCOSE-254* UREA N-72* CREAT-2.1* SODIUM-138
POTASSIUM-5.4* CHLORIDE-97 TOTAL CO2-29 ANION GAP-17
[**2137-10-7**] 02:24PM cTropnT-0.13*
[**2137-10-7**] 03:20PM IRON-13*
[**2137-10-7**] 03:20PM calTIBC-329 HAPTOGLOB-122 FERRITIN-64 TRF-253
[**2137-10-7**] 03:20PM CK-MB-3 proBNP-1495*
[**2137-10-7**] 03:20PM ALT(SGPT)-20 AST(SGOT)-23 LD(LDH)-405*
CK(CPK)-48 ALK PHOS-48 TOT BILI-0.3
[**2137-10-7**] 08:36PM RET MAN-15.1*
[**2137-10-7**] 10:03PM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2137-10-7**] 10:03PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2137-10-7**] 10:03PM URINE OSMOLAL-335
[**2137-10-7**] 10:03PM URINE HOURS-RANDOM UREA N-451 CREAT-71
SODIUM-39 POTASSIUM-44 CHLORIDE-29
.
Day of Discharge:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
11.4* 3.32* 9.7* 30.1* 91 29.3 32.3 16.7* 169
.
PT PTT INR(PT)
20.4* 47.3* 1.9
.
Glucose UreaN Creat Na K Cl HCO3 AnGap
87 76* 1.7* 152 3.1* 109* 28 18
.
Anemia work-up
retic: 6.6
calTIBC Hapto Ferritn TRF
329 122 64 253
.
LFTs:
ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili
30 28 72 492* 0.4
.
TFTs
TSH: 12
FT4: 1.1
Images:
[**10-7**] Chest AP: Low lung volumes with known idiopathic pulmonary
fibrosis. While a subtle superimposed acute consolidation in the
lung bases is difficult to exclude, it would be highly
coincidental and is felt less likely with the increased opacity
likely due to crowding.
CXR ([**10-8**]):
FINDINGS: As compared to the previous radiograph, there is no
relevant
change. Status post sternotomy, status post valvular
replacement. The
external and internal pacemaker with leads are visible.
Unchanged evidence of a right basal opacity with a predominantly
reticular pattern, that might, in part be, fibrotic. These are
likely to be related to the known history of idiopathic
pulmonary fibrosis. There is no evidence of fluid overload on
the current image. No pleural effusions. No parenchymal
opacities have newly occurred.
.
CT Torso: [**10-27**]
IMPRESSION:
1. Emphysema and pulmonary fibrosis with mild bibasilar
consolidations, worse on the right than the left, likely
reflecting atelectasis, although
superimposed pneumonia cannot be excluded.
2. Status post right mastectomy.
3. Cholelithiasis in a nondistended gallbladder with mild wall
edema/pericholecystic fluid likely reflects either CHF or
hypoproteinemia.
4. Diverticulosis without diverticulitis.
5. No evidence of intra-abdominal free air or organized fluid
collection.
6. Indistinct pancreatic head; correlate with pancreatic enzymes
if clinical concern for pancreatitis.
.
RUQ US [**10-25**]
1. Sludge and stones in the gallbladder neck without other
findings to
suggest acute cholecystitis. If there is continued clinical
concern, a HIDA scan may be more definitive in the exclusion of
acute cholecystitis.
2. Dilated hepatic veins consistent with diastolic dysfunction
.
CT Head [**10-20**]
1. No acute intracranial abnormality.
2. Small vessel ischemic disease and diffuse cerebral atrophy.
.
Pathology:
Bronchial lavage:
ATYPICAL.
Atypical squamous cells.
Bronchial cells and inflammatory cells.
.
Colonic polyp, distal ascending/proximal transverse (biopsy):
1. Fragments of adenoma with focal high grade dysplasia.
.
Micro:
[**2137-10-28**] 2:47 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2137-10-29**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2137-10-29**]):
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 15154**] @ 0550 ON
[**2137-10-29**].
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
[**2137-10-27**] 2:27 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2137-10-29**]**
GRAM STAIN (Final [**2137-10-27**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2137-10-29**]):
MODERATE GROWTH Commensal Respiratory Flora.
[**2137-10-27**] 1:09 am URINE Source: Catheter.
**FINAL REPORT [**2137-10-28**]**
URINE CULTURE (Final [**2137-10-28**]):
YEAST. ~7000/ML.
Brief Hospital Course:
76 y.o woman with PMH of IPF,COPD,anemia, mechanical mitral
valve,and pacemaker presents with worsening dyspnea, acute renal
failure, and fluid overload.
#. Anemia: On admission hemoglobin of 4.6 and hematocrit of 14.2
from a
hgb 10 and hct 33.1 within the last several weeks. Hemolysis
labs negative, and rectal exam showed guiac positive brown
stool. Her anemia was believed to be secondary to a GI bleed.
She was transfused 4 units total with appropriate hct response,
and her hct/hgb ramined stable. She underwent EGD/colonoscopy
which showed esophageal and fundal varices and a large polyp in
the colon, concerning for malignancy which was believed to be
the source of bleeding. On biopsy, this lesion was found to be
an adenoma with high grade dysplasia. Gastroenterology believed
that it would be possible to perform a transluminal resection
but that the procedure would have high risk of perforation and
death. After a goals of care discussion with the [**Hospital 228**]
health care proxy, [**Name (NI) **] [**Name (NI) 15155**], and the gastroenterology team
it was decided that though the adenoma is high risk for
malignancy, she will likely succumb to her severe pulmonary
disease in the next 1-5 years and removal of the mass is not in
line with her goals of care. She was started on nadolol for
esophageal varaces.
OUTPATIENT ISSUES:
-- Obtain 2x weekly HCTs and transfuse for HCT <21
-- Continue Fe supplementation and epo administration
.
#. Hypoxemic respiratory failure: The patient presented on 5L
trans-trach from a baseline of 4L at home in the setting of
known IPF, COPD, and chronic heart failure. Her dyspnea was
attributed to anemia vs fluid overload from CHF, and remained
stable in-house and gradually improved upon discharge from the
ICU. There was low suspicion for a COPD or IPF exacerbation.
She was given IV Torsemide for diuresis with her packed red cell
transfusions, and her home Bumex was held in-house. Her home
prednisone and nebulizers were continued in-house. Related to
her shortness of breath, she occassionally coughed up "blood
balls", which she attributed to bloodly mucous originating at
her catheter site. These were inconsistent, and associated with
epistaxis, and we believed that there was a component of bloody
post-nasal drip contributing, exacerbated by the fact that she
was on a heparin gtt for her heart valve. The total blood loss
from these episodes was essentially non-contributory. On the
floor, she continued to be dyspneic at times. She was found to
have evidence of a RUL HAP, so she was started empirically on
vancomycin and cefepime. She developed progressive respiratory
distress and returned the MICU where she was intubated. She
underwent broncheoalveolar lavage which was culture negative and
her antibiotics were discontinued on [**10-23**]. She continued to be
intermittently diuresed but it was stopped when her creatinine
bumped from 1.8 to 2.7. She was extubated and returned to the
medical floor with o2 sats 95% on 2LNC The thought is that her
respiratory distress was likely due to a mucus plug and
pulmonary edema. After two days on the medical floor, she pulled
out a nasogastric tube which had been used for tubefeeds,
aspirated and developed respiratory distress with hypoxia and
acidemia. She was transferred to the MICU for a third time where
she was again intubated. Out of concern for HCAP the pt was
started on vanc/[**Last Name (un) 2830**]. Due to increasing wbc and decreased stool
output there was also concern for c.diff, which ultimately was
positive, and the pt was started on flagyl/PO vanc. The pt's
respiratory status improved and she was successfully extubated.
Vancomycin was discontinued on [**10-30**] with plan to complete a
total of 8d of meropenem.
OUTPATIENT ISSUES:
-- Continue meropenem thru [**11-3**].
-- Ongoing discussion regarding replacement of transtracheal
catheter.
.
#Clostridium Difficile: The pt was found to have a rising WBC,
episodes of hypotension and decreased stool output. She was
empirically started on IV flagyl and PO vanco which were
continued when stool culture was positive for c.diff. Pt had
subsequent decreased in WBC to normal with improvement in loose
stools.
OUTPATIENT ISSUES:
-- Plan to complete PO vancomycin 125mg PO Q6hrs as well as
Flagyl 500mg Q8hrs; end date [**11-9**].
.
#Anticoagulation: Patient anticoagulated due to presence of
mechanical valve. Patient presented with an INR of 10 for
unclear reasons. She received 5mg PO Vit K, and her INR
down-trended to the sub-therapeutic range and she was started on
a Heparin gtt for her mechanical mitral valve. She experienced
epistaxis and coughed up bloody mucus in the setting of a
slightly supratherapeutic PTT which resolved with decreasing her
Heparin gtt. She was kept on a heparin drip for bridging on the
medicine floor. When the decision was made to pursue
endomucosal resection of her adenoma, her warfarin was
discontinued, however given this was put on hold, the pt was
restarted on coumadin [**10-29**]. At time of discharge patient
remained on hep gtt as well as coumadin 3mg daily; INR on day of
discharge 1.9
OUTPATIENT ISSUES:
-- COntinue hep gtt and coumadin until INR therapeutic (2.5 -
3.5).
.
#Volume Status/Acute Renal Failure. Patient with oscillating
renal function in house. Peak Cr 2.8 from a baseline of ~1.4,
likely secondary to hypovolemia as well as renal hypoperfusion
[**2-27**] anemia. Urine lytes showed were consistent with
hypovolemia. Initially Bumex was held and she was given IV
hydration. Creatinine increased from 1.8-2.7 in the setting of
diuresis (as above) and bumex was held. During hospital stay
patient was intermittently diuresised and prior to discharge
restarted on PO Bumex 5mg daily with creatinine of 1.7. Weight
at time of discharge: 62.4kg ; sating >95% on 5L NC.
OUTPATIENT ISSUES:
-- Pleae continue Bumex 5mg PO daily; monitor weights daily as
well as renal function; may consider increasing bumex to [**Hospital1 **] or
transitioning to IV if weight increases >3lb
.
# Esophageal Varices. Newly diagnosed. Patient placed on nadolol
10mg daily.
.
# Hypertension. Patient largely hypotensive to normotensive in
house. Decision made to hold home amlodipine 5mg daily as well
as spironolactone 50mg [**Hospital1 **] at time of discharge.
OUTPATIENT ISSUES:
-- Close hemodynamic monitoring; plan to re-initiate
anti-hypertensives if needed.
.
# Pulmonary fibrosis. Patient with transtracheal O2 catheter as
well as use of chronic steriods as an outpatient. During 1st
intubation transtracheal cath was removed. In house patient
received stress dose steriods which were weanted to home
prednisone 10mg daily at time of discharge.
OUTPATIENT ISSUES:
-- Continue chronic prednisone; consider need for PCP [**Name9 (PRE) **]
[**Name9 (PRE) **] Continue discussion re replacement of transtracheal cath
.
# Hypernatremia. Patient noted to be intermittently
hypernatremic when NPO/intubated. Received free water boluses
thru NGT as well as IV D5 with improvement. Na at time of
discharge 152
OUTPATIENT
-- Continue monitoring of electrolytes; encourage PO intake and
adminster D5W if needed (however by cautious in setting of known
diastolic CHF).
# Goals of Care: On [**2137-10-25**] a goals of care discussion was held
with the patient's HCP [**Name (NI) **] [**Name (NI) 15155**]. The decision was made to
forgo aggressive management of the colonic adenoma as her life
expectancy with idiopathic pulmonary fibrosis (which she has
suffered with for ~8 years) is now less than 5 years and likely
less than one. The family wanted the patient to remain full code
and to have aggressive management of her pulmonary disease.
# Code: Full
# HCP [**Name (NI) **] [**Name (NI) 15155**] [**Telephone/Fax (1) 15156**]
.
.
TRANSITIONAL ISSUES
===================
Health Care Associated Pneumonia treatment
-- Continue on meropenem for planned 8d course, end date [**11-3**]
.
C. Difficile infection
-- Continue on flagyl and PO vanc for planned 10d course; end
date: [**11-9**]
.
Congestive Heart Failure
-- Continue PO Bumex 5mg daily; monitor weights as well as renal
function with weekly chem 10 panel
.
Mitral Valve Replacement; goal INR 2.5 - 3.5
-- Continue hep gtt until bridged with coumadin, 3mg daily, to a
therapeutic INR
.
Colonic Polyp; GI bleed
-- Please check twice weekly hematocrit check with plan to
transfuse if <24
.
Arrythmia
-- Restarting home dofetilide on discharge; primary cardiologist
aware.
.
Hypernatremia
-- Patient with improved PO intake in days leading up to
discharge however sodiums borderine in 140s-150s. Please monitor
closely to ensure patient does not need additional free water to
correction of electrolyte abnormality.
.
PCP [**Name Initial (PRE) **]:
[**Month (only) 116**] consider starting PCP prophylaxis given chronic steroid use.
Discussed with the patient's pulmonologist, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Patient
has been on it in the past, but when she was on higher doses of
PO steroids (~20 mg) chronically.
Left kidney mass was seen on CT abdomen which is new since [**2134**]
and will need follow up ultrasound and monitoring.
Medications on Admission:
1.amlodipine 5 mg PO DAILY
2.fexofenadine 60 mg Tablet PO BID
3.levothyroxine 112 mcg Tablet PO DAILY
4.omeprazole 20 mg Capsule, Delayed Release PO BID
5.multivitamin One Tablet PO DAILY
6.tiotropium bromide 18 mcg Capsule, w/Inhalation Device One Cap
Inhalation DAILY
7.atorvastatin 20 mg Tablet One Tablet PO DAILY
8.docusate sodium 100 mg Capsule One Capsule PO BID
9.dofetilide 125 mcg Capsule One Capsule PO Q12H
10.albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Two
Puff Inhalation Q4H (every 4 hours)PRN dyspnea.
11.cholecalciferol (vitamin D3) 1,000 unit Tablet Two Tablet PO
DAILY 12.fluticasone 110 mcg/Actuation Aerosol Two Puff
Inhalation [**Hospital1 **] 13.morphine 15 mg Tablet Extended Release One
Tablet
14.morphine 10 mg/5 mL Solution [**1-28**] PO Q4H PRN dyspnea.
15.calcium carbonate 200 mg calcium (500 mg) Tablet [**Hospital1 **]
16.warfarin 5 mg One Tablet PO 4X/WEEK ([**Doctor First Name **],MO,WE,FR).
17.warfarin 2 mg One Tablet PO 3X/WEEK (TU,TH,SA).
18.Epogen 20,000 unit/mL One Injection once a week.
19.guaifenesin 600 mg Tablet Extended Release One
Tablet Extended Release PO twice a day.
20.bumetanide 5 mg Tablet [**Hospital1 **]
21.prednisone 10 mg Tablet Sig: Please follow attached taper
instructions. Tablet PO once a day: On [**8-9**], take 40mg (4
tablets once daily). On [**8-11**], take 30mg (3 tablets once
daily). On [**8-14**], take 20mg (two tablets once daily). On
[**9-26**] and onwards, take 10mg per day (one tablet once daily).
22.ferrous sulfate 325 mg (65 mg iron) One Tablet PO once a day.
23.spironolactone 50mg [**Hospital1 **] added [**2137-10-5**]
Discharge Medications:
1. Outpatient Lab Work
Please obtain twice weekly hematocrits, INR (INR goal 2.5 - 3.5)
2. Outpatient Lab Work
Please obtain twice weekly chemistry panels (sodium, potassium,
chloride, bicarb, BUN, creatinine, mag, calcium, phosp) to
monitor for hypernatremia and chronic kidney insufficiency
3. bumetanide 1 mg Tablet Sig: Five (5) Tablet PO once a day.
4. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
5. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM: goal inr 2.5 - 3.5.
6. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): TO END [**2137-11-9**].
7. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO twice a day.
9. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO once a
day.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
11. multivitamin Capsule Sig: One (1) Capsule PO once a day.
12. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Inhalation once a day.
13. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
14. dofetilide 125 mcg Capsule Sig: One (1) Capsule PO twice a
day.
15. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Inhalation every four (4) hours as needed for shortness
of breath or wheezing.
16. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO once a day.
17. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
18. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO once a day as needed for pain: hold for
sedation, RR< 12.
19. morphine 10 mg/5 mL Solution Sig: [**1-28**] PO every four (4)
hours as needed for shortness of breath or wheezing.
20. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO twice a day.
21. Epogen 20,000 unit/mL Solution Sig: One (1) Injection once
a week: Please administer on Monday.
22. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
23. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours): TO END [**2137-11-9**].
24. heparin (porcine) in D5W Intravenous
25. nadolol 20 mg Tablet Sig: 0.5 Tablet PO once a day.
26. meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous every eight (8) hours for 3 days: TO END [**2137-11-3**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
GI bleed secondary to colonic lesion
Health care associated pneumonia
Acute on chronic kidney insufficiency
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms [**Known lastname **] it was a pleasure taking care of you.
You were admitted to [**Hospital1 18**] for evaluation of GI bleed and while
in house you developed respiratory compromise requiring
intubation.
.
Regarding the GI bleed, you were seen by our team of GI doctors
who performed a colonscopy. During the procedure a colonic
lesion was seen and a plan was devised to proceed for excisional
biopsy. You were transfused RBCs as needed and your blood counts
were monitored closely. After discussion with your family the
decision to undergo biopsy was deferred to the outpatient
setting.
.
While in house your breathing became labored on several
occassions which required intubation twice. The cause of the
distress included aspiration and possible pneumonia. You were
started on antibiotics with a plan to complete an 8d course.
Your transtracheal catheter was removed with plan to discuss
replacement as an outpatient. At time of discharge you were
oxygenating well using supplemental oxygen delivered by nasal
cannula.
Also you were noted to have an infection in your GI tract and
were started on antiobiotics to eradicate this bacteria.
Prior to discharge you were feeling much improved and the
decision was made to transition to a nursing facility/rehab
where you can work to optimize strength, mobility and nutrition.
.
CHANGES TO YOUR MEDICATIONS:
START 10mg Nadolol daily for gastric varices
CONTINUE MEROPENEM until [**2137-11-3**]
CONTINUE VANCOMYCIN AND FLAGYL until [**2137-11-9**]
STOP SPIRONOLACTONE and AMLODIPINE until told otherwise
CHANGE COUMADIN to 3mg daily (goal INR 2.5 to 3.5)
CHANGE BUMEX to 5mg daily (previously 5mg twice a day)
Again it was a pleasure taking care of you. Please contact with
any questions or concerns.
Followup Instructions:
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2137-11-26**] at 8:45 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
ICD9 Codes: 486, 2851, 5849, 2760, 4280, 2724, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1158
} | Medical Text: Admission Date: [**2141-4-5**] Discharge Date: [**2141-4-10**]
Date of Birth: [**2094-11-10**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 46-year-old
woman with history of migraine headaches. She had a head CT
and MRI done at an outside hospital which revealed a cerebral
aneurysm. She subsequently underwent a diagnostic angiogram at
[**Hospital1 18**] by Dr. [**Last Name (STitle) 1132**] which revealed 3 aneurysms, 1 of the right
internal carotid artery bifurcation, 1 of the right MCA
bifurcation, and 1 of the left origin of the anterior choroidal
artery.
HOSPITAL COURSE: The patient was admitted and taken to the
OR on [**2140-4-5**] and had a clipping of a right MCA and right ICA
bifurcation aneurysms. Intraoperatively there were no
complications. The patient was transferred to the Intensive Care
Unit for close monitoring where she remained awake, alert,
oriented times three, moving all extremities strongly with no
drift. Her chest was clear to auscultation. Cardiovascular was
regular rate and rhythm, her abdomen as soft, nontender, non
distended. Her extremities were warm. She had positive
pedal pulses and no edema. Her muscle strength was [**4-16**] in
all muscle groups and sensation was intact to light touch.
She was transferred to the regular floor on [**2140-4-6**] in stable
condition. She had a T max of 101.3 on [**2141-4-9**], all cultures
were negative. On [**4-10**] she had been afebrile and was
discharged to home in stable condition with follow-up with
Dr. [**Last Name (STitle) 1132**] in one weeks time.
DISCHARGE MEDICATIONS: Fioricet 1-2 tabs po q 4 hours prn.
Patient was stable at the time of discharge.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2141-4-10**] 09:31
T: [**2141-4-10**] 20:32
JOB#: [**Job Number 40852**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1159
} | Medical Text: Admission Date: [**2196-3-13**] Discharge Date: [**2196-3-17**]
Date of Birth: [**2196-3-13**] Sex: M
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname 49922**] was a 34 and
[**3-28**] week gestation male infant admitted to the Neonatal
Intensive Care Unit for prematurity. He was born to a 21
year-old G2 P0 now 1 mother with unremarkable prenatal
screens, A positive, antibody negative, hepatitis B surface
unknown. Estimated date of delivery was [**2196-4-20**] for
estimated gestational age of 34 and 4/7 weeks. Pregnancy was
complicated by antepartum hemorrhage at 30 weeks gestation,
spontaneous onset of preterm labor, rupture of membranes one
hour prior to delivery yielding clear amniotic fluid. There
was some maternal fever to 100.4 degrees Fahrenheit, but no
fetal tachycardia. Intrapartum antibiotics were administered
vaginal delivery under epidural anesthesia and nubain.
Infant was vigorous at delivery. He was suctioned, dried,
tactile stimulation provided. There was mild grunting
and free flow oxygen was provided. Apgars were 8 and 9. He
was transferred to the Neonatal Intensive Care Unit for
further management.
INITIAL PHYSICAL EXAMINATION: Birth weight 2385 grams (50th
to the 70th percentile). Head circumference 31 cm (25 to
50th percentile), length 47 cm (50 to the 70th percentile).
Well appearing infant in no acute distress. HEENT anterior
fontanel soft and flat, nondysmorphic. Palette intact. Neck
and mouth normal. No nasal flaring. Chest no retractions.
Good breath sounds bilaterally. No crackles. No grunting.
Cardiovascular well perfused, regular rate and rhythm.
Femoral pulses normal. S1 and S2 normal. No murmur.
Abdomen soft, nondistended, no organomegaly. Active bowel
sounds. Anus patent. Genitourinary normal male genitalia.
Testes descended bilaterally. Neurological active, alert,
responds to stimulation, tone appropriate for gestational age
moving all limbs symmetrically. Suck, root, gags, grasp,
were all normal. Musculoskeletal normal spine and clavicles,
hip deferred. Skin normal, hyperpigmented macule on lower
sacrum and buttocks.
LABORATORY: Initial glucose was 57.
IMPRESSION: Baby [**Name (NI) **] [**Known lastname 49922**] is a 34 [**3-28**] week gestation age
male with transient respiratory symptoms secondary to
respiratory positioning, and sepsis risk, based on maternal
GBS colonization status, preterm labor, maternal fever and
initial respiratory symptoms.
HOSPITAL COURSE: 1. Respiratory: The baby's initial
respiratory symptoms resolved without further respiratory
support. He remained on room air throughout his admission.
No apneic or bradycardic episodes noted.
2. Cardiovascular: The baby boy [**Name (NI) 49922**] remained
hemodynamically stable throughout his admission. No murmurs.
3. FEN: The patient has been tolerating breast milk PE 20
po ad lib without problems. His birth weight was 2385 grams.
His weight on the day of discharge was 2380 grams.
4. Gastrointestinal: Baby boy [**Known lastname 49922**] had no issues with
hyperbilirubinemia. His bilirubin level on [**3-15**] was 6.0.
No phototherapy initiated.
5. Hematology: Baby boy [**Known lastname 49923**] initial hematocrit was
44.3. No transfusions required during this admission.
6. Infectious disease: The patient was started on
Ampicillin and Gentamicin for a 48 hour sepsis rule out. His
blood culture remained negative at this time and antibiotics
were discontinued at 48 hours.
7. Audiology: Hearing screen was performed with automated,
auditory brain stem responses and the patient passed
bilaterally.
CONDITION ON DISCHARGE: Baby boy [**Known lastname 49922**] has been stable on
room air without any apneic or bradycardiac episodes. He has
been tolerating full feeds well.
DISCHARGE DISPOSITION: The baby is to be discharged home
with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 49924**] [**Name (STitle) 49925**], telephone
number [**Telephone/Fax (1) 3581**].
CARE AND RECOMMENDATIONS: Feeds at discharge po breast milk
or PE 20 ad lib. Medications, none. Car seat position
screening, passed. State newborn screening sent.
Immunizations hepatitis B vaccine was given [**3-15**].
Immunization recommendations, Synagis RSV prophylaxis should
be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet
any of the following three criteria, one born at less then 32
weeks, born between 32 and 35 weeks with plans for day care
during RSV season, with a smoker in the household or with
preschool siblings or 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 care
givers should be considered for immunization against
influenza to protect the infant.
FOLLOW UP APPOINTMENTS SCHEDULED: [**3-18**] with Dr. [**Last Name (STitle) 49924**]
[**Name (STitle) 49925**] or associates.
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Transitional respiratory distress, resolved.
Reviewed By: [**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) 36250**]
Dictated By:[**Last Name (un) 49926**]
MEDQUIST36
D: [**2196-3-17**] 02:08
T: [**2196-3-17**] 14:15
JOB#: [**Job Number 49927**]
ICD9 Codes: V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1160
} | Medical Text: Admission Date: [**2171-1-7**] Discharge Date: [**2171-1-13**]
Date of Birth: [**2105-4-22**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 65-year-old
male with a history of coronary artery disease, peripheral
vascular disease, chronic obstructive pulmonary disease, and
chronic renal insufficiency secondary to bilateral renal
artery stenosis who presents from Spinal [**Hospital **] Rehabilitation
for intractable hypertension.
He was seen at the [**Hospital1 69**] in
the middle of [**2170-10-1**] after experiencing lower
extremity paralysis at an outside hospital in the setting of
an aggressive antihypertensive regimen. Ultimately, it was
discovered that his relative hypotension had resulted in
significant end-organ damage including an anterior spinal
artery infarct resulting in T11 paraplegia, acute renal
failure, and a troponin leak. The patient was sent to
neurologic rehabilitation at the end of [**Month (only) 359**].
Since arriving at rehabilitation, the patient has made
significant neurologic improvement progressing from 0/5
strength in his lower extremities to 4- strength in some
muscle groups at present. His course has been marked
continued hypertension that is refractory to four
antihypertensive medications including minoxidil. It is
believed that his hypertension is most likely secondary to
his bilateral renal artery stenosis. Because of this, he was
transferred back to [**Hospital1 69**] for
definitive treatment. Given that aggressive blood pressure
lowering has yielded catastrophic results in the past, it was
decided to admit him to the Intensive Care Unit for invasive
blood pressure monitoring and parenteral therapy.
On admission the patient denies chest pain, fever, chills,
nausea, vomiting, shortness of breath, palpitations, bowel or
bladder incontinence, lightheadedness, or headache. He is
able to move his legs spontaneously.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post myocardial
infarction in the setting of sudden hypotension.
2. Peripheral vascular disease, status post aortobifemoral
bypass.
3. Chronic obstructive pulmonary disease.
4. Chronic renal insufficiency with a baseline creatinine
of 2, and bilateral renal artery stenosis as described above.
5. Anterior spinal artery infarct secondary to
hypoperfusion in the setting of antihypertensive medications.
6. Difficult to control hypertension.
7. Recent hospitalization in [**2170-9-1**] for a right
upper lobe pneumonia requiring intubation for one month,
status post a long course of levofloxacin.
8. Clostridium difficile colitis.
9. Eosinophilic fasciitis, currently on prednisone,
methotrexate, and leucovorin.
10. Steroid-induced hyperglycemia.
MEDICATIONS ON TRANSFER:
1. NPH insulin 10 units subcutaneous q.12h.
2. Acidophilus 3 tablets p.o. q.i.d.
3. Aspirin 81 mg p.o. q.d.
4. Plavix 75 mg p.o. q.d.
5. Diltiazem 50 mg p.o. q.8h.
6. Xanax 0.25 mg p.o. q.6h.
7. Colace 100 mg p.o. q.h.s.
8. Epogen 5000 units subcutaneous every Monday and every
Thursday.
9. Methotrexate 20 mg every Wednesday.
10. Leucovorin 5 mg 12 hours after her receives his
methotrexate dose.
11. Os-Cal 500 mg p.o. q.a.c.
12. Lasix 60 mg p.o. q.d.
13. Miacalcin 1 spray in alternating nostril q.d.
14. Lopressor 100 mg p.o. q.12h.
15. Minoxidil 10 mg p.o. q.d.
16. Nitroglycerin paste 1 inch to 2 inches q.4h.
17. Prednisone 30 mg p.o. b.i.d.
18. Zantac 150 mg p.o. q.12h.
19. Multivitamin 1 tablet p.o. q.d.
20. Vancomycin 250 mg p.o. b.i.d. until [**1-24**];
then 250 mg p.o. q.d. until [**2171-2-7**].
21. Regular insulin sliding-scale.
22. Dulcolax 10 mg p.r. p.r.n.
23. Benadryl 25 mg p.o. q.6h. p.r.n.
24. Lactulose 30 cc p.o. q.d. p.r.n.
25. Fleets enema p.r.n.
26. Ultram 15 mg p.o. q.6h. p.r.n.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He lived with his mother and daughter at
home prior to his admission to [**Hospital1 188**] in [**2170-10-1**]. He has a 50-year smoking history,
smoking three packs per day. He quit in [**2170-10-1**].
Since then he has resided at [**Hospital1 **] [**Hospital **]
Rehabilitation.
FAMILY HISTORY: Family history noncontributory.
PHYSICAL EXAMINATION ON PRESENTATION: This is a pleasant
65-year-old gentleman in no acute distress who was afebrile
with a blood pressure of 186/74 by cuff, and 195/72 by
arterial line. His heart rate was 75. He was satting at 98%
to 100% on room air. His head, ears, nose, eyes and throat
examination was unremarkable. He had no jugular venous
distention. His lungs were clear with no wheezes or rales.
His heart was regular in rate and rhythm with normal first
heart sound and second heart sound, and a 2/6 systolic
ejection murmur at the left sternal border. His abdomen was
benign except for multiple ecchymoses along his lower abdomen
and guaiac-positive stool. His extremities were significant
for clubbing bilaterally. He had good distal pulses. He had
3+ pitting edema to his calves bilaterally. There were no
femoral bruits. He had [**5-5**] upper extremity strength
bilaterally with decreased range of motion at bilateral
elbows. Neurologically, his mental status was intact. His
cranial nerves II through XII were grossly intact. He had
[**5-5**] upper extremity strength bilaterally. He had [**1-5**] to [**2-5**]
lower extremity strength bilaterally except for 4- bilateral
plantar flexion. His toes were equivocal. He had 0 deep
tendon reflexes of his biceps, patellar, and Achilles.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories
revealed a white blood cell count of 9.2, hematocrit of 26.9,
and platelet count of 157. His sodium was 134,
potassium 5.2, chloride 100, bicarbonate 24, blood urea
nitrogen 67, and creatinine of 1.2. His glucose was 226.
His albumin was 3.4. His calcium was 8.5, magnesium 2, and
phosphorous of 2.7. His coagulations were within normal
limits.
RADIOLOGY/IMAGING: Electrocardiogram revealed normal sinus
rhythm with normal axis and normal intervals. He had left
ventricular hypertrophy with strained pattern. He had a Q
wave in III.
Echocardiogram from [**2170-10-25**], showed an ejection
fraction of 45%, with mild left atrial dilatation, and mild
symmetric left ventricular hypertrophy. He had resting
regional wall motion abnormalities including akinesis of the
basal and middle inferoposterior wall, and hypokinesis of the
posterolateral wall. He had a normal size and wall motion of
his right ventricle. He had moderate 2+ mitral
regurgitation.
HOSPITAL COURSE:
1. CARDIOVASCULAR: Mr. [**Known lastname **] was admitted to the
Coronary Intensive Care Unit. His oral antihypertensive
medications were held, and he was started on a Nipride drip
to keep his systolic blood pressure between 150 and 170. He
had a single episode of chest pain associated with a systolic
blood pressure of 220 while on the Nipride drip, so a
nitroglycerin drip was added as well. He had no
electrocardiogram changes or enzyme leak associated with the
chest pain. It resolved quickly after his blood pressure was
lowered.
He was then taken to the catheterization laboratory where he
received a left renal artery stent for a 90% proximal
stenosis. His right renal artery was totally occluded
proximally. He also had 3-vessel coronary artery disease
with normal left main artery, moderately diseased left
anterior descending artery, totally occluded middle left
circumflex and proximal right coronary artery, with good
collateral flow to the distal portions of both of those
vessels.
After the procedure, he was weaned off of the Nipride and
nitroglycerin drips and changed to oral antihypertensives.
His goal systolic blood pressure is 140 to 160. To that end,
he was started on metoprolol 100 mg p.o. q.6h.,
captopril 50 mg p.o. t.i.d., and Norvasc 5 mg p.o. q.d. He
continued to have systolic blood pressures in the 170s to
200s after two days of this regimen, so minoxidil 10 mg p.o.
q.d. was added. His systolic blood pressure was initially in
the 150s the following day but then dropped into the 130s the
day after. This pressure is most likely too low for him
given the range of systolic blood pressures he is typically
accustomed to. He began having 5-minute episodes of slightly
blurred vision, that were most likely due to his low blood
pressure. Thus, his regimen was changed to metoprolol 200 mg
b.i.d., captopril 25 mg t.i.d., and minoxidil 10 mg q.d. at
staggered times. If his systolic blood pressure is
consistently below 130, he should have his minoxidil stopped.
If he then has systolic blood pressures greater than 170 on
a regular basis after stopping the minoxidil, he should have
his captopril dose increased to 50 mg t.i.d.
His renal function would most certainly benefit from the
stent placement. We are hopeful that his hypertension may be
more easily managed in the weeks that follow as well.
2. RENAL: His creatinine remained stable at 1 to 1.2 during
his entire hospital course. He received hydration and
Mucomyst prior to catheterization. He was closely followed
by the Renal consultation team during his hospitalization.
Of note, a urine culture revealed a Proteus urinary tract
infection that was treated with three days of ceftriaxone.
3. GASTROINTESTINAL: He was treated with a course of Flagyl
for his Clostridium difficile colitis. He had no diarrhea
during his hospital stay, and his stool was negative for
Clostridium difficile toxin times two. He did have trace
guaiac-positive stool on admission, and his hematocrit
drifted down over the first few days in the hospital. He
received 2 units of packed red blood cells with good
response, and his hematocrit stabilized after that. He will
need a colonoscopy as an outpatient in the future to work up
this possible gastrointestinal bleed.
4. ENDOCRINE: He was continued on his steroids,
methotrexate, and leucovorin for his eosinophilic fasciitis.
His fingerstick blood sugars were well controlled on his
current NPH regimen.
5. LINES: He had an arterial line initially for intensive
blood pressure monitoring while on Nipride that was removed
after his drips were stopped. He came with a Foley catheter,
and when we spoke to him, he said that he preferred having an
indwelling Foley to intermittent straight catheterization,
and so the Foley catheter was left in place.
6. CODE STATUS: Full code.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: To [**Hospital1 700**] [**Hospital **]
Rehabilitation to follow up with Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] in four
to six weeks.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, 3-vessel.
2. Chronic renal insufficiency with a baseline creatinine
of 1 to 1.2.
3. Bilateral renal artery stenosis, status post left renal
artery stenting.
4. Hypertension; currently controlled on Lopressor,
captopril, and minoxidil.
5. Paraplegia secondary to anterior spinal artery infarct.
6. Eosinophilic fasciitis complicated by steroid-induced
hyperglycemia.
7. Chronic obstructive pulmonary disease.
MEDICATIONS ON DISCHARGE:
1. NPH insulin 10 units subcutaneous q.12h.
2. Aspirin 81 mg p.o. q.d.
3. Plavix 75 mg p.o. q.d.
4. Colace 100 mg p.o. q.h.s.
5. Epogen 5000 units subcutaneous every Monday and every
Thursday.
6. Prednisone 30 mg p.o. b.i.d.
7. Methotrexate 20 mg every Wednesday.
8. Leucovorin 5 mg 12 hours after receiving methotrexate.
9. Multivitamin 1 tablet p.o. q.d.
10. Regular insulin sliding-scale.
11. Dulcolax 10 mg p.o./p.r. p.r.n.
12. Lactulose 30 cc p.o. q.d. p.r.n.
13. Zantac 150 mg p.o. q.12h.
14. Os-Cal 500 mg p.o. q.a.c.
15. Miacalcin 1 spray in alternating nostrils q.d.
16. Captopril 25 mg p.o. t.i.d.
17. Lopressor 200 mg p.o. q.12h.
18. Minoxidil 10 mg p.o. q.d. (please monitor blood pressure
medications; namely captopril, Lopressor, and minoxidil).
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Name8 (MD) 1552**]
MEDQUIST36
D: [**2171-1-14**] 19:25
T: [**2171-1-16**] 14:59
JOB#: [**Job Number **]
ICD9 Codes: 4111, 486, 5990, 5849, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1161
} | Medical Text: Admission Date: [**2153-10-9**] Discharge Date: [**2153-10-13**]
Service: MEDICINE
Allergies:
Lipitor
Attending:[**First Name3 (LF) 5119**]
Chief Complaint:
[**First Name3 (LF) **], hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Initial history and physical is as per the ICU team
.
Ms. [**Known lastname **] is an 84 yo female with DMII, CHF (last EF 30%),
presenting to the ED with [**Known lastname **]. She was referred to the ED by
visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] on VS check. Per hx from [**Last Name (Titles) 802**] who
last saw her 2 weeks, states that patient had a cough and has
chronic SOB. She is wheelchair bound secondary to generalized
muscle weakness.
.
In the ED her initial vitals were T 103.5 (rectal), BP 113/73,
HR 80, RR 16, with transient increase in RR to 30. Her BP then
briefly dropped to SBP 70s which returned to >110 with IVFs
(1.5L NS). She was satting 93-97% on RA. On CXR, she was found
to have a likely RUL infiltrate. Placement of a right IJ line
was attempted with the complication of entering the right
carotid artery, no hematoma was observed after pressure held. A
right EJ was placed as well as a left femoral line.
.
On interviewing the patient, she has no acute complaints except
for L lower leg pain which she states is not new. She denies
chest pain, shortness of breath, cough, pain with inspiration,
abdominal pain, nausea or vomiting. She states that she
otherwise is comfortable.
.
ROS: Denies HA, Cough, Chest Pain, Vomiting, Abdominal Pain,
Chills, Dysuria. No recent trauma.
Past Medical History:
PVD s/p bypass [**2151**]
DM2 with complications neuropathy
HTN
cardiomyopathy - systolic CHF with EF 35-40%
chronic LE edema
hyperlipidemia
osteoporosis
GERD
s/p appy
B12 deficiency
vertebral disc surgery - hardware in lumbar spine
Pacemaker - [**Hospital3 9642**] in [**2149**] for intermittent AV block and
bradycardia
Social History:
She lives with her son, who has mental illness. Denies any
tobacco, alcohol or IVDU. Her [**Last Name (LF) 802**], [**Name (NI) 1154**] [**Name (NI) 23531**] is a nurse on
[**Wardname 836**] here at [**Hospital1 18**] and is her HCP. She has a visiting nurse
once weekly, but likely needs a home health aid per her [**Hospital1 802**].
Family History:
There is no family history of premature coronary artery disease
or sudden death
Physical Exam:
T=36.9, BP=105/70, RR=15, HR=71 paced, SpO2=100%
Gen: Well nourished, NAD
HEENT: EOMI. Sclera Anicteric. No scleral edema. Irregular pupil
borders, evidence of prior cataract surgery. Minimal exudate on
oropharynx. Moist mucus membranes. Upper/Lower dentures in
place.
Neck: No lymphadenopathy. Palpable carotid upstrokes. Right EJ
in place. No hematoma appreciated
Cards: Distant heart sounds. RRR. Systolic murmur heard at LLSB.
Lungs: Bronchial breath sounds heard at Right apex. Otherwise
CTAB.
Abd: Soft, nontender, nondistended. Positive bowel sounds. No
organomegaly.
Ext: 10cm area of superficial ulceration consistent with a tear
on medial left shin. Bilateraly 1+ pitting edema up to
mid-shins; tender to palpation.
Neuro: Hard of hearing with better hearing on Left. Barely able
to raise legs off bed. Wiggles toes.
Psych: Alert. Knows own name and that of PCP. [**Name10 (NameIs) **] to state
location, but knows she is in a hospital. Able to describe
weather, but was unable to state current month.
Pertinent Results:
[**2153-10-9**] 01:00PM WBC-12.4*# RBC-3.84* HGB-12.3 HCT-36.0 MCV-94
MCH-32.1* MCHC-34.2 RDW-14.3
[**2153-10-9**] 01:00PM NEUTS-90.8* LYMPHS-6.6* MONOS-2.1 EOS-0.2
BASOS-0.2
[**2153-10-9**] 01:00PM PLT COUNT-219
[**2153-10-9**] 01:00PM GLUCOSE-282* UREA N-27* CREAT-1.3* SODIUM-134
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-21* ANION GAP-16
[**2153-10-9**] 01:10PM LACTATE-1.6
[**2153-10-9**] 01:00PM CALCIUM-8.9 PHOSPHATE-3.3 MAGNESIUM-2.1
[**2153-10-9**] 01:00PM CK-MB-3 cTropnT-0.04* proBNP-[**Numeric Identifier **]*
[**2153-10-9**] 01:00PM CK(CPK)-297*
[**2153-10-9**] 08:44PM PT-13.2 PTT-25.3 INR(PT)-1.1
[**2153-10-9**] 12:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2153-10-9**] 12:45PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG
[**2153-10-9**] 12:45PM URINE RBC-[**2-28**]* WBC-[**2-28**] BACTERIA-MANY
YEAST-NONE EPI-0
AP PORTABLE CHEST, [**2153-10-9**]
IMPRESSION: Suggestion of right suprahilar or mediastinal
airspace process, likely pneumonia. Repeat radiography
recommended after appropriate therapy.
EKG: Rate 85bpm. Baseline artifact. Probable sinus rhythm with
atrial sensed and ventricular paced rhythm but baseline artifact
makes assessment difficult. Since the previous tracing of
[**2152-9-25**] sinus rate is faster and there appears to be atrial
sensed and ventricular paced rhythm.
Legionella Urinary Antigen (Final [**2153-10-10**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 71024**] AT 14:25PM ON [**2153-10-10**]
- 4I.
PRESUMPTIVE POSITIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
URINE CULTURE (Final [**2153-10-11**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
Brief Hospital Course:
84 year old female with PMH of DM2, CHF, s/p PPM in [**2148**],
chronic LE edema who presented to the ED after a visiting nurse
found her to be febrile.
# Legionella Pneumonia/sepsis: Patient had RUL infiltrate on CXR
with [**Year (4 digits) **] on admission and elevated white count. Due to low
blood pressure with SBP in the 80s at times, patient received an
arterial line yesterday and levophed, which was subsequently
weaned. Urine culture data is positive for Legionella, and
patient was given levofloxacin which was started in the ED.
Blood cultures were negatvie to date. Pt instructed to complete
14 day course of Levofloxacin as coverage for legionella.
.
# Enterococcus UTI: Patient's UA in the ED showed many bacteria
with few WBC and negative Leuk esterase. Urine culture grew
>100k enterococcus. Patient was intitailly on vancomycin in the
ICU this was changed to ampacillin and the patient was
instructed to complete a 7 day course. An attempt was made to
discontinue the patient's foley but she was unable to urinate
and had a significant amount of urinary retention. An attempt
should be made to remove the patient's foley in a few days after
antibiotic course completed.
.
#Delirium: Patient's mental status seemed to wax and wane at
times. Was likely related to acute infection. Electrolytes
were stable. Patient did not require any pharmocologic
restraint. TSH, free t4, RPR, b12, folate, pending. The
patient reportedly has some baseline cognition issues at home
and is extremely heard of hearing. Patient seen by geriatrics
consult team who agrred with our management and recommended
frequent reorientation
.
#Chronic Systolic CHF: Patient has history of systolic CHF with
EF=30% on [**2152-9-22**]. BNP=[**Numeric Identifier **] in ED with unknown baseline.
Multiple CXR are inconsistent with a CHF exacerbation. Patient
did not complain of shortness of breath. Stirct I/os were
monitored. Before discharge the patient was restarted on her
beta blocker, ace inhibitor, and lasix.
.
# Left Leg Ulcer: Chronic issue. Appears superficial without
substantial erythema. Wound care with antibiotic ointment, moist
barrier w/ sterile gauze.
.
# DM2: Patient was covered with a regular insulin sliding scale.
Glipizide was restarted at discharge.
.
#Hyperlipidemia: The patient was continued on ezetimibe
.
# Hypothyroidism: Patient recently prescribed synthroid by Dr.
[**Last Name (STitle) 713**]. Will continue levothyroxinedose of 25 mcg daily.
.
# PPx: SC heparin, PPI
.
# Code: Full Code (confirmed with HCP)
.
# Dispo: PT recommended STR but patient refuses to go. Patient
will be discharged hoe with home VNA services.
.
# Contact: [**Name (NI) 1154**] [**Name (NI) 4587**] ([**Name (NI) **]) [**Telephone/Fax (1) 71025**]
Medications on Admission:
Ezetimibe 10 mg qd
Furosemide 120 mg qd
Glipizide 2.5 mg qd
Vicodin 1 tab qid prn pain
Levobunolol 0.25 % Drops - 1 drop in each eye twice a day
Lisinopril 2.5 mg Tablet - 1 Tablet(s) by mouth daily
Toprol XL 25 mg qd
Tylenol 500 mg qd
ASA 325 mg qd
Vitamin B12 1000 mcg qd
Colace 100 mg qd
Senna
Vitamin D 400u qd
Discharge Medications:
1. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
4. Levobunolol 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
11. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Levaquin 750 mg Tablet Sig: One (1) Tablet PO q48h: Continue
through [**2153-10-22**].
13. Ampicillin 250 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours): Continue through [**2153-10-17**].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Legionella Pneumonia
Enterococcus UTI
Discharge Condition:
Good
Discharge Instructions:
-Complete course of levaquin for Legionella pneumonia (take
through [**10-22**])
-Complete course of ampacillin for enterococcus UTI (take
through [**10-17**])
-Take all other medications as prescribed
-VNA nursing should attempt to remove you foley on Monday (after
receiving antibiotics for UTI) and ensure that you are able to
void.
-Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
-Adhere to 2 gm sodium diet.
-Follow up with your PCP next week
[**Name9 (PRE) 21421**] follow up with podiatry and the heart failure NP as
already scheduled.
-Return to ED if have worsening shortness of breath, chest pain,
[**Name9 (PRE) **]/chills or other worrisome signs/symptoms.
Followup Instructions:
1. Please call [**Telephone/Fax (1) 719**] on Monday and arrange follow up with
your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 713**] for next week.
2.Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2153-11-21**] 10:30
3. Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**]
Date/Time:[**2153-12-19**] 11:00
4. Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**]
Date/Time:[**2153-12-19**] 11:30
[**First Name7 (NamePattern1) 1569**] [**Initial (NamePattern1) **] [**Name8 (MD) **] MD [**MD Number(2) 5122**]
Completed by:[**2153-10-13**]
ICD9 Codes: 5990, 4254, 2930, 5859, 2449, 2724, 3572, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1162
} | Medical Text: Admission Date: [**2169-3-15**] Discharge Date: [**2169-3-20**]
Date of Birth: [**2121-2-10**] Sex: F
Service: PSU
HISTORY: The patient is a bilateral prophylactic mastectomy
with bilateral [**Last Name (un) 5884**] inferior epigastric perforator flap, who
was admitted on [**2169-3-15**] and discharged on [**2169-3-20**].
Attending surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. The patient was
admitted status post operation. Please see operative
dictation. She had her flaps monitored for 24 hours and did
well. She had no hematoma, no seroma and flap remained
viable for the first 24 hours of Q-1 hour Doppler checks.
These were backed off to Q-3. Doppler checks seemed to have
been doing quite well. The patient continued to do well and
was progressed after surgery. Her pain medication was
advanced from intravenous medication to p.o. Her diet was
advanced. Flap checks were moved to every three hours. The
flap remained incredibly viable and appeared well. The
patient's hematocrit was checked twice in the duration of her
hospital stay. It was low, with the lowest point being 20.
She was placed on iron. Her heart rate remained in the 70s
to 80s range and, therefore, it was decided that the patient
would not necessarily need a transfusion and that she would
be observed for any signs of necessary transfusion. She was
given fluid boluses and seemed to do fine. She was able to
tolerate ambulation and her postop course was fairly
uneventful. The patient is to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
and have some of the JP drains removed at that time. She was
given oral pain control and discharged in stable condition,
status post [**Last Name (un) 5884**] flap for breast cancer.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 39103**]
Dictated By:[**Last Name (NamePattern1) 7823**]
MEDQUIST36
D: [**2169-3-21**] 11:34:43
T: [**2169-3-21**] 12:21:12
Job#: [**Job Number 57317**]
ICD9 Codes: 5180, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1163
} | Medical Text: Admission Date: [**2157-10-15**] Discharge Date: [**2157-10-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Fall/Confusion
Major Surgical or Invasive Procedure:
Thoracocentesis
History of Present Illness:
89-year-old gentleman who has a past medical history
of known CAD s/p CABG (LIMA-LAD; SVG-OM1; SVG-PDA) in [**2149**],
multiple prior PCI's, recent NSTEMI in [**9-16**] thought to be [**2-8**]
demand, on plavix and ASA, Afib no longer on coumadin,
hypertension, hyperlipidemia, and diet controlled diabetes, who
presents s/p unwitnessed fall. He was admitted to the MICU 1 day
ago. Patient does not recall fall or whether there was LOC. He
feel in his home from a standing position and hit his head. He
was noted to have a scalp laceration that was bleeding badly on
arrival to ED. He was estimated to have lost approx 1 unit of
blood and so was given one in the ED. The scalp lesion was
stapled by trauma [**Doctor First Name **]. He was hypotensive to SBP 50s in the ED.
In total he has received 2 PRBCS and 3L IVF over the past 24
hours. His BP stabilizied and so a lower dose of his lasix was
started this morning. CT head was negative.
In addition, he was hypoxic in the ED, requiring at NRB for a
short period of time. CT torson found a right sided non-diplaced
rib fracture and a fairly large left sided pleural effusion
which increased over the past 24 hours. A thoracentesis was
performed and removed 1500 cc of blood fluid. It was felt that
the effusion was secondary to rib fractures.
He reported that he had been feeling unwell all week. He was
found to have a UTI; cutlure is postive for GNRs. He was
initally given broad spectrum antibiotics but narrowed to
ceftriaxone for UTI. He currently feels well. He denies pain,
SOB, lightheadedness or dizziness.
.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
.
Past Medical History:
CAD h/o MI s/p CABG s/p PCI
DM, diet controlled
Afib following CABG not anticoagulated
HTN
hyperlipidemia
Anemia
OA
BPH s/p TURP
h/o scrotal hydrocele
spinal stenosis
carotid stenosis
diverticulosis
GERD
h/o hernia repair
h/o stroke
h/o colon polyps
labyrinthitis
s/p detatched retina
s/p tonsillectomy
Social History:
Non smoker. No EtOH. Married with 5 adult children. He is
retired. Prior to retiring he sold life insurance.
Family History:
noncontributory
Physical Exam:
Physical Exam:
Vitals: Tm: 98.8 Tc: 96.8 BP: 100/58 P: 69 R: 19 18 O2: 99% RA.
LOS 2 L positive. good UOP 1.8 over last 24 hrs.
General: Alert, oriented x3, no acute distress
HEENT: Right scalp lac with staples in place, no oozing. Sclera
anicteric, OP with Dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Dullness to percussion and decrease breath sounds on
right LL. Dressing from [**First Name5 (NamePattern1) 576**] [**Last Name (NamePattern1) 1830**].
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, + colostomy
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN grossly intact, MAE. sensation grossly intact.
Pertinent Results:
GENERAL LABS (CBC/LFT'S/CMP/COAGS)
.
[**2157-10-15**] 09:15AM BLOOD WBC-8.8 RBC-3.55* Hgb-11.0* Hct-31.8*
MCV-90 MCH-30.9 MCHC-34.5 RDW-14.4 Plt Ct-340
[**2157-10-18**] 09:05AM BLOOD WBC-6.7 RBC-3.43* Hgb-10.4* Hct-30.3*
MCV-88 MCH-30.3 MCHC-34.4 RDW-14.5 Plt Ct-265
[**2157-10-15**] 12:00PM BLOOD Neuts-81.3* Lymphs-12.8* Monos-5.0
Eos-0.5 Baso-0.3
[**2157-10-18**] 09:05AM BLOOD PT-14.2* PTT-34.2 INR(PT)-1.2*
[**2157-10-15**] 09:15AM BLOOD Glucose-144* UreaN-19 Creat-0.8 Na-126*
K-4.3 Cl-91* HCO3-27 AnGap-12
[**2157-10-18**] 09:05AM BLOOD Glucose-116* UreaN-13 Creat-0.6 Na-130*
K-4.1 Cl-98 HCO3-28 AnGap-8
[**2157-10-16**] 03:31AM BLOOD ALT-7 AST-18 LD(LDH)-185 CK(CPK)-52
AlkPhos-81 TotBili-1.3
[**2157-10-15**] 09:15AM BLOOD proBNP-5063*
[**2157-10-18**] 09:05AM BLOOD Calcium-8.1* Phos-3.1 Mg-1.8
.
..
Thoracentesis Fluid Analysis
.
PLEURAL ANALYSIS WBC RBC Hct,Fl Polys Lymphs Monos
[**2157-10-16**] 17:58 2.0*1
PLEURAL FLUID
[**2157-10-16**] 17:58 [**2147**]* [**Numeric Identifier 71296**]* 82*2 12* 6*
PLEURAL FLUID
.
.
LESS THAN
SPUN HEMATOCRIT PERFORMED
DIFFERENTIAL REVIEWED BY [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 85107**] [**2157-10-18**]
.
.
PLEURAL CHEMISTRY TotProt Glucose LD(LDH) Albumin
[**2157-10-16**] 17:58 3.4 122 186 2.5
PLEURAL FLUID
.
.
.
URINE CULTURE
**FINAL REPORT [**2157-10-18**]**
URINE CULTURE (Final [**2157-10-18**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. SECOND
MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 8 S 8 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-------- 64 I 32 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
.
.
.
EKG- [**2157-10-15**]
Ectopic atrial rhythm and increase in rate compared to the
previous tracing of [**2157-10-3**]. Left ventricular hypertrophy with
ST-T wave change.
Intraventricular conduction delay. There is scooping of the ST
segments
consistent with use of digitalis. Clinical correlation is
suggested.
TRACING #1
.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
74 170 118 442/[**Medical Record Number 97199**] 122
.
.
.
IMAGING
.
CXR [**2157-10-15**]
CHEST, AP SEMI-UPRIGHT: Again seen is a moderate right pleural
effusion, with partial redistribution along the lateral right
hemithorax and lung apex, likely due to positioning. Chronic
loculated effusion and pleural thickening along the left lateral
hemithorax and lung base are unchanged. There is continued
moderate vascular congestion and interstitial edema. Moderate
cardiomegaly is present, with median sternotomy wires,
mediastinal clips, and coronary bypass grafts. There is no
pneumothorax. Evaluation of the right middle and lower lobes is
limited by superimposed effusion. Mild retrocardiac atelectasis
persists. Diffuse skeletal demineralization persists, with
S-shaped thoracolumbar scoliosis and severe degenerative
changes. Vascular calcification are seen in the upper left
abdomen. Multiple punctate calcifications in the left upper
quadrant of the abdomen are compatible with splenic granulomas
as seen on prior CT.
.
.
CXR [**2157-10-17**]
COMPARISON: [**2157-10-16**].
.
FINDINGS: Moderate right and small partially loculated left
pleural effusions appear unchanged. No visible pneumothorax.
Acute right rib fracture is again demonstrated. No new or
progressive abnormalities.
.
IMPRESSION:
1. Stable moderate right effusion with compressive atelectsis.
2. Continued cardiomegaly and interstitial edema.
3. Chronic loculated left effusion and pleural thickening.
.
.
.
CT HEAD- [**2157-10-15**]
FINDINGS: There is no evidence of acute hemorrhage, large acute
territorial
infarction, or large masses. There is evidence of
periventricular white
matter hypodensities, in keeping with chronic vessel ischemic
changes.
Hypodensity along the subcortical white matter in the right
frontal lobe,
appears unchanged, 2B:26. Ventricles and sulci are prominent,
stable. There
is no hydrocephalus. There is no shift of midline structures.
Moderate
calcification in the carotid arteries, 3B:27, bilaterally.
Minimal mucosal
thickening is seen in the left maxillary sinus. There is no
evidence of
fracture. There is device in the right globe, 3B:33, correlate
with history.
.
IMPRESSION: No acute intracranial process. No fracture.
.
.
CT NECK [**2157-10-15**]
FINDINGS: Hypodensities in the thyroid gland could be further
evaluated with thyroid ultrasound in a nonurgent setting.
Complete opacification of the visualized portion of the right
lung apex.
.
No prevertebral soft tissue edema. The alignment of the cervical
spine is
grossly preserved. There are moderate-to-severe multilevel
degenerative
changes, and bones are diffusely osteopenic. With this
limitation in mind, no definite fracture is seen.
At level C6 posteriorly, there are osteophytes, impinging on
thecal sac, and in a patient with mechanism of injury, these
could put the patient at more risk for cord injury. Multilevel
narrowing of the cervical canal due to multilevel osteophytes.
There is multilevel narrowing of the neural foramina; however,
appears similar compared to MRI, and incompletely evaluated.
Moderate calcifications along bilateral carotid arteries; cannot
exclude a high-grade stenosis.
.
IMPRESSION:
1. Diffuse osteopenia with severe multilevel degenerative
changes through the
cervical spine. Suboptimal evaluation of the cervical spine for
fractures;
however, no definite fracture is seen.Incidental hemangioma of
C6 vertebra.
2. No prevertebral soft tissue edema.
3. Hypodensities in the thyroid gland, could be further
evaluated with
thyroid ultrasound in a non-emergent setting.
4. Complete opacification over the imaged portion of the right
lung apex.
5. Moderate calcification at the cerotids, cannot exclude high
grade
stenosis.
.
.
.
CT CHEST/ABDOMEN/PELVIS [**2157-10-15**]
CT CHEST: The airways are patent up to subsegmental level. There
is a large right pleural effusion, with adjacent atelectasis.
There is a small left pleural effusion with minimal atelectasis
at the left lung base. There is minimal atelectasis in the
lingula and left anterior lung, (3A:43). There is no evidence of
pneumothorax. There are no pathologically enlarged lymph nodes i
n the mediastinum, hilum, or axilla. There are scattered
prominent lymph nodes in the mediastinum, however, do not meet
the CT criteria for pathologic enlargement.
.
CTA: There is no filling defect in the pulmonary arteries to
suggest
pulmonary embolus. Patient is s/p remote CABG. There are severe
calcifications in the coronary arteries. There is no pericardial
effusion. The ascending aorta is slightly prominent, measuring
3.4 cm in diameter.
.
CT ABDOMEN: The liver enhances homogeneously. There is a
hypodensity in the right liver lobe, (3B:127), too small to be
characterized. There is no evidence of liver laceration. There
is no extra- or intra-hepatic biliary duct dilatation. The
gallbladder appears normal. Multiple small
calcifications are seen in the spleen, likely suggesting old
granulomatous infection. The adrenal glands and visualized loops
of small and large bowel appear within normal limits. There is
no evidence of bowel obstruction. Pancreas is atrophic. There
are moderate calcifications in the splenic vessels.
.
The kidneys enhance symmetrically and excrete contrast
symmetrically with no evidence of hydronephrosis. There are
bilateral hypodensities in the kidneys, too small to be
characterized. Stable small hyperdense cystic lesion in the
interpolar region of the left kidney. There is no perinephric
stranding. No free fluid or free air in the abdomen. There are
no pathologically enlarged lymph nodes in the retroperitoneum or
mesentery. There are moderate calcifications in the abdominal
aorta and iliac vessels.
.
CT PELVIS: The urinary bladder, prostate, and seminal vesicles
appear within normal limits. There is a small fat-containing
inguinal hernia, with a small amount of soft tissue as seen on
prior, (3B:162). There is no free fluid in the pelvis. There is
Foley catheter in the urinary bladder.
.
OSSEOUS STRUCTURES: There are similar fractures through the
right eighth and ninth ribs, comminuted as seen on most recent
CT. Nondisplaced rib fracture in the postero-superior rib on the
right, unable to compare to prior since that part of the chest
was not included on prior CT. Multilevel degenerative changes in
the spine.
.
IMPRESSION:
1. No filling defect in the pulmonary artery to suggest
pulmonary embolus.
.
2. Large right pleural effusion with adjacent atelectasis.
.
3. Small left pleural effusion with minimal atelectasis at the
left lung
base, in the lingula, and in the left anterior lung.
.
4. Segmental right eighth and ninth comminuted rib fractures,
similar to
prior. Nondisplaced rib fracture in the upper left posterior
chest wall,
uncertain if it is new since we do have prior CT chest to
compare.
.
5. Additional incidental findings are described in the report,
unchanged.
.
.
.
Fluid analysis (pleural fluid) [**2157-10-18**]
DIAGNOSIS: Pleural fluid:
NEGATIVE FOR MALIGNANT CELLS.
.
Brief Hospital Course:
This is an 89-year-old gentleman with a history of CAD s/p CABG
in [**2149**], multiple prior PCI's, recent NSTEMI in [**9-16**], on plavix
and ASA, Afib no longer on coumadin, HTN, HL, DM2, BPH, s/p
unwitnessed fall.
.
.
# s/p Fall: Unclear etiology based on history. [**Month (only) 116**] be secondary
to dehydration. Does not appear orthostatic. No vertigo. History
of carotid artery stenosis and CAD, but no changes on EKG s/o
cardiac etiology. Was mildly dehydrated and found to have a UTI,
which may have caused confusion and falls. Patient has a
history of falls. Ruled out for MI. Improved with minimal
intervention. Evaluated by PT, who suggested inpatient
rehabilitation.
.
# Hypotension: Initially hypotensive in the ED, most likely
secondary to blood loss, dehydration, and hypertensive
medications. Resuscitated with 3 L NS and 2 U PRBC's to
maintain blood pressures in the 110's-130's. Asymptomatic in
this range. BP medications initially held on the floors due to
concern of recurrent hypotension/blood loss status post fall.
HCT trended and stabalizaed around 30. Was stable throughout
hospital course. Continued sotalol as well as furosemide 20 mg
po daily upon discharge. Valsartan was held because blood
pressures were in the low hundreds range. FUROSEMIDE DOSE
DECREASED FROM 40 TO 20MG IN HOUSE AND PT LEFT ON THIS DOSE.
VALSARTAN HELD ON DISCHARGE for potential low BP in the presence
of acute fall.. PRIMARY CARE DOCTOR TO DECIDE WHEN TO
RESTART/CHANGE DOSING OF THESE MEDICATIONS.
.
# Pleural Effusion: found to ahve significant right sided
pleural effusion on admission xray. Tapped effusion, drained
1.5 L of bloody fluid. No malignant cells present. Thought to
be potential hemothorax from broken rib. Possible
reaccumulation seen by HD3, but interventional pulmonology
hesistant to tap given pt. is asymptomatic, breathing well on
room air, and on continual clopidogrel administration. Will
re-evaluate as an outpatient as necessary, but did not re-tap
patient during hospital stay. No further intervention pursued.
MR. [**Known lastname **] SHOULD HAVE A FOLLOW UP CXR IN [**1-9**] WEEKS.
.
# Rib fracutre: found to have non-displaced rib fracture on
right. Asymptomatic during stay. No further intervention
pursued.
.
# UTI: patient with GNRs in urine found to be pansensitive
(except to TMP/SMX) K. pneumoniae. Pt. received 5 days worth of
ceftriaxone, and will continue to receive 5 days worth of
cefpodoxime out of hospital for complicated UTI. Asymptomatic
during hospital course.
.
# Hyponatremia: Initially 126. Improved to 130s with IV
hydration. Likely initially hypovolemic hyponatremia. Encouraged
PO intake with minimal IVF supplementation. Ranged from 127-132
in house. Pt. discharged at 128. Encouraged not to drink free
water but rather diluted juices. Fluid intake limited to 2L per
day.
.
# CAD: s/p CABG and recent NSTEMI in [**2157-9-7**]. Currently
CP free and ruled out for MI by enzymes on this admission. Last
echo in [**9-/2157**] showed EF 30%. Held Valsartan for several days
due to BP 100-110's. Had Sotalol held a few times due to
hypotension. Continued on ASA, Plavix, and Simvastatin for
entire stay. Lasix was given at 20 mg dose, but held for 2 days
as pt appeared dry. Discharged on all original cardiac meds
(ASA, Plavix, Sotalol, SImvastatin, Valsartan, Furosemide),
except furosemide and valsartan given at lesser dose of 20 mg
and 160 mg qday respectively given possible overdiuresis that
caused his dehydration/fall and relatively low blood pressures.
.
# Systolic Heart Failure: Pt. has prolonged cardiac hx as well
as hx of HF flares. Recently hospitalized in [**9-/2157**] with HF
exacerbation. Last documeneted EF in [**9-/2157**] was 30%. Was
maintained on BB, [**Last Name (un) **], with diuresis PRN furosemide. Did not
have issues with being fluid overloaded while in the hospital.
Effusions felt to be [**2-8**] traumatic injury rather than pulmonary
congestion. Discharged on home regimen with f/u with his
cardiologist within the month. Lasix was decreased to 20 mg
daily and valsartan was held due to hypotension/low normal BP.
PCP'S DECISION TO CHANGE FUROSEMIDE DOSE AND RESTART VALSARTAN.
Pt encouraged to have PO intake of fluids, but to limit intake
to <2L / day and to weigh himself daily based on hx. of sHF.
.
# Afib: Was initially in NSR. Not on coumadin because of history
of falls. Was removed from tele 2nd day on the general medical
floors, as he was not symptomatic/having fib waves. He was
managed with sotalol and ASA 325mg and Plavix 75mg daily without
issues.
.
#BPH- history of difficulty urination, s/p TURP. Wife requested
in house urology evaluation, but based on the lack of acuity of
pt's symptoms, was deferred for outpatient management. Had
foley in place to manage UOP, which was borderline on HD3/4 in
the range of 400-500 cc's per day. Bolused sparingly, 500 cc's
NS once a day toward the end of hospital stay. UOP normalized,
and foley removed. Pt encouraged to have PO intake of fluids,
but to limit intake to <2L / day and to weigh himself daily
based on hx. of sHF.
.
# Diet controlled DM: managed with qid fingersticks, SSI, and
diabetic diet without issues.
.
Comm: [**Name (NI) **] [**Name (NI) 97194**] (wife) [**Telephone/Fax (1) 97200**]
Code: FULL -confirmed with HCP
.
.
.
Medications on Admission:
1. Sotalol 20 mg po bid
2. Simvastatin 40 mg po daily
3. Nitroglycerin 0.3 mg SL PRN chest pain
4. Tamsulosin 0.4 mg po qhs
5. Omeprazole 20 mg po daily
6. Multivitamin po daily
7. Furosemide 80 mg po daily
8. Valsartan 320 mg po daily
9. Aspirin 325 mg po daily
10. Clopidogrel 75 mg po daily
11. Docusate Sodium 100 mg po bid
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
2. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. sotalol 80 mg Tablet Sig: 0.25 Tablet PO BID (2 times a day).
9. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day:
Please continue to take until [**2157-10-26**] for a total of 10 days
worth of antibiotics.
Disp:*12 Tablet(s)* Refills:*0*
10. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]
Discharge Diagnosis:
Primary:
Traumatic Rib Fracture
Pulmonary Effusion (Hemothorax)
Urinary Tract Infection
.
Secondary:
Coronary Artery Disease status post coronary artery
stents/angioplasty/bypass grafting
History of myocardial infection
Diabetes Mellitus
Atrial fibrillation
Hypertension
hyperlipidemia
hyponatremia
Anemia
Osteoarthritis
Benign Prostatic Hyperplasia
Spinal stenosis
Carotid stenosis
Diverticulosis
Gastroesophageal Reflux Disease
Stroke
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after a fall in your
home. Prior to the fall, you were feeling confused which may
have caused you to fall. You were found to be dehydrated and
also have a urinary tract infection when you came to the
hospital, which may have been contributing to your feelings of
confusion. You had imaging done in the emergency department,
which was negative for a bleed in your brain. Images of your
chest showed an old rib fracture on the right and an old
collection of fluid around your right lung (most likely from
your previous fall 1 month ago).
You were taken to the intensive care unit because you were
having difficulty maintaining oxygenation and keeping your blood
pressure up. You had the fluid around your lung drained, which
was mostly blood likely from your old rib fracture. You
received 2 blood transfusions as you also had a cut on your head
which bled a significant amount. These interventions helped
stabilize your blood pressure and oxygenation.
You were transferred to the general medical service, where
your UTI was treated. You remained stable for several days, and
were transferred to a rehabilitation facility for further
strengthing prior to going home.
.
.
.
While in the hospital, some of your medications were adjusted or
even stopped briefly. The following changes have been made to
your daily medications.
.
.
STOP TAKING : Furosemide 40 mg by mouth daily
START TAKING: Furosemide 20 mg by mouth daily
.
STOP TAKING: Valsartan 320 mg by mouth daily (to be resumed by
your PCP)
.
START TAKING: Cefpodoxime 200 mg by mouth daily (antibiotic for
UTI)
.
.
Since you have a diagnosis of systolic heart failure, you should
weigh yourself every morning, and [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs, as you may need to increase your fursoemide.
.
It has been a pleasure taking care of you [**Known firstname **]!
Followup Instructions:
You have an appointment with your primary care [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 97201**] on [**2157-10-27**] at 2:30 PM. Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 97202**]
Phone: [**Telephone/Fax (1) 53711**]
.
Other Appointments
.
Department: CARDIAC SERVICES
When: [**Telephone/Fax (1) **] [**2157-10-31**] at 1 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: CARDIAC SERVICES
When: THURSDAY [**2157-11-10**] at 2:40 PM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**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
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
ICD9 Codes: 5990, 2761, 2851, 4019, 2724, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1164
} | Medical Text: Admission Date: [**2160-1-6**] Discharge Date: [**2160-1-8**]
Date of Birth: [**2099-11-6**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Pt awoke with c/o the worst headache.
Major Surgical or Invasive Procedure:
External Ventricular Drain placed [**2160-1-6**]
Cerebral Angiogram [**2160-1-6**]
History of Present Illness:
This nonsmoking Right handed 60yo male awoke this am with c/o
the worst
headache of his life behind R.eye. Shortly after began vomiting.
Pt without headache relief, became diaphoretic around 4pm with
continued headache extending from behind his right eye
posteriorly down his neck, nausea and vomiting x4-5. Pt called
his wife and 911. Pt brought to OSH, head CT obtained, which
showed diffuse SAH involving sylvian fissure and basal cisterns
with hydrocephalus. Received Nimodipine at OSH without any other
medication given. Transferred to [**Hospital1 18**].
He became increasingly lethargic while he was in the ER. Ancef
1gram was given and a ventriculostomy was placed prior to taking
him for an angiogram.
Past Medical History:
Legally blind with Macular degeneration [**2132**]'s, 4vessel CABG
[**2132**], Type II diabetes, hypercholesterolemia, HTN
Social History:
Lives with his wife, social [**Name (NI) 75920**] weekend, tobacco
quit
19yrs ago
Family History:
unknown
Physical Exam:
Gen: WD/WN, c/o posterior headache radiating down neck,
restless.
HEENT: Pupils: [**6-1**] bilat, brisk rxn EOMs: intact with
conjugated
lateral nystagmus, + Left homonomous hemianopsia
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, lethargic, difficulty keeping
eyes open during conversation, 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, 5to4 mm
bilaterally. Left homonomous hemianopsia,
III, IV, VI: Extraocular movements intact bilaterally, bilateral
conjugate
lateral 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 [**6-2**] throughout.Minimal left
pronator
drift.
Decreased finger to nose coordination.
Sensation: Intact to light touch, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 5---------->
Left 5---------->
Toes downgoing bilaterally
Pertinent Results:
COMPLETE [**Month/Day (1) 3143**] COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2160-1-8**] 02:48AM 10.8 3.85* 12.2* 34.6* 90 31.8 35.3* 12.8
212
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
[**2160-1-6**] 11:16PM 93.5* 0 3.7* 2.6 0.2 0.1
[**2160-1-6**] 06:07PM 93.0* 0 4.1* 2.9 0.1 0
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr
[**2160-1-6**] 11:16PM NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL
[**2160-1-6**] 06:07PM NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2160-1-8**] 02:48AM 212
[**2160-1-8**] 02:48AM 12.61 25.2 1.1
1 NOTE NEW REFERENCE RANGE AS OF [**2159-12-12**] 12:00A
[**2160-1-6**] CT/CTA HEAD W/W-O CONTRAST:
1. Large amount of subarachnoid hemorrhage with diffuse
distribution in basilar cisterns and throughout bilateral
fronto-temporal lobes and falx. Slight asymmetry with
predominance on the right. 2. CTA source and MIP images do not
demonstrate aneurysm or vascular malformation.
[**2160-1-6**] CEREBRAL ANGIOGRAM
TECHNIQUE: After obtaining written informed consent, the patient
was brought to the interventional neuroradiology suite and
placed on the fluoroscopy table in the supine position. Moderate
sedation was obtained using 15 mcg of fentanyl and 4 mg of
Versed. Both groins were prepped and draped in the usual sterile
fashion. Using local anesthesia with 1% lidocaine mixed with
sodium bicarbonate and aseptic precautions, access was obtained
into the right common femoral artery using a 6 French vascular
sheath. The sheath was connected to a continuous saline
infusion. A 5 French [**Doctor Last Name **] catheter was advanced coaxially
over a 0.038 hydrophilic glidewire into the aortic arch. Under
fluoroscopy, the following vessels were selectively catheterized
and arteriograms were performed in AP and lateral projections:
The right common carotid artery, the right internal carotid
artery, the left vertebral artery, and the left common carotid
artery. After review of the films, the catheter and sheath were
withdrawn and pressure was applied on the groin until hemostasis
was obtained. The patient was sent to the CT scanner for a post-
angiogram head CT. Then, the patient was sent to the surgical
ICU for further management.
The study is slightly limited due to patient motion.
Arteriogram of the right common carotid artery demonstrates
prompt flow of contrast into the internal and external carotid
artery including their main branches. There is no high-grade
stenosis or occlusion at the origin of either the internal and
external carotid artery.
Arteriogram of the right internal carotid artery demonstrates
prompt flow of contrast into the right anterior and right middle
cerebral arteries. There is no aneurysm identified in the
anterior communicating artery or the bifurcation of the right
middle cerebral artery. There is no high-grade stenosis or
occlusion present.Mild irregularity of the supraclinoid artery
Upon arteriogram of the left vertebral artery, there was prompt
flow of contrast into both posterior cerebral arteries. The
basilar artery appears to be within normal limits. Both anterior
inferior cerebellar arteries as well as the left posterior
inferior cerebellar artery was obtained. There was no reflux of
contrast into the right vertebral artery to evaluate the right
PICA.
Arteriogram of the left common carotid artery demonstrates
prompt visualization and flow into the right internal and
external carotid arteries showing normal caliber vessels.
Visualization of the left anterior and middle cerebral artery
was also obtained, which shows no aneurysm. There is also no
high-grade stenosis or vessel occlusion.
There is no vascular malformation.
Catheterization of the right vertebral artery was going to be
attempted for evaluation of right PICA. However, due to patient
motion, the study had to be terminated.
IMPRESSION: Limited study due to patient motion. Evaluation of
the right vertebral artery and right PICA was not done due to
significant patient motion. No aneurysm was identified. No
vascular malformation or AV fistula present.Irregularity of
right supraclinoid artery likely to be atherosclerotic.
[**2160-1-6**] POST CEREBRAL ANGIOGRAM CT 11PM
There is a new subdural [**Month/Day/Year **] collection along the right
cerebral convexity, measuring 8 mm in the maximal thickness.
There is a small amount of [**Month/Day/Year **] in the occipital [**Doctor Last Name 534**] of the
left lateral ventricle. The extent of large amount of
subarachnoid hemorrhage with diffuse distribution in basilar
cisterns and along bilateral frontotemporal lobes and falx has
increased with more hemorrhage along the cerebellar tentorium.
There has been interval placement of the intraventricular
catheter with decompression of the lateral ventricles. [**Doctor Last Name **]-
white matter differentiation is preserved. Density values of
brain parenchyma are within normal limits. There is a tiny focus
of pneumocephalus along the left frontal lobe, consistent with
recent intervention. Imaged paranasal sinuses and mastoid air
cells are well aerated.
IMPRESSION: Interval development of subdural hematoma and
intraventricular hemorrhage; marginal increase in extent of
extensive subarachnoid hemorrhage.
Interval placement of intraventricular catheter with
decompression of the lateral ventricles.
[**2160-1-7**] REPEAT CT 5AM
HEAD CT WITHOUT CONTRAST.
INDICATION: Evaluate progression of intracranial hemorrhage.
COMPARISON: [**2160-1-6**] at 11:00 p.m.
FINDINGS: There has been interval increase in intraventricular
hemorrhage, with small amount of [**Year (4 digits) **] now layering in the
occipital [**Doctor Last Name 534**] of the lateral ventricles bilaterally.
Additionally, there is a 6-mm focus of hyperdensity in the right
frontal lobe, that may represent an intraparenchymal hemorrhage.
The appearance of subdural hematoma overlying the right cerebral
convexity is not appreciably changed. The extent of subarachnoid
hemorrhage has slightly increased, with slightly more hemorrhage
now noted on the left. Ventriculostomy catheter is in place. The
ventricles have enlarged since the prior study, raising a
concern of catheter obstruction. The patient is intubated.
IMPRESSION: Interval progression of intraventricular as well as
subarachnoid component of the hemorrhage. Enlargement of the
lateral ventricles. Probable focus of intraparenchymal
hemorrhage in the right frontal lobe. Unchanged right subdural
hematoma. No new mass effect or shift of normally midline
structures.
[**2160-1-8**] CT/CTA/CTP:
TECHNIQUE: Five-mm axial images of the head were obtained
without IV contrast. 1.25 mm axial images of the head were
obtained after the administration of 111 cc of Optiray IV
contrast. Curved reformat, volume rendered, and multiplanar
reformats were also obtained. Utilizing a second smaller bolus
of contrast, CT perfusion was performed with mean transit time,
relative cerebral [**Name2 (NI) **] flow, and relative cerebral [**Name2 (NI) **] volume
maps generated on an independent workstation.
FINDINGS: Comparison is made to a head CT dated [**2160-1-7**] and
cerebral angiogram from [**2160-1-6**].
CT:
Again seen is a large extensive subarachnoid hemorrhage filling
the basal cisterns extending down into the prepontine cistern.
Subarachnoid hemorrhage is also seen within the sylvian fissures
and along the frontoparietal sulci bilaterally. The left frontal
ventricular shunt is seen with the tip at the left foramen of
[**Last Name (un) 2044**]. Intraventricular [**Last Name (un) **] is seen. The ventricles have not
significantly changed in size.
There is a newly apparent hypodensity involving the anterior and
medial right temporal lobe consistent with infarct. Adjacent
subdural hematoma is also seen.
CTP:
There is a limited mean transit time, decreased CVS and _____,
corresponding to the infarct of the right temporal lobe.
CTA HEAD:
There is a fusiform aneurysm involving the distal right internal
carotid artery just proximal to the bifurcation. This aneurysm
measures approximately 8 x 5 mm in size.
Along the lateral aspect of the right cavernous internal carotid
artery is a small outpouching which may represent an
infundibulum of the inferolateral trunk versus an aneurysm. This
measures approximately a mm in size.
The caliber of the vertebrobasilar system and the internal
carotid arteries, middle cerebral arteries, and anterior
cerebral arteries are otherwise normal with no evidence of
vasospasm. No vascular malformations are seen.
IMPRESSION:
1. Eight x 5 mm fusiform aneurysm of the distal right internal
carotid artery just before the bifurcation.
2. Tiny, approximately 1 mm outpouching along the lateral aspect
of the right cavernous ICA which may represent an infundibulum
of the inferolateral trunk versus a tiny aneurysm.
3. Extensive subarachnoid hemorrhage, intraventricular
hemorrhage, and right subdural hematoma as described above.
4. New infarct involving the anterior and medial right temporal
lobe
[**2160-1-7**] ECG:
Sinus rhythm. Compared to tracing #1 the findings are similar.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
92 134 94 338/394 57 42 88
[**2160-1-7**] CXR:
FINDINGS: The lungs are well expanded and clear. The mediastinum
is unremarkable. There has been prior median sternotomy. The
cardiac silhouette is within normal limits for size. No effusion
or pneumothorax is evident. The visualized osseous structures
are otherwise unremarkable.
IMPRESSION: No acute pulmonary process.
Brief Hospital Course:
60yo male presented to [**Hospital1 18**] with diffuse SAH as reported from
OSH transfer. On admission CT/CTA performed. Pt became
increasingly somnolent, external ventricular drain placed in the
ED, and immediately brought for a cerebral angiogram. Post angio
CT obtained revealing new SDH, increased hemorrhage.
Pt then transferred to and remained in Surgical ICU. SBP
maintained <140, EVD open at 15, loaded with Dilantin and
continued with 100mg TID, Nimodipine 60mg given Q4hrs.
Repeat CT obtained in AM revealing extension of hemorrhage.
Neurological exam significant for increased somnolence.
[**1-8**] CT/CTA/CTP (perfusion) obtained revealing Right ICA
aneurysm
Case discussed with Dr.[**Last Name (STitle) 70160**]. It was decided that due to the
complexity of the R.Supraclinoid carotid artery fusiform
dilatation, a possible bypass surgery may be required to treat
the aneurysm. Considering Dr.[**Last Name (STitle) **] at [**Hospital6 13185**] is the only surgeon available to perform bypass
surgery, the patient will be transferred immediately to [**Hospital1 **] for further care.
Medications on Admission:
Zetia 10mg QD, Lipitor 80mg QD, Lisinopril 5mg QD, Actos 45mg
[**Last Name (LF) 244**],
[**First Name3 (LF) **] 32mg QD, MVI, Metformin 1000mg QD
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for headache.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours).
7. Nicardipine 2.5 mg/mL Solution Sig: One (1) Intravenous
INFUSION (continuous infusion).
8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Insulin Regular Human 100 unit/mL Solution Sig: Five (5)
Injection TITRATE TO (titrate to desired clinical effect (please
specify)).
12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day) as needed for HTN.
13. CefazoLIN 1 gm IV Q8H
14. HYDROmorphone (Dilaudid) 0.25 mg IV Q4H:PRN
15. Midazolam 1-2 mg IV Q4H:PRN agitation
16. Metoprolol 5 mg IV Q4H:PRN PRN SPB > 130 Start: [**2160-1-7**]
hold for HR < 65
17. Phenytoin 100 mg IV Q8H
18. Phenytoin 300 mg IV ONCE Duration: 1 Doses
19. HydrALAzine 20 mg IV Q6H:PRN PRN SBP>130 Start: [**2160-1-8**]
Discharge Disposition:
Extended Care
Discharge Diagnosis:
SAH
Potential for bypass for R. supraclinoid carotid artery fusiform
dilatation.
Discharge Condition:
Stable
Discharge Instructions:
PATIENT TRANSFERRED TO [**Hospital6 **], [**Doctor First Name **], [**Location (un) **].
Followup Instructions:
Per receiving institution
Completed by:[**2160-1-8**]
ICD9 Codes: 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1165
} | Medical Text: Admission Date: [**2109-10-27**] Discharge Date: [**2109-11-1**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2518**]
Chief Complaint:
Fall/Stroke.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a [**Age over 90 **] year-old right handed woman with alzheimers and a
left bundle branch block was admitted to the trauma service
after a fall. The history is entirely obtained from the record
as the patient is a very poor historian. When asked why she was
in the hospital, she said "I don't know."
The patient lives by herself in [**Hospital3 4634**]. She fell on the
morning prior to consultation when she was reaching from her
walker from the bedside. The walker slipped away and she fell
forward onto her face. She denied LOC, dizzyness, CP, SOB, or
Palpitions prior to the fall per the Neurosurg [**MD Number(3) 7057**] ED.
Of note the patient fell two weeks ago and was seen here. At
that time there was no blood on her head ct. A new head CT
performed [**2109-10-27**] revealed an acute left parieto-occipital
hemorrhage.
ROS: This was attempted but the patient is not felt to be an
adequate
historian.
Past Medical History:
Mild Dementia, Alzheimers
Hearing Impariment -requires left ear hearing aid.
R-frozen shoulder
Osteoporosis
Depression
Has Left bundle branch block on EKG.
Social History:
Lives at "[**Doctor Last Name 62292**] House" [**Hospital3 **]. Goes to day care
twice weekly. Daughter [**Name2 (NI) 17486**] supportive and invloved. Uses
walker at home. Non-smoker, no ETOH.
Family History:
NC
Physical Exam:
Vitals: T:99.7 P:60 R:15 BP:143/71 SaO2:99%RA
General: Awake, at times cooperative and times inattentive, NAD.
HEENT: She has ecchymoses over face under eyes and over upper
lip, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs with rare crackles at the bases bilaterally.
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Intermittently Alert and intermittently
cooperative with the exam. She will close her eyes and drift off
in the middle of being examined. She is unable to tell a linear
history. She was able to tell the days of the week forward but
not backwards. Language is quite sparse. Prosody was normal, no
dysarthria. patient able to name neck tie and fingers, but was
unable or unwilling to name knot of neck tie, knuckles, thumb or
finger nails. She is able to read, though she read a sentence
other than the one she was instructed to. Registration and
recall were not tested as patient was too inattentive.
-Cranial Nerves: Olfaction not tested. PERRL 2 to 1mm and brisk.
Possible right homonymous hemianopsia - patient difficult to
assess. There is bilateral ptosis. Funduscopic exam impossible
with intattentive and increasingly uncooperative patient. Normal
saccades. Facial sensation intact to light touch. No facial
droop, facial musculature symmetric. Hearing diminished and
shouting required. Tongue protrudes in the midline. Palate not
visualized.
-Motor: Normal bulk, tone increased in the lower extremities.
Patient doesn't comply with pronator drift testing. No
adventitious movements noted. No asterixis noted.
.
Unable to perform formal motor exam due to inatentiveness.
Patient has anti-gravity movement of all four extremities. Her
right shoulder is apparently quite painful to her.
-Sensory: Patient's response to could, pin, and joint position
were not correct despite testing in the upper and lower
extremity. Responses for vibration were correct in the upper
extremity.
-Coordination: No intention tremor, dysdiadochokinesia noted. No
dysmetria on FNF or HKS bilaterally.
Pertinent Results:
[**2109-10-27**] 03:30PM BLOOD WBC-10.4# RBC-3.62* Hgb-11.9* Hct-35.0*
MCV-97 MCH-33.0* MCHC-34.2 RDW-13.4 Plt Ct-298
[**2109-10-30**] 06:10AM BLOOD WBC-7.8 RBC-3.51* Hgb-11.5* Hct-34.4*
MCV-98 MCH-32.7* MCHC-33.4 RDW-12.8 Plt Ct-311
[**2109-10-27**] 03:30PM BLOOD PT-13.1 PTT-29.3 INR(PT)-1.1
[**2109-10-27**] 03:30PM BLOOD Glucose-92 UreaN-29* Creat-0.8 Na-138
K-4.1 Cl-104 HCO3-25 AnGap-13
[**2109-10-30**] 06:10AM BLOOD Glucose-101 UreaN-15 Creat-0.8 Na-136
K-4.1 Cl-102 HCO3-25 AnGap-13
[**2109-10-29**] 03:55AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2109-10-29**] 06:55AM BLOOD CK-MB-3 cTropnT-<0.01
[**2109-10-29**] 03:55AM BLOOD CK(CPK)-87
[**2109-10-29**] 11:10AM BLOOD CK(CPK)-72
[**2109-10-28**] 03:52AM BLOOD Calcium-8.9 Phos-2.5* Mg-2.2
[**2109-10-30**] 06:10AM BLOOD Calcium-8.5 Phos-2.3* Mg-2.3
[**2109-10-29**] 06:55AM BLOOD calTIBC-274 VitB12-347 Ferritn-52 TRF-211
[**2109-10-29**] 03:55AM BLOOD %HbA1c-5.1
[**2109-10-29**] 03:55AM BLOOD Triglyc-73 HDL-61 CHOL/HD-2.3 LDLcalc-62
[**2109-10-30**] 06:10AM BLOOD TSH-1.6
[**2109-10-28**] 03:52AM BLOOD Phenyto-10.8
X-Ray: Shoulder:
No evidence of acute fracture or dislocation. Unchanged from
[**2109-10-14**]
CT Head:
Acute left parieto-occipital intraparenchymal hemorrhage with
subarachnoid component. Mild adjacent edema, but no significant
mass effect or midline shift.
CT Chest:
Benign 1cm calcified granuloma in the right lower lobe.
Carotids:
Duplex and color Doppler demonstrate no appreciable plaque or
wall thickening involving either carotid system. The peak
systolic velocities bilaterally are normal as are the ICA/CCA
ratios. There is also normal antegrade flow involving both
vertebral arteries.
MRI:
1. Extremely motion limited examination.
2. Subacute left parietooccipital intraparenchymal hemorrhage
with no demonstrable features of amyloidosis or infarction.
Possible etiologies include traumatic hemorrhage, hypertension,
and cannot exclude a very occult underlying mass or vascular
malformation.
MRA Brain:
There are no major areas of stenosis identified. Extremely
motion limited examination.
Brief Hospital Course:
Ms. [**Known lastname 62291**] was initially admitted to the Trauma service as her
ICH was felt to be secondary to the trauma of her fall. However
after further history was obtained, it appeared that her fall
was forward onto her face, not towards the back, therefore it
was felt that the bleed was not secondary to the fall. Her
daughter raised the fact that the walker was actually placed to
the right of her bed and as she developed a R sided neglect she
may have fallen trying to reach the walker.
Her work-up included an MRI of the brain to evaluate for
amyloid. This did not show old microbleeds. Carotid dopplers
were also ordered to evaluate for possible embolic etiologies
however these vessels appeared clear. A TTE was not repeated, as
she had a one very recently. Another possibility for her ICH may
have been from an embolic metastasis. Her initial CXR showed a
RLL coin lesion. This was evaluated further with CT which showed
an old calcified granuloma and not malignancy.
Her management included a FLP which was excellent (LDL 62/ HDL
61) and an A1c of 5.1. She was therefore not treated for either
DM or HLD. She was also not treated with aspirin or heparin
given her recent bleeding. She was treated with dilantin to
prevent seizures. She was sub therapeutic initially and was
reloaded. She will complete a 10 day course with a 3 day taper.
For her dementia, she had a work-up including a TSH and B12
which were both normal. She was continued on Aricept. Her anemia
was evaluated with iron studies which were consistent with
chronic disease. Her Hct remained stable.
She was diagnosed with a UTI and was treated with Bactrim DS,
renally dosed and will complete a 7 day course.
After discharge, she has follow-up scheduled with Dr. [**First Name (STitle) **]
Medications on Admission:
Aricept 10 daily
Namenda 10 [**Hospital1 **]
Celexa 10 daily
Enablex 7.5 [**Hospital1 **]
Omeprazole 20mg Daily
Ultram 50mg 0.5-1 daily
Alleve 220mg
Ca/VitD 500-125 three times daily.
Estring (Changed every three months)
Fosamax 70mg once weekly.
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Memantine 5 mg Tablet Sig: Two (2) Tablet PO bid ().
4. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO daily ().
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day): Taper on [**11-6**]:
[**11-6**]-TID
[**11-7**]-[**Hospital1 **]
[**11-8**]-QD then stop.
7. Enablex 7.5 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO BID (2 times a day).
8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Intracranial hemorrhage
Dementia
UTI
Discharge Condition:
Stable
Discharge Instructions:
Please follow-up with Dr. [**First Name (STitle) **] as scheduled
Please continue with your dilantin as prescribed
Please complete your course of antibiotics for your UTI
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2109-12-20**] 10:00, needs registration update & referral
from PCP
Follow-up MRI of brain in [**1-13**] weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2533**]
ICD9 Codes: 431, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1166
} | Medical Text: Admission Date: [**2199-8-1**] Discharge Date: [**2199-8-6**]
Date of Birth: [**2150-7-11**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Latex / Morphine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
angina with exertion
Major Surgical or Invasive Procedure:
cabg x 2 with IABP [**2199-8-2**] (LIMA to LAD, SVG to OM)
History of Present Illness:
49 yo female with 4 months of increasing chest discomfort with
exertion. Cath at [**Hospital 1474**] Hospital revealed 70-90% LM, RCA with
mild irregularities and nl LAD and CX. EF was 18% by ETT on
[**7-25**]. IABP placed post-cath at OSH. Referred for CABG with Dr.
[**Last Name (STitle) 914**].
Past Medical History:
pancreatitis
elev. chol.
NIDDM
depression/anxiety
ETOH
Non-Hodgkin's lymphoma with XRT
retinal artery stenoses
COPD/asthma
hypothyroid
shoulder injury post-MVA
s/p splenectomy/partial pancreatectomy
Social History:
lives with mother
works as a lunch lady
smokes 1 ppd for 20 years
3-4 beers/week
Family History:
father died of MI at 47
brother with PTCA at 50
Physical Exam:
HR 82 158/98 RR 20 100% sat on 2L
5'7" 145 #
NAD, conversant, A and O X3
PERRL , EOMI, MMM
OP benign
neck supple, no LA, carotids with radiated IABP
CTAB
RRR S1 S2 no murmur
abd soft, NT, + BS
extrems warm, no edema
2+ bil. carotids/ radials
2+ left fem/DP, right with IABP
Pertinent Results:
[**2199-8-5**] 06:35AM BLOOD WBC-11.4* RBC-3.84* Hgb-10.7* Hct-31.8*
MCV-83 MCH-27.7 MCHC-33.5 RDW-17.5* Plt Ct-303
[**2199-8-5**] 06:35AM BLOOD Plt Ct-303
[**2199-8-5**] 06:35AM BLOOD PT-12.2 PTT-28.2 INR(PT)-1.0
[**2199-8-5**] 06:35AM BLOOD Glucose-114* UreaN-14 Creat-0.8 Na-132*
K-4.7 Cl-98 HCO3-22 AnGap-17
[**2199-8-1**] 08:26PM BLOOD ALT-18 AST-17 LD(LDH)-131 AlkPhos-50
TotBili-0.2
[**2199-8-1**] 08:26PM BLOOD Albumin-4.2
[**2199-8-1**] 08:26PM BLOOD %HbA1c-6.6* [Hgb]-DONE [A1c]-DONE
[**2199-8-4**] 03:40PM BLOOD TSH-11*
Brief Hospital Course:
Admitted from OSH post - cath with IABP on [**8-1**] on IV heparin and
NTG. Hct decreased to 26.5 and vascular surgery consult done to
evaluate for retroperitoneal bleed. This was negative by CT
scan.Underwent cabg x2 (please see operative report for details
of procedure) on [**8-2**] and transferred to the CSRU in stable
condition on a phenylephrine drip. IABP pulled later that day
after weaning. Extubated overnight and transferred to the floor
on POD #1 to begin increasing her activity level. Psych consult
obtained for better management of anxiety and agitation and meds
were adjusted. Chest tubes removed without incident. Pacing
wires removed without incident on POD #3. She has remained
hemodynamically stable, and ready for discharge home today.
Medications on Admission:
lipitor 10 mg daily
lamictal 200 mg daily
methocarbamol 750 mg daily
prevacid 30 mg [**Hospital1 **]
levothyroxine 88 mcg daily
trazodone 300 mg daily
metformin 850 mg daily
citalopram 40 mg daily
albuterol 2 puffs 4 times daily
flovent 2 puffs [**Hospital1 **]
serevent 2 puffs [**Hospital1 **]
singulair 10 mg daily
xanax 0.5 mg TID
NTG prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
9. Lamotrigine 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
7 days.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
13. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
14. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
15. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
16. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
17. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
Disp:*30 Tablet(s)* Refills:*0*
18. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
CAD
elev. cholesterol
COPD
pancreatitis
non-Hodgkin's lymphoma
DM-2
HTN
depression
ETOH abuse
Discharge Condition:
good
Discharge Instructions:
no lotions, creams or powders on any incision
may shower and pat dry
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100, redness or drainage
Followup Instructions:
see Dr. [**Last Name (STitle) 29478**] in [**11-26**] weeks
see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**12-28**] weeks
See Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2199-8-6**]
ICD9 Codes: 4111, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1167
} | Medical Text: Admission Date: [**2147-9-22**] Discharge Date: [**2147-10-2**]
Service: MEDICINE
Allergies:
Morphine / Mirtazapine / Ambien
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
chest pain s/p ICD firing for sustained VT
Major Surgical or Invasive Procedure:
elective intubation - [**2147-9-25**]
repeat ablation for recurrent ventricular tachycardia - [**2147-9-25**]
ICD generator change - [**2147-10-2**]
History of Present Illness:
Mr. [**Known firstname **] [**Known lastname **] is a 86 yo man with h/o CAD s/p MI and CABG in
[**2136**], chronic AFib with V-pacing, chronic systolic CHF with EF
20%, multiple recent admission to the CCU for ICD firing,
readmitted from [**Hospital **] rehab for left sided chest pain. He
reports that he had severe left sided chest pain, worse with
inspiration and palpation. He denies any dyspnea, nausea,
vomiting, abdominal pain, diaphoresis, left arm or jaw pain or
any other complaints. He does not know if his ICD fired. Of note
he has been admitted numerous times recently for VT and ICD
firing due to sustained VT. During his recent admission from [**9-19**]
-[**9-21**] he was bolused with IV amiodarone twice for episodes of VT
during the admission. During that admission he continued to
refuse VT ablation and turning off ICD.
.
In the ER his VS were stable and he his mental status was at his
baseline. He was in VT 120-130s without any changes from before
on ECG. However, the ER docs were impressed by the abnormalities
and wanted to rule him out for MI with CK: 70 MB: Notdone
Trop-T: 0.25. He was admitted to the CCU for unclear reasons
given he is DNR/DNI and has not wanted to pursue aggresive
treatment in the past.
.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
MI X2 (inferior and anteroseptal)
- CABG: LIMA to LAD, SVG to OM/PDA ([**Hospital1 112**] [**2136**])
- Afib w/o anticoag (fall risk)
- Sustained VTach in [**2146**] s/p admission
- PACING/ICD: BiV ICD ([**2122**]?). ICD generator changed to
[**Company 1543**] Concerto in [**2145**].
.
3. OTHER PAST MEDICAL HISTORY:
- legally blind secondary to glaucoma
- Hiatal hernia
- Hepatic cysts/hemangioma and lipoma in hepatic flexure
- s/p Lt BKA (WWII trauma [**2078**])
- BPH s/p suprapubic prostatectomy ([**2131**])
- s/p cholecystectomy ([**2110**])
- Chronic low back pain
- Osteoarthritis
- Positive PPD in past
- Depression and anxiety
Social History:
The patient immigrated from [**Country 532**] 20 years ago; lives at [**Hospital1 100**]
Senior Center w/ wife. Former oncology surgeon w/ one daughter
and grandaughter in [**Name (NI) 86**].
-Tobacco history: None currently
-ETOH: None
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: T=99.3 BP=115/76 HR=120 (VT) RR=15 O2 sat=97%
GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 7 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
IMAGING:
CT abdomen/pelvis [**2147-9-28**]:
1. Focal colitis in the proximal sigmoid colon. Differential
considerations include various infectious causes, such as C.
difficile colitis, less likely inflammatory or ischemic
etiology.
2. 2.3 x 2.1 cm lobulated, coarsely calcified pulmonary nodule
at the left
lung base, most probably represents a pulmonary hamartoma.
3. Multiple liver and renal cysts.
.
CXR portable [**2147-9-28**]:
1. Persistent left retrocardiac density, which might represent
pneumonia/atelectasis.
.
Portable abdomen [**2147-9-28**]:
Dilated bowels with ileus.
.
MICRO:
C diff [**2147-9-27**]: negative
Urine cx klebsiella 10-100k: sensitive to cipro/ceftriaxone
Blood cx [**2147-9-28**]: negative
.
Labs on admission:
WBC 11.6, Hb 14.3, Hct 42, plt 216
Na 133, K 4.2, Cl 98, bicarb 18, BUN 19, Cr 1.3, glu 150
.
Labs on discharge:
Brief Hospital Course:
Mr. [**Known firstname **] [**Known lastname **] is a 86 y/o Russian speaking man with h/o CAD s/p
MI and CABG in [**2136**], chronic AFib/recurrent VT with V-pacing,
chronic systolic CHF with EF 20%, recently discharged from CCU
with ICD firing, now returns with recurrent VT and ICD firing.
.
#. Rhythm - Pt with known VTach and presents s/p ICD firing.
During prior CCU admission, patient was confirmed to be
DNR/DNI/no external shocks/do not hospitalize. Patient presented
to [**Hospital1 18**] from [**Hospital 100**] Rehab due to chest pain associated with ICD
firing. Patient has stable vital signs with his slow VT and was
in VT at 120-130s. He was bolused with 450 mg of IV amiodarone
in the ER and was started on amiodarone gtt. This was
transitioned to PO amiodarone, as levels were likely
supersaturated. IV lidocaine was initiated at 1 mg/min.
Lengthy discussion with patient and family took place regarding
whether to keep the ICD on or turn it off (as patient has now
presented twice with complaints of ICD firing). After
discussion, pt and family would like to keep ICD on, and realize
that it will provide painful shocks if his rhythm becomes
irregular and dangerous. Patient was informed that repeat
ablation is the only way to cure his VT, and he underwent this
procedure on [**2147-9-25**]. On [**2147-9-26**], pt had five episodes of ICD
firing for recurrent VT, which finally brought him out of his
VT. Since that time, his ICD has not fired. Upon device
interrogation, it was noted that the generator would need to be
changed at a point in the near future, as battery was running
low. This procedure was performed on [**2147-10-2**]. Upon discharge,
patient was in sinus rhythm and stable.
.
# Delerium/AMS - pt developed delerium while in the hospital,
and on one occasion, pulled out his lines/tubes/clothes. He was
initially treated with ativan and zydis. Geriatrics was
consulted. His narcotics and ativan were discontinued. His
mental status and delerium improved without use of further
medications such as haldol.
.
# Focal colitis - pt developed diffuse abdominal pain with
guarding during hospital stay. CT abdomen and pelvis showed
focal colitis in the proximal sigmoid colon. Differential
considerations included various infectious causes, such as C.
difficile colitis, less likely inflammatory or ischemic
etiology. Lactate was wnl. Given rapid elevation in WBC to 25,
low grade temperature, and diarrhea stool, clinical concern for
C. diff despite negative toxin assay. Pt initially placed on PO
vancomycin and IV flagyl with resolution of WBC. PO vancomycin
was discontinued. IV flagyl therapy was completed for 5 days.
.
# Klebsiella UTI - urine cloudy, U/A with 9 wbc, and urine cx
showed 10-100k klebsiella. Pt was initially started on
ciprofloxacin, then switched to ceftriaxone. Sent home with 7
day course of cefpodoxime 200mg PO BID.
.
#. Pump - No signs of CHF at this time. Pt with known chronic
systolic heart failure with EF of 20%. Pt was continued on his
home medications: statin, ASA, and metoprolol. ACEi and Lasix
were held given hypotension.
.
#. CAD - Pt with known CAD s/p CABG. Chest pain free, other than
his VT and shocks. ASA, statin, BB were continued as above.
ACEI held as above, due to hypotension. Enzymes suggest mild
cardiac injury after shock, but most likely he is not having
ACS.
.
#. OA - pain was well controlled on Tylenol and oxycodone prn.
.
#. Code - patient is DNR/DNI/not to be externally shocked.
.
#. Contact - Next of [**Doctor First Name **]: [**Last Name (LF) **],[**First Name3 (LF) **], Relationship: DAUGHTER,
Phone: [**Telephone/Fax (1) 93241**] (home) and [**Telephone/Fax (1) 93242**] (cell). She is HCP.
Medications on Admission:
-Aspirin 81 mg PO Daily
-Digoxin 125 mcg QOD
-Dorzolamide 2% Both eyes [**Hospital1 **]
-Escitalopram 10 mg PO Daily
-Lasix 120 mg PO BID
-Brimonidine 0.15% Both eyes [**Hospital1 **]
-Latanoprost 0.005% QHS
-Lorazepam 1.5 mg PO QHS
-Polyethylene Glycol 3350 100% Powed Daily
-Simvastatin 20 mg Daily
-Amiodarone 200 mg PO Daily
-Metoprolol Tartrate 12.5 Tablet PO BID
-Nitroglycerin 0.3 mg SL PO PRN chest pain
-Captopril 12.5 mg PO TId
-Isosorbide Mononitrate SR 30 mg Daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
3. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
8. Miralax 17 gram (100 %) Powder in Packet Sig: Seventeen (17)
grams PO once a day.
9. Verapamil 40 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
10. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 7 days.
11. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day: Hold
SBP< 100, HR<55.
12. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
HOLD SBP<100.
13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
14. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO three times
a day as needed for pain.
15. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
16. Senna 8.6 mg Capsule Sig: [**2-17**] Capsules PO twice a day as
needed for constipation.
17. Miralax 17 gram (100 %) Powder in Packet Sig: One (1) packet
PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Ventricular tachycardia
Urinary tract infection
Secondary diagnoses:
MI X2 (inferior and anteroseptal)
- CABG: LIMA to LAD, SVG to OM/PDA ([**Hospital1 112**] [**2136**])
- Afib w/o anticoag (fall risk)
- Sustained VTach in [**2146**] s/p admission
- PACING/ICD: BiV ICD ([**2122**]?). ICD generator changed to
[**Company 1543**] Concerto in [**2145**].
- Chronic Systolic Congestive Heart Failure. EF 35%
- legally blind secondary to glaucoma
- Hiatal hernia
- Hepatic cysts/hemangioma and lipoma in hepatic flexure
- s/p Lt BKA (WWII trauma [**2078**])
- BPH s/p suprapubic prostatectomy ([**2131**])
- s/p cholecystectomy ([**2110**])
- Chronic low back pain
- Osteoarthritis
- Positive PPD in past
- Depression and anxiety
Discharge Condition:
stable, afebrile
Discharge Instructions:
You were admitted to [**Hospital1 **] Hospital for chest
pain after repeated ICD firings. Your heart was found to be in
a rhythm known as ventricular tachycardia which was stimulating
your ICD to fire. Your code status was DNR/DNI and your options
to fix this condition involved either shutting off the ICD or
reversing your code status temporarily and performing an
ablation procedure to fix the part of your heart that was
triggering this rhythm. You chose to have the ablation
procedure. The first procedure was unsuccessful, but it seems
like the second ablation procedure has worked well to stop your
ventricular tachycardia and your ICD has not fired since
[**2147-9-26**]. Since your ICD was firing so often, it was also noted
that the battery life on your device was low and needed
replacement. You underwent battery replacement prior to
discharge on [**2147-10-2**]. You were also found to have a urinary
tract infection and were treated
with antibiotics accordingly.
.
day or 6 pounds in 3 days. Adhere to a 2 gm sodium diet.
The following changes have been made to your home medication
regimen:
-You will continue your antibiotics regimen with cefpodoxime
-Your ACE inhibitor, Captopril was
-You Furosemide was held during your hospital stay and you had
no symproms of fluid overload. It will be held until your oral
intake improves.
Please follow-up with all of your outpatient medical
appointments listed below.
Please seek medical care if you experience any concerning
symptoms such as chest pain, increased shortness of breath,
painful urination, increased abdominal pain, or bright red blood
per rectum.
Followup Instructions:
Cardiology:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**] Phone: [**Telephone/Fax (1) 62**]. Date/Time:
[**11-9**] at 3:00pm. [**Location (un) 8661**] clinical Center, [**Location (un) 436**].
[**Location (un) **], [**Location (un) 86**].
.
DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2147-10-11**] 1:00.
[**Hospital Ward Name 23**] clinical center, [**Location (un) 436**].
Completed by:[**2147-10-3**]
ICD9 Codes: 4271, 5990, 412, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1168
} | Medical Text: Admission Date: [**2181-10-18**] Discharge Date: [**2181-10-21**]
Date of Birth: [**2123-7-24**] Sex: F
Service: MEDICINE
Allergies:
Ampicillin
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Low Hematocrit
Major Surgical or Invasive Procedure:
None
History of Present Illness:
58 yo F with HIV on HAART, (CD4+:266 and VL undetectable
[**8-/2181**]), HCV cirrhosis w/o known varices, ESRD on HD ([**3-13**] HIV
nephropathy) p/w a Hb of 7 found in HD today. Of note, patient
was recently admitted to the medicine service from [**10-13**]- [**10-16**] for
melana. Push enteroscopy performed on [**10-16**] did not show any
active bleeding but was significant for gastritis. She did not
require any blood transfusions and since she remained HDS was
discharged home with close followup. Since discharge she
continued to have melontic stools x 5 days with associated
lightheadedness and fatigue that has been constant. Since 5 days
ago Hct: 36.5 ([**10-13**])--> 33 ([**10-16**]) --> 23.2 today. In HD today, 2.7
kg of fluid was taken off.
.
Of note, she was also admitted [**6-/2181**] with melana, and
underwent a capsule study which showed active bleeding in her
duodenum. EGD at that time revealed no active bleeding, portal
HTN-ive gastropathy, no esophageal varices noted. A colonoscopy
also performed showed two sessile adenomatous polyps though
examination of mucosa limited by melena which were removed. An
enteroscopy had been attempted at this time but was deferred
since the patient had eaten. She remained without evidence of
melana until this most recent admission [**10-13**].
.
In ED VS were 97.5 95 113/68 16 97% RA. (Baseline sbp in the
110s-120s noted in OMR) Received 1 liter NS. Did not receive
prbcs. NG lavage pink in first 150 cc and did not clear with
another 300 cc -> pink with specs of blood. Given 40 IV
pantoprazole. GI consulted and suggested a tagged RBC scan to
find active bleeding. Notably, guaiac positive brown stool.
Vitals prior to transfer BP: 109/61 87 100% 2L
.
Upon arrival to the MICU, patient was HDS and felt mildly
fatigued. C/O mild abdominal pain. Blood transfusion was started
prior to transfer to nuclear medicine for tagged rbc.
Past Medical History:
1. ESRD due to HIV nephropathy, on hemodialysis (TuThuSat),
right transposed basilic AV fistula
2. HIV, diagnosed [**2165**]; last CD4 143 VL 49 ([**5-/2181**])
3. Hepatitis C with reported cirrhosis and portal hypertension;
diagnosed mid-[**2161**] per pt; not treated with interferon,
followed and monitored by Liver Center
4. Zoster [**2177**]
5. Bronchitis (recently diagnosed, pt has not started treatment
Social History:
Patient on disability. Lives alone, but has 5 adult children.
>25 pack-year tobacco history, currently smokes [**2-10**] ppd. History
of crack cocaine use and IVDU (per pt, last use 10 yrs ago);
stopped since starting dialysis ~[**2171**]. Denies EtOH use. Family
aware of HIV diagnosis.
Family History:
Mother with DM, HTN; died from brain aneurysm. GM with DM, HTN;
died from diabetic coma. Older sister died of liver cancer.
[**Name (NI) **] sister w/ breast cancer.
Physical Exam:
VS: 84 127/68 18 100% 2L
GA: AOx3, NAD
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.
2-3/6 SEM heard best at base
Pulm: Diffuse crackles and rhonchi heard bilaterally. Moving air
Abd: soft, TTP in RUQ and RLQ, +BS. no g/rt. neg HSM.
Extremities: wwp, no edema. DPs, PTs 2+. 16G and 18G in left
arm. Fistula with palpable thrill in right arm.
Skin: no rashes
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
sensation intact to LT, gait deferred.
Pertinent Results:
ADMISSION LABS:
[**2181-10-18**] 07:20PM BLOOD WBC-3.9* RBC-2.50*# Hgb-7.4* Hct-23.2*#
MCV-93 MCH-29.8 MCHC-32.1 RDW-17.6* Plt Ct-83*
[**2181-10-18**] 07:20PM BLOOD Neuts-63.5 Lymphs-26.3 Monos-5.3 Eos-4.3*
Baso-0.5
[**2181-10-18**] 07:55PM BLOOD PT-15.7* PTT-27.6 INR(PT)-1.4*
[**2181-10-18**] 07:20PM BLOOD Glucose-89 UreaN-27* Creat-4.6* Na-140
K-3.6 Cl-98 HCO3-33* AnGap-13
[**2181-10-18**] 07:20PM BLOOD ALT-9 AST-15 AlkPhos-50 TotBili-0.3
[**2181-10-18**] 07:20PM BLOOD Lipase-73*
[**2181-10-19**] 02:02AM BLOOD Calcium-7.9* Phos-4.6* Mg-1.6
[**2181-10-18**] 06:15AM BLOOD %HbA1c-5.6 eAG-114
.
Pertinent Labs
[**2181-10-19**] 06:14AM BLOOD Hct-27.9*
[**2181-10-19**] 04:39PM BLOOD Hct-27.8*
[**2181-10-20**] 08:10AM BLOOD WBC-4.7 RBC-3.00* Hgb-9.0* Hct-27.7*
MCV-92 MCH-29.9 MCHC-32.4 RDW-17.6* Plt Ct-82*
[**2181-10-21**] 08:00AM BLOOD WBC-5.0 RBC-3.23* Hgb-9.6* Hct-30.6*
MCV-95 MCH-29.6 MCHC-31.3 RDW-17.7* Plt Ct-87*
MICROBIOLOGY: none
IMAGING:
[**2181-10-18**] TAGGED RBC SCAN:
Following intravenous injection of autologous red blood cells
labeled with Tc-[**Age over 90 **]m, blood flow and dynamic images of the
abdomen for 60 minutes were obtained.
Blood flow images show normal vascular tracer distribution.
Dynamic blood pool images show no evidence of tracer within the
gastrointestinal tract.
IMPRESSION: No evidence of GI bleeding.
ADMISSION CXR:
Mild central vascular congestion without overt edema. Stable
cardiomegaly.
Small Bowel Enteroscopy: [**2181-10-16**]
Impression: Erythema in the whole stomach compatible with
gastritis
Otherwise normal small bowel enteroscopy to jejunum
Colonoscopy:[**2181-6-27**]
Polyp in the transverse colon (polypectomy, endoclip), Polyp in
the sigmoid colon (polypectomy) Grade 1 internal hemorrhoids
There was melanotic blood coating along th ecolon mucosa. We
were unable to thoroughly examine the mucosa of colon. Otherwise
normal colonoscopy to cecum
EGD: [**2181-7-3**]: Hiatal hernia noted. Erythema, congestion,
petechiae and abnormal vascularity in the whole stomach
compatible with portal hypertensive gastropathy. Otherwise
normal EGD to third part of the duodenum. No esophageal or
gastric varices noted. No source of bleeding visualized on
examination to the 3rd portion of the duodenum. Recommend
continue PPI. Would recommend enteroscopy for further
evaluation.
Capsule Study: [**2181-6-28**]
Summary: 1. The capsule remained in the stomach for 3h 2. Active
bleeding in the duodenum 3. Fresh blood in the small bowel 4.
Ileocecal valve could not be identified
Brief Hospital Course:
58 year old female with HIV on HAART, (CD4+:266 and VL
undetectable [**8-/2181**]), HCV cirrhosis w/o known varices, ESRD on
HD ([**3-13**] HIV nephropathy) admitted with melena and significant
hematoctrit drop s/p 2 units of PRBCs
.
1. GI Bleed: Source likely Upper GI given melana and pink NG
lavage. Tagged RBC scan did not show active bleeding. She was
given two units of PRBCs overnight. She was started on IV
pantoprazole 40 [**Hospital1 **]. Her hematocrit remained stable after red
blood cell transfusion.
.
2. Abdominal Pain: TTP in RUQ/RLQ of unclear etiology. @
baseline.
.
3. ESRD on HD: On T/Th/Sat schedule. Continued on sevelemer,
nephrocaps with Epogen in HD
.
4. HIV: Last VL undetectable, CD4+ 266 (7/[**2181**]). Patient started
on Bactrim in previous admissions, however has not been taking.
Reportedly refused Bactrim in previous admission. Continued
HAART regimen. Bactrim was held since CD4 is >200, no h/o PCP,
[**Name10 (NameIs) **] no history of oral candidiasis which is based on CDC
guidelines. She was discharged on Bactrim to be further managed
by her primary care/ Infectious disease doctor.
.
5. Hepatitis C: c/b reported cirrhosis and portal hypertension
(portal hypertensive gastropathy, no esophageal varices).
Followed by liver clinic. Last viral load less than one
million. Not on interferon.
.
6. Murmur: Harsh holosystolic murmur heard throughout the
precordium. This should be followed up as an outpatient with an
echocardiogram.
.
Patient left AMA before she was seen by attending and could
receive discharge paperwork. She was aware of the risks and
benefits of leaving. She was aware of her post discharge follow
up appointments tomorrow.
Medications on Admission:
1. Lamivudine 50 mg DAILY
2. Etravirine 200 mg [**Hospital1 **]
3. Tenofovir Disoproxil Fumarate 300 mg One QFRI
4. B Complex-Vitamin C-Folic Acid 1 mg DAILY
5. Sevelamer HCl 800 mg PO TID W/MEALS
6. Albuterol Sulfate 90 mcg/Actuation 1-2 Puffs Inhalation Q6H
as needed for shortness of breath or wheezing.
7. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Omeprazole 40 mg Capsule twice a day.
Discharge Medications:
1. Lamivudine 100 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Etravirine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
3. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO QFRI (every Friday).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
6. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
8. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day.
9. Outpatient Lab Work
CBC tomorrow for Hct check.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
1. Melena
.
Secondary Diagnosis
1. Hepatitis C with cirrhosis
2. End stage renal disease on hemodialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted because you were noted to have melena,
weakness and significant drop in your blood volume. You were
given two units of blood. Upper GI endoscopy and tagged RBC
study showed no active bleeding.
.
NO MEDICATION CHANGES WERE MADE TO YOUR REGIMEN
.
Patient left AMA before she was seen by attending and could
receive discharge paperwork. She was aware of the risks and
benefits of leaving. She was aware of her post discharge follow
up appointments tomorrow.
Followup Instructions:
Please make an appointment with your primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **] within the next two days. [**Telephone/Fax (1) 3581**]
Department: ADVANCED VASC. CARE CNT
When: MONDAY [**2181-10-22**] at 10:00 AM
With: [**Name6 (MD) 5536**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5537**]
Building: [**Street Address(2) 7298**] ([**Location (un) 583**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
Department: LIVER CENTER
When: MONDAY [**2181-10-22**] at 11:15 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2181-11-6**] at 3:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 22561**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
ICD9 Codes: 5856, 2875, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1169
} | Medical Text: Admission Date: [**2106-1-3**] Discharge Date: [**2106-1-22**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9853**]
Chief Complaint:
Unresponsive
Major Surgical or Invasive Procedure:
Central Line Placement and removal
PICC placment
Intubation and extubation
Chest Tube placement and removal
Bronchoscopy
History of Present Illness:
This is a [**Age over 90 **] year-old female with a history of recent ICU stay
for pneumonia who presents unresponsive from her nursing home.
Per EMS notes, patient had a roughly 24 hr decline in MS to the
point that she was unable to take any meds. She arrived via EMS
who had to bag-mask her for airway protection.
.
In the ED, Patient was intubated for airway protection. intitial
vitals were T: 100.3 BP: 155/85 HR: 101 RR: O2Sat: 97% Ambu bag.
CT scan showed consolidation in LLL. Central line was placed and
patient transfered to [**Hospital Unit Name 153**].
.
Upon arrival patient was hypotensive to 70s/30s with sats in 80s
despite AC 100% fio2, peep 5. Pressors started. CXR showed large
Pneumothorax, presumably from R IJ placement in ED. ED attending
arrived minutes later and placed 14 G angiocath in 2nd
intercostal mid-clavicular line with rush of air. Thoracic
surgery resident arrived and assisted Dr. [**Last Name (STitle) 11721**] with R chest
tube placement. Repeat CXR with small Pneumothorax, much
improved and patient weaned off pressors.
.
ETT suctioning reveal copious amounts of food indicating
aspiration, probably chronic.
.
Of note, Ms. [**Known lastname 98899**] was admitted [**Date range (1) 98900**] for respiratory
failure, pneumonia, hypotension and required intubation and
pressors at that time as well. During that admission, she had
atrial fibrillation with a rapid ventricular response and
amiodarone was started. She was only discharged for 8 days when
she presented for this admission.
.
ROS: Unable to obtain as patient intubated.
Past Medical History:
Past Medical History:
depression
dementia
anxiety
constipation
thrombocytopenia from valproic acid
s/p incarcerated inguinal hernia repair
Social History:
Ms. [**Known lastname 98899**] [**Last Name (Titles) 546**] at [**Hospital1 599**] of [**Location (un) 55**]. She was married
many years ago and never had any children.
FUNCTIONAL STATUS: She at baseline is minimally oriented and
interactive according to staff ([**Name (NI) **], PT at [**Hospital1 599**] in
conversation [**2106-1-18**]). Prior to her first ICU admission this
fall, she was able to transfer with a two person assist. After
her last ICU admission, during her approximate 1 week stay at
[**Hospital1 599**], nursing staff reportedly required a [**Doctor Last Name 2598**] lift to
transfer her.
ADVANCE DIRECTIVES:
Health Care Proxy = [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 98901**]
CODE STATUS = FULL CODE during this hospitalization
Family History:
Mother died of old age in her late 90's.
Physical Exam:
Vitals: T: 98.6 BP: 73/33 HR: 96 RR: 19 O2Sat: 98% on AC 100%
fio2, 5 peep
GEN: Patient thin, mal-nourished, intubated non-responsive
HEENT: PERRL, sclera anicteric, MMM
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Decreased breath sounds on R, hyper resonant -> ED
attenting placed Chest tube as above, -> good BS bilat.
ABD: Soft, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: Intubated, brain stem reflexes intact.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
Admission Labs
[**2106-1-3**] 09:50AM
URINE RBC-[**4-15**]* WBC-[**12-31**]* BACTERIA-FEW YEAST-FEW EPI-21-50
URINE BLOOD-SM NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-150
BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-MOD
URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.022
URINE GR HOLD-HOLD
URINE HOURS-RANDOM
[**2106-1-3**] 09:55AM
FIBRINOGE-261
PLT COUNT-297
PT-15.5* PTT-31.2 INR(PT)-1.4*
NEUTS-88.5* LYMPHS-6.5* MONOS-3.7 EOS-1.0 BASOS-0.3
WBC-14.0* RBC-3.56* HGB-11.1* HCT-34.5* MCV-97 MCH-31.2
MCHC-32.2 RDW-16.0*
ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
CALCIUM-9.5 PHOSPHATE-3.4 MAGNESIUM-1.8
LIPASE-29
ALT(SGPT)-32 AST(SGOT)-35 ALK PHOS-129* TOT BILI-0.3
estGFR-Using this
UREA N-22* CREAT-0.8
GLUCOSE-114* LACTATE-1.3 NA+-163* K+-2.7* CL--111
TYPE-[**Last Name (un) **] PO2-270* PCO2-36 PH-7.53* TOTAL CO2-31* BASE XS-7
COMMENTS-GREEN TOP POTASSIUM-2.4*
CT PELVIS W/CONTRAST Study Date of [**2106-1-3**] 11:50 AM
IMPRESSION:
1. Soft tissue density within the left main bronchus may
represent
aspiration with collapse of the left lower lobe. Small
left-sided pleural
effusion and trace on the right.
2. Multifocal patchy opacities as described above may represent
inflammatory
vs small airway infection.
3. Limited study for the evaluation of the pulmonary embolism
due to poor
opacification of the pulmonary artery without central or
interlobar evidence
of PE.
4. 5 mm lung nodule in the right lower lobe. According to the
[**Last Name (un) 8773**]
society guidelines, in low- risk patient, followup CT at six
months is
recommended.
5. Malpositioned endotracheal tube and NG tube as described
above. Re-
positioning is recommended.
6. Cholelithiasis.
7. Degenerative changes of the spine with multilevel compression
deformities
as described above.
CT HEAD W/O CONTRAST Study Date of [**2106-1-3**] 11:50 AM
IMPRESSION: No acute intracranial pathology. Brain and medial
temporal
atrophy.
CHEST (PORTABLE AP) Study Date of [**2106-1-3**] 4:04 PM Final Report
CLINICAL HISTORY: 91. New central line placed. Check position.
Patient is considerably rotated. A large right-sided
pneumothorax is present, which may actually cross the midline
and indicate some mediastinal shift. Medical team informed.
IMPRESSION: Large right pneumothorax.
CHEST (PORTABLE AP) Study Date of [**2106-1-3**] 4:04 PM
IMPRESSION: AP chest compared to [**1-3**]:
Right apical pleural tube still in place. Minimal if any right
apical
pneumothorax and no right pleural effusion. Left lower lobe
atelectasis and a small-to-moderate left pleural effusion are
unchanged since [**1-3**]. There is mild residual edema in
the perihilar left lung. ET tube is in standard placement.
Nasogastric tube passes to the distal stomach. No
pneumothorax on the left.
CHEST (PORTABLE AP) Study Date of [**2106-1-20**]
The right apical pneumothorax has now resolved.
Small right-sided pleural effusion is unchanged. Left
retrocardiac atelectasis accompanied by a small-to-moderate
sized left-sided pleural effusion is stable. Mild cardiomegaly
persists.
Brief Hospital Course:
Ms. [**Known lastname 98899**] is a [**Age over 90 **] year-old female with a history of recent ICU
stay for pneumonia who presented to the ED unresponsive with
poor respiratory effort on [**2106-1-3**]. She was found to have LLL
infiltrate. She was intubated and admitted and treated for
aspiration pneumonia with septic shock. She had LLL collapse
(or at least partial collapse) and underwent a bronchoscopy.
Her course has been complicated by a tension pneumothorax on
[**2106-1-3**] after central line placement with transient hypotension
prior to decompression. She had a Chest tube placed [**1-3**] and
removed [**1-16**]. Her initial antibiotic regimen included
vancomycin, piperacillin/tazobactam and metronidazole.
.
She was intubated from [**2106-1-3**] through [**2106-1-16**] and initially
required pressors for BP support. While her aspiration pneumonia
was felt to have improved, she was felt to develop a Ventilator
Acquired Pneumonia. Sputum culture has grown pan-sensitive
Klebsiella pneumonia and Methicillin-resistant Staph aureus.
She has been treated with levofloxacin and vancomycin with plans
to continue this course through [**2106-1-24**].
PNEUMONIA - VENTILATOR-ASSOCIATED/RECURRENT ASPIRATION:
clinically improved with O2 sat in the high 90s on room air.
--to complete levofloxacin and vancomycin through [**2106-1-24**]
--continue aspiration precautions, HOB > 30 degrees with meals
with supervision, and HOB > 30 degrees after all meals
--thin liquids and ground consistency solids as per Speech and
Swallow
[**Hospital **] medical team had several extensive discussions about the
patient's frail status with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], the health care proxy.
It was explained that the patient has severe dementia and
recurrent aspiration and is likely nearing the end of her
natural life. It was recommended to Ms. [**Name13 (STitle) **] that she
consider what Ms. [**Known lastname 98899**] would wish for further care --- a focus
on comfort with antibiotics but avoiding heroic measures
including artificial life support and resuscitation versus
ongoing treatment including recurrent intubation and mechanical
ventilation. Ms. [**Name13 (STitle) **] at this time feels Ms. [**Known lastname 98899**] would
continue to "want everything done" though she is not sure. She
says she speaks with her own brother (a Rabbi [**First Name8 (NamePattern2) **] [**Name (NI) **]) often
about this difficult situation and stated that her brother feels
everything must be done medically to prolong Ms. [**Known lastname 98902**] life
and alluded to the fact that this was keeping with his religious
beliefs. As much of her aspiration appears to be due to her own
secretions, it does not seem a PEG tube would offer any
additional benefit. Although a PEG tube was considered by the
HCP, on hearing that the patient was not likely aspirating food
or liquid on a repeat speech and swallow evaluation she decided
not to have the PEG tube placed and give her a chance to eat, as
she feels that would be important to the patient. She
understands that the patient may not be able to take in all of
the necessary calories by mouth alone, and that recurrent silent
aspiration cannot be fully prevented despite the best efforts at
precautions.
.
TENSION PNEUMOTHORAX S/P CHEST TUBE [**1-3**] THROUGH [**1-16**]
--f/u CXR obtained [**2106-1-20**] showed full resolution of the
pneumothorax.
.
DIASTOLIC HEART FAILURE with mild pulmonary artery systolic
hypertension
--Continued Amiodarone. Will need f/u LFTs and TFTs as per
amiodarone protocol
.
DEMENTIA/DELIRIUM - patient with likely delirium/worsening
encephalopathy on top of underlying dementia. This had resolved
by discharge with improvement of her medical issues.
--reorient and redirect as needed
--oob to chair daily as tolerated. patient is very
deconditioned and may not tolerate this right away
--avoid sedating medications or medications with anticholinergic
properties
--was on acetaminophen 1000 mg po tid around the clock as she
likely had some discomfort w/recent chest tube, this can be
given prn at rehab
--avoid tethers
.
ATRIAL FIBRILLATION, PAROXYSMAL
--rate controlled on amiodarone
--held systemic anticoagulation for now given multiple
comorbidities, s/p recent chest tube etc. [**Month (only) 116**] consider in the
future as an outpatient.
.
INCIDENTALLY NOTED LUNG NODULE - 5 mm lung nodule in the right
lower lobe
--f/u in 6 months as patient/HCP/primary physician [**Name Initial (PRE) **]
HCP - CONTACT = [**First Name4 (NamePattern1) **] [**Name (NI) **] [**Telephone/Fax (1) 98901**]
Medications on Admission:
Heparin 5,000 unit/mL TID
Memantine 10 mg qam, 5mg qpm
Acetaminophen PRN
Amiodarone 200 mg daily
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain.
3. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Memantine 10 mg Tablet Sig: One (1) Tablet PO qam.
5. Memantine 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Docusate Sodium 50 mg/5 mL Liquid Sig: Five (5) mL PO BID (2
times a day).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
10. Levofloxacin in D5W 750 mg/150 mL Piggyback Sig: Seven
[**Age over 90 1230**]y (750) mg Intravenous Q24H (every 24 hours) for 2
days: last day [**1-24**].
11. Vancomycin 1,000 mg Recon Soln Sig: 1,000 mg Intravenous
once a day for 2 days: last day [**1-24**].
12. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Primary:
1) Respiratory Failure attributed to aspiration pneumonia
necessitating artificial ventilation, vasopressors, and broad
spectrum antibiotics. Septic Shock with thrombocytopenia
possibly related to consumption.
2) Left Lower Lobe collapse/partial collapse s/p bronchoscopy
3) Tension Pneumothorax on Right s/p central line insertion, s/p
chest tube placement for nearly 2 weeks. Significant
subcutaneous emphysema, resolving
4) Ventilator associated pneumonia - MRSA and pan-sensitive
Klebsiella pneumonia cultured from sputum
5) Acute renal failure - resolved
6) Atrial Fibrillation with rapid ventricular response, on
amiodarone since [**2105-12-12**]
.
Secondary:
1) Moderate to severe dementia
2) Delirium
3) mildly noted hyperglycemia
4) Osteoporosis
5) Malnutrition - moderate to severe, likely secondary to
dementia
6) Acute on Chronic Diastolic Heart failure
7) mild-moderate systolic pulmonary hypertension
8) history of depression
.
Health Care Proxy - [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] - Home [**Telephone/Fax (1) 98901**], Cell =
[**Telephone/Fax (1) 98903**]
Code Status during this admission = FULL CODE
Discharge Condition:
Good, demented at baseline, tolerating some POs with supervision
Discharge Instructions:
Ms. [**Known lastname 98899**] was admitted with another episode of severe
pneumonia. It is thought that her dementia and overall frailty
is contributing to her repeated bouts of pneumonia. During her
hospitalization, she suffered a collapsed lung after a central
IV line was placed (a known possible complication) and required
a chest tube for nearly two weeks to treat this. She was
treated with broad spectrum antibiotics as well as treatment
with an artificial ventilator (breathing machine) to help her
through. While on the ventilator, she was felt to develop a new
pneumonia related to this machine and her antibiotcs were
continued with the plans to treat through [**2106-1-24**].
.
If she develops fever, chills, inability to eat, or drink or
take her medication or any other worrisome symptoms, please call
the doctor on call, Dr. [**First Name (STitle) 9850**] [**Name (STitle) 9851**] or take her to the
closest Emergency Room.
.
Please give all medications as instructed.
.
Please supervise all meals/eating. Have patient sit upright in
bed or in a chair during the meal and for at least one hour
afterwards. She may have thin liquids and ground solids. Do
not feed her difficult to chew foods. Meds should be crushed
with purees. Oral care should be done q4h given the possibility
of silent aspiration.
Followup Instructions:
Please have Dr. [**First Name (STitle) 9850**] [**Name (STitle) 9851**] see Ms. [**Known lastname 98899**] upon her return
to [**Hospital1 599**].
.
Please follow liver function tests and thyroid function tests at
regular intervals as patient is on amiodarone.
ICD9 Codes: 5070, 0389, 5849, 2760, 5990, 4280, 2859, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1170
} | Medical Text: Admission Date: [**2120-7-2**] Discharge Date: [**2120-7-23**]
Date of Birth: [**2064-12-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Motrin / Glyburide / Glucophage
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Diarrhea, confusion, fever.
Major Surgical or Invasive Procedure:
L BKA/Guillotine [**2120-7-4**]
AVR(21mm St. [**Male First Name (un) 923**]) [**2120-7-9**]
L BKA Closure [**7-17**]
History of Present Illness:
55 yo male w/PMHx sx for DM2 presents with abdominal discomfort,
nausea, vomiting, altered mental status, and hyperglycemia.
Patient originally presented to his PCP this am with complaints
of GI upset. He reported that he had been having abdominal pain
for the past seven days, with nonbloody watery diarrhea x3 days,
with associated nausea. He has had a 1 day hx of nonbloody
emesis as well. He has had diminished po intake secondary to
nausea, and self-decreased insulin dose from 25U --> 20U qam and
20U --> 15U qpm. [**Name (NI) **] wife stated that patient has also had
AMS for approx 8 days, with confusion and difficulty carrying
out commands. She also notes labored breathing and chills, as
well as fevers at home to 101 over the last three days.
He states that he does not believe that his foot is infected
because when his left foot gets infected, it swells and becomes
tender, and currently it is at baseline. He does have a sick
child at home, and several children who live at home who are in
daycare. He also notes some nasal congestion.
Patient denies any headache, vision changes (but does note some
burning in his eyes), numbness, tingling, dysuria, hematuria,
dizziness, lightheadnesses, neck stiffness, or back pain.
He denies any recent travel, rashes, cough, unusual food
consumption, melena, hematochezia, bloody emesis, or sputum
production.
In the ED, patient was found to be febrile to 101, with WBC
34.0, with elevation in creatinine to 1.9 (baseline 1.0) with
glucose 459, with UA positive for mild ketones. He had an LP
done as well, which showed elevated WBC count. He received 3L
NS, and was given 10u regular insulin, and was initially started
on vancomycin, ceftriaxone, and metronidazole, and transferred
to the floor.
Past Medical History:
DM2
Charcot left foot
Hx cellulitis, ?osteomyelitis s/p amputation of foot
Nonproliferative retinopathy
Left conductive hearing loss
Hx MRSA
Anemia of chronic disease
Recent admit for gallstones
Social History:
Currently on disability. Lives at home with his partner, Ms.
[**Name13 (STitle) **] [**Telephone/Fax (1) 96486**]. Denies alcohol, drugs, or tobacco. Has
young children at home, who go to daycare. No pets.
Family History:
Family ALW. No hx of MI, CAD, or DM.
Physical Exam:
On Admission:
VS: Tm 101.9 HR 120 BP 123/85 RR 30 O2sat 100%
Gen: sleepy but arousable. Alert and oriented x3. Responds
appropriately to questions.
HEENT: PERRLA. Scerla not injected. Clear discharge from eyes.
No nasal erythema. Oral mucosa moist with no ulcers. White
exudate on tongue. No cervical LAD. Neck supple.
Lungs: CTAB from front. Limited exam [**1-24**] recent LP.
Hrt: Tachycardic. No MRG. Distant heart sounds.
Abd: S/NT/ND +BS. Obese. No palpable masses. No HSM.
Ext: Right extremity - Charcot foot. No ulcers or drainage. No
tenderness or erythema. Left extremity - Thickened skin over
dorsal surface with hyperpigmentation. Linear scar over left
medial malleolar region with no tenderness or drainage at site.
Swollen. No erythema or open ulcers. Amputation of three toes on
left foot. 2+radial pulses.
Neuro: CN2-12 intact. 2+DTRs. 5/5 strength throughout. Sensation
to light touch and pinprick diminished over plantar surface of
both feet, L>R. Negative Brudzinski's. Negative Kernig's.
Pertinent Results:
[**2120-7-22**] 01:41AM BLOOD WBC-16.7* RBC-3.40* Hgb-9.7* Hct-28.0*
MCV-82 MCH-28.5 MCHC-34.6 RDW-15.6* Plt Ct-460*
[**2120-7-23**] 06:33AM BLOOD WBC-18.5* Hct-29.2* Plt Ct-533*
[**2120-7-22**] 04:07PM BLOOD PT-17.6* PTT-114.6* INR(PT)-2.0
[**2120-7-22**] 01:41AM BLOOD Glucose-102 UreaN-18 Creat-1.7* Na-128*
K-4.5 Cl-98 HCO3-22 AnGap-13
[**2120-7-23**] 06:33AM BLOOD WBC-18.5* Hct-29.2* Plt Ct-533*
[**2120-7-23**] 06:33AM BLOOD Plt Ct-533*
[**2120-7-23**] 06:33AM BLOOD Glucose-114* UreaN-19 Creat-1.6* Na-128*
K-4.8 Cl-95* HCO3-22 AnGap-16
[**2120-7-23**] 06:33AM BLOOD PT-17.5* INR(PT)-2.0
Brief Hospital Course:
55 yo w/hx of DM2 presents with 7d episode of abdominal upset,
AMS, fever, nausea, vomiting, and diarrhea. LP shows 29 WBCs,
normal to low glucose, and normal protein, concerning for a
viral meningitis, esp in context of AMS and immunocompromised
state.
Mr. [**Known lastname **] [**Last Name (Titles) 1834**] a guillotine amuptation of his LLE on
[**2120-7-4**]. He then had a TEE which showed aortic valve
endocarditis. He had a mechanical AVR on [**2120-7-9**], after which he
was transferred to the ICU in critical but stable condition on
Neo. He was extubated and his drips were weaned by post op day
one. His L BKA was revised on [**2120-7-17**]. He continued to have a
slightly elevated white count, with no fever or signs of sepsis,
and is to remain on vancomycin until followup with infectious
diseases on [**2120-8-20**]. He was anticoagulated with heparin and
coumadin for his mechanical valve.
Medications on Admission:
Moxepril 7.5 mg po qd
Percocet 5-325 1-2 tabs q4-6h prn pain
Fluticasone inh.
NPH insulin 100U
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. 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*
4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
6. Erythromycin 5 mg/g Ointment Sig: One (1) gtt Ophthalmic QID
(4 times a day).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
8. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO DAILY (Daily).
9. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
11. Vancomycin HCl 1000 mg IV Q 24H
check trough after 3rd dose
12. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
13. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: INR
goal of [**2-22**].5.
14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: One (1)
unit Subcutaneous twice a day: 25 U qAM
20 u qPM. unit
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Aortic valve endocarditis
L foot infection
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
You may not drive for 4 weeks.
You may not lift more than 10 lbs. for 3 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Do not use lotions, creams, or powder on wounds.
Call our office for sternal drainage, temp.>101.5
Followup Instructions:
Make an appointment with Dr. [**First Name (STitle) **] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
You have an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2505**] (Infectious
Diseases) [**2120-8-20**] at 9:30. LMOB Suite GB ([**Telephone/Fax (1) 6732**]
See Dr. [**Last Name (STitle) **] (podiatry) after discharge for shoe fitting
Completed by:[**2120-7-23**]
ICD9 Codes: 4241, 5849, 2765, 2859, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1171
} | Medical Text: Admission Date: [**2182-12-1**] Discharge Date: [**2182-12-12**]
Date of Birth: [**2121-8-3**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Back pain status-post fall
Major Surgical or Invasive Procedure:
Endotracheal intubation
Central line placement
History of Present Illness:
61 year-old male s/p fall down ~[**8-21**] stairs 1 day prior to
presentation to an area hospital. He does not recall the events
surrounding his fall, but awoke at home the next day and was
unable to move his lower extremities. He complained of back pain
and was initially seen at [**Hospital 8641**] Hospital where a CT scan
revealed an L1 burst fracture without obvious spinal cord
damage. He was then transferred to [**Hospital1 18**] for continued care.
Past Medical History:
HTN
COPD
left TKA
s/p esophagectomy
Social History:
1 ppd smoker, +EtOH daily, denies IVDU.
Family History:
Noncontributory
Physical Exam:
VS: 97.2, 106, 164/92, 13
GEN: NAD, NCAT, EOMI
CV: RRR
PULM: CTAB, nl chest wall excursion
ABD: soft, nt/nd, pelvis stable, nl rectal tone.
EXT: no gross deformity. MAE. Strength 5/5 bilaterally.
Sensation intact to lt touch.
BACK: +TTP bony midline, lumbar spine.
Pertinent Results:
TRAUMA #2 (AP CXR & PELVIS POR Clip # [**Clip Number (Radiology) 70280**]
IMPRESSION: Limited study. Tortuous aorta. Opacity in the
right apex, which may represent atelectasis, consolidation, or
contusion. Further assessment by CT scan is recommended if
clinically indicated.
------------
CT T-SPINE W/O CONTRAST Clip # [**Clip Number (Radiology) 70281**]
IMPRESSION:
1. L1 burst fracture with posterior retropulsion of a fracture
fragment in the spinal canal. There is greater than 50% loss of
the spinal canal diameter at this level.
2. No additional fractures are seen.
3. Destruction of the posterolateral aspect of the right sixth
rib, with
associated soft tissue density. Characterization is limited as
this lesion is at the perimeter of the field of view. While
this may represent scar from prior resection, further evaluation
with CT chest is recommended when the patient's condition
stabilizes.
4. Status post esophagectomy with gastric pullthrough.
5. Emphysema. Pleural calcification along the right lung base
is consistent with prior asbestos exposure.
6. Left adrenal adenoma.
7. Atherosclerosis.
8. Diverticulosis.
--------
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 70282**]
IMPRESSION: No evidence for hemorrhage, mass effect, or acute
ischemic
changes.
-------
L-SPINE (AP & LAT) Clip # [**Clip Number (Radiology) 70283**]
IMPRESSION:
L1 vertebral body compression fracture. The degree of vertebral
body collapse is unchanged.
-------
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to [**Hospital1 18**] as a trauma transfer from [**Hospital 8641**]
hospital after a fall down stairs resulting in amnesia to the
event and an L1 burst fracture diagnosed at [**Location (un) 8641**]. He was
intubated in the emergency department after sudden onset of
respiratory distress secondary to aspiration following the
administration of Ativan. He was then transferred to the Trauma
SICU on ventilator support.He remained on ventilatory support
secondary to a significant pneumonitis and was treated with
Ceftriaxone IV; this was later changed to Ciprofloxacin, he has
3 more days to complete his course. He was eventually extubated
and then required re-intubation secondary to acute respiratory
distress and declining mental status. On HD # * he was
successfully extubated and transferred to the regular nursing
unit. He has required nasal oxygen at 2-3 L/min with saturations
>93%; his FiO2 requirements have been decreased because of his
history of COPD and should be eventually weaned off. He was
started back on his Albuterol and [**Doctor First Name **] as this was part of
his home medication regimen; Albuterol neb treatments have been
administered intermittently during his hospital stay.
He was evaluated by the Orthopedic Spine service, who determined
that his fracture was nonoperative in nature and he was fitted
for a TLSO brace; this is to be worn at all times. He will
follow up with Dr. [**Last Name (STitle) 1352**], Spine Surgery, in 2 weeks. Neuro
exams off sedation remained stable throughout his stay,
consistently moving all extremities.
His blood pressure was elevated throughout his hospital stay; he
initially required IV Lopressor & Hydralazine. He was later
changed to oral Diltiazem and HCTZ; it is likely he will require
further adjustment of his medications to control his blood
pressure during his rehab stay.
He was also noted to be agitated during his initial
hospitalization and required Haldol and was also placed on
Ativan per CIWA scale for alcohol withdrawal. He was also
started on a clonidine patch for DT prophylaxis. His mental
status currently is awake, alert, oriented X2, cooperative with
care. He is likely experiencing a delirium related to his fall
and recent respiratory infection (head CT imaging was negative
for any intracranial processed).
He was evaluated by PT & OT and it was recommended that he go to
a short term rehab facility in order to improve function.
Medications on Admission:
Paxil, Inhalers
Discharge Medications:
1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
Disp:*15 Suppository(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) dose
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) dose
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
8. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) dose
Injection [**Hospital1 **] (2 times a day).
11. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
12. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily): hold for SBP <110.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
s/p Fall
Lumbar (L1) spine fracture
Aspiration pneumonitis
Discharge Condition:
Good.
Discharge Instructions:
Call your doctor or return to the emergency department if you
experience any of the following: fever, worsening back pain,
weakness, numbness or tingling in your legs or feet, inability
to walk, any new or concerning symptom.
You need to wear your TLSO brace at all times when out of bed.
Wear this brace until you are seen in follow up with Dr.
[**Last Name (STitle) **].
Followup Instructions:
You will need to follow-up with Dr. [**Last Name (STitle) **] (Orthopedics Spine
Service) in two weeks; call [**Telephone/Fax (1) 1228**].
You may also follow up in the trauma clinic; call [**Telephone/Fax (1) 6429**]
for an appointment.
Completed by:[**2182-12-12**]
ICD9 Codes: 5070, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1172
} | Medical Text: Admission Date: [**2143-7-11**] Discharge Date: [**2143-7-19**]
Date of Birth: [**2063-9-6**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Headache, difficulty speaking
Major Surgical or Invasive Procedure:
[**2143-7-11**] Left craniotomy evacuation of L SDH
History of Present Illness:
79 y/o male transferred from [**Hospital **] hospital. Per report,
patient fell a few days ago and presented to [**Hospital3 **] with
altered mental status and difficulty speaking.
Patient is a poor historian and has limited speech, but claims
he fell just a few days ago, but he is here form his home town
of [**Location 30319**] for a festival, and claims he fell at home. He
can't provide history of the details around the fall, so it is
unclear whether it was syncopal or mechanical.
Past Medical History:
DM, HTN, HL
Social History:
married, lives in [**Location 30319**]. no tobacco/etoh
Family History:
non-contributory
Physical Exam:
On Admission:
Language: Speech slow and hesitant, questionable
comprehension.Naming intact with pen and wrist watch. Some
degree
of dysphasia and word finding difficulty.
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 [**5-18**] throughout. No pronator drift
Sensation: Intact to light touch.
PHYSICAL EXAM UPON DISCHARGE:
AAOx2 (person, day, year is "12", hospital), strength 5/5 all
extrem
Pertinent Results:
CT head [**2143-7-11**]:
FINDINGS: A massive mixed density left subdural hematoma shifts
the normally midline structures at least 10 mm to the right.
The basal cisterns are patent and there is no evidence of
downward transtentorial herniation. No parenchymal hemorrhage,
edema, or large territorial infarction is seen. The occipital
[**Doctor Last Name 534**] of the left lateral ventricle is effaced as are left
frontal lobe sulci. There is preservation of [**Doctor Last Name 352**]-white matter
differentiation. No fracture is identified. Mucosal thickening
is seen of the bilateral maxillary sinuses and left frontal
sinus. There is partial opacification of multiple ethmoidal air
cells. The middle ear cavities and mastoid air cells are clear.
The globes are unremarkable.
IMPRESSION: Massive acute on chronic left subdural hematoma
with 10-mm
rightward shift of normally midline structures. Basal cisterns
are patent. No fracture.
CT head [**2143-7-11**]:
CT HEAD: The patient is status post left frontal craniotomy
with evacuation of the large left subdural hemorrhage. A
hypodense subdural collection remains with new pneumocephalus.
There is left sulcal effacement. Small hyperdense foci within
the collection are likely post surgical blood products.
Persistent 9 mm rightward shift of normally midline structures
is unchanged. No new intra- or extra-axial hemorrhage is
identified. The basal cisterns are patent. The [**Doctor Last Name 352**]-white
matter differentiation is preserved. Opacification of the
ethmoid air cells is similar to the prior study. A small mucus
retention cyst is seen in the left maxillary sinus. The mastoid
air cells and middle ear cavities are clear. The globes and
orbits are unremarkable.
IMPRESSION: Status post left frontal craniotomy with interval
evacuation of the left subdural hematoma. The subdural space is
largely replaced by
pneumocephalus with residual hypodense fluid and small
hyperdense blood
products. Unchanged 9 mm rightward shift of normally midline
structures. No new hemorrhage.
[**7-12**] ECG: Baseline artifact. Sinus rhythm with ventricular
premature beat. Possible Q waves through lead V5, consider
anteroseptal myocardial infarction with ST-T wave
abnormalities. The ventricular premature beat Q waves support
that likelihood. Other ST-T wave abnormalities. Since the
previous tracing of [**2143-7-11**] atrial premature beats are now not
seen.
[**7-18**] LENI's: Deep venous thrombosis involving left superficial,
popliteal, and posterior tibial veins.
Brief Hospital Course:
79 yo M with h/o HTN and DM s/p fall one week PTA, found to have
L SDH with midline shift.
# LEFT SDH WITH MLS: CT head in the ED showed large acute on
chronic SDH with 10mm MLS. He was admitted to the ICU and
started Dilantin for seizure ppx. He was taken to the OR for L
craniotomy and evacuation of L SDH. There were no
intra-operative complications. Pt extubated and transferred to
ICU for monitoring. His post-op neuro exam was significant for
right sided weakness 3/5, but full strength on left side, face
symmetric, PERRL. Post-op head CT showed L frontal
pneumocephalus so he was placed on high-flow O2 via NRB and lay
flat. SBP was maintained <140 with nipride PRN. On HD #2 (POD
#2), neuro exam stable. On HD#3, his lethargy was improving and
he was transferred to floor. BP control was liberalized to
SBP<160. On HD#6 pt walked with PT, they recommended rehab but
pt desired to go to [**Location 30319**] and cannot fly until POD #14. On
HD #9 pt's neuro exam notable for full strength in all
extremities, but residual subtle expressive/receptive aphasia.
# DVT: On HD #8 screening LENIs revealed LLE DVT. Patient was
started on Lovenox 80mg SC q12 hrs, to be continued for total of
6 months.
# EKG CHANGES: Pt's cardiac enzymes were trended x4 given fall
and EKG showing ST-T changes and possible Q waves through V5
(question anteroseptal MI). His troponin peaked at 0.03, CK/MB
were flat. EKG unremarkable.
Patient was recieved bed and insurance approval for transfer to
[**Hospital6 **] on the evening of [**7-19**].
=======================
TRANSITION OF CARE:
-Pt should continue Enoxaparin SC for 6 months for LLE DVT
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Paroxetine 30 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Lantus *NF* (insulin glargine) 14 units Subcutaneous qhs
5. GlyBURIDE 5 mg PO DAILY
Discharge Medications:
1. Lisinopril 10 mg PO DAILY
2. GlyBURIDE 5 mg PO DAILY
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Paroxetine 30 mg PO DAILY
5. Acetaminophen 325-650 mg PO Q6H:PRN pain, t>38.5
6. Bisacodyl 10 mg PO/PR DAILY
7. Docusate Sodium 100 mg PO BID
8. Enoxaparin Sodium 80 mg SC Q12H
9. HydrALAzine 10-20 mg IV Q6H:PRN sbp>160
10. Ondansetron 4 mg PO Q8H:PRN nausea
11. Oxycodone-Acetaminophen (5mg-325mg) [**1-14**] TAB PO Q4H:PRN pain
12. Phenytoin Sodium Extended 100 mg PO TID
13. Senna 1 TAB PO DAILY
14. Glargine 14 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] Hospital
Discharge Diagnosis:
Subdural hematoma with midline shift
Dysphasia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Craniotomy for Subdural Hematoma
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
?????? 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 have dissolvable sutures you may wash your hair as you
normally would do although refrain from scrubbing the area of
your incision
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure
medicine, take it as prescribed and follow up with laboratory
blood drawing in one week. This can be drawn at your PCP??????s
office, but please have the results faxed to [**Telephone/Fax (1) 87**].
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 9403**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
this appointment.
Completed by:[**2143-7-19**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1173
} | Medical Text: Admission Date: [**2194-7-11**] Discharge Date: [**2194-7-17**]
Date of Birth: [**2117-6-7**] Sex: M
Service: NEUROLOGY
Allergies:
Phenytoin / Valproic Acid And Derivatives / Shellfish / Ace
Inhibitors / Loperamide
Attending:[**First Name3 (LF) 7575**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 9995**] is a 77-year-old man with a history of multiple
prior strokes, cavernous hemangioma, and seizures who presents
with a recurrent seizure. His wife observed him in bed this
morning to have a one-minute GTC convulsion. It appeared
generalized at onset, with head version to the left. She thought
to give him lorazepam, but the bottle was expired. His most
recent seizure prior to this was over three years ago. He has
been maintained on Keppra 500 mg [**Hospital1 **] and has not missed any
doses. His wife has noted no recent infectious symptoms and no
change in his neurologic symptoms. She states that he had been
doing well at home.
On neuro ROS, Mr. [**Known lastname 9995**] (who communicates via nods) denies
headache, diplopia, new dysphagia (his swallowing had been
improving, and he was up to pureed solids), lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies focal weakness,
numbness, parasthesiae.
On general review of systems, his wife reports that he has been
having 2 loose stools per day since his last hospital discharge.
He denies recent fever or chills. No night sweats or recent
weight loss or gain. Denies cough, shortness of breath. Denies
chest pain or tightness, palpitations. Denies nausea,
vomiting,constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denies arthralgias or
myalgias. Denies rash.
Past Medical History:
1. Multiple strokes including left corona radiata, left frontal,
left posterior cerebral artery occlusion with resultant left
occipital lobe infarction, left internal capsule, right
cerebellar.
2. Right cavernous hemangioma
3. Hypertension
4. Diabetes, managed with diet
5. History of seizures secondary to cavernous hemangioma. [**2185**]
EEG showed left temporal theta rhythmic activity consistent with
electrographic seizures.
6. Status post prostatectomy for prostate cancer
7. Status post cataract surgery right eye
8. Hypothyroidism
9. Patent foramen ovale
10. PEG
11. h/o R humerus fracture
Social History:
Cared for at home by his wife. Former contractor. Aphasic at
baseline, can answer yes/no questions. Needs help with
transfers, can sit up in a wheelchair. Nonsmoker. Used to drink
alcohol on occasion.
Family History:
Significant family history of stroke. Son and granddaughter with
seizure disorders. Sister with DM and HTN.
Physical Exam:
Vitals: T: 99.0 P: 74 R: 13 BP: 180/90 SaO2: 100%2L NC
General: Awake with eyes closed, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. Well-healed scar at
site of prior trach.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: PEG in place, no evidence infection. soft, NT/ND,
normoactive bowel sounds, no masses or organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, but keeps eyes closed. Produces no
intelligible words, although wife states she understood him to
say his name when asked. He nods yes/no appropriately. Follows
(or correctly attempts to follow) 2-step commands - bringing his
right thumb towards his left ear.
-Cranial Nerves:
I: Olfaction not tested.
II: Pupil 4 to 2mm and brisk OS, post-surgical OD. no blink to
threat from right OU. Uncooperative with funduscopic exam.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: Appears to have R NLF flattening and mild facial droop, old
per wife.
[**Name (NI) 7060**]: [**Name2 (NI) **] intact to voice.
IX, X: He does not or cannot comply with this testing.
[**Doctor First Name 81**]: 5/5 strength in trapezii bilaterally.
XII: He does not or cannot comply with this testing.
-Motor: Normal bulk, slight increase in tone in left UE. Slight
pronator drift bilaterally. No adventitious movements, such as
tremor, noted. No asterixis noted. Seems to have difficulty
abducting L UE past 30 degrees. He also does not or cannot
comply with testing of bilateral TA.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 4+ 5 4+ 4+ 5 4+ 5 5 5 - 5
R 5 5 5 5 5 5 5 5 4+ - 5
-Sensory: No deficits to light touch, pinprick throughout.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 3 1 3 3 3
R 3 1 3 3 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Stoops forward, has a narrow base, small, cautious steps.
Pertinent Results:
[**2194-7-11**] 11:30AM BLOOD WBC-3.9* RBC-4.48* Hgb-13.5* Hct-41.5
MCV-93 MCH-30.2 MCHC-32.6 RDW-13.9 Plt Ct-177
[**2194-7-11**] 11:30AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Schisto-OCCASIONAL
[**2194-7-16**] 06:45AM BLOOD PT-14.1* PTT-38.3* INR(PT)-1.2*
[**2194-7-11**] 01:00PM BLOOD Glucose-124* UreaN-12 Creat-0.9 Na-142
K-4.5 Cl-107 HCO3-26 AnGap-14
[**2194-7-12**] 02:21AM BLOOD ALT-22 AST-79* LD(LDH)-629* AlkPhos-74
Amylase-131* TotBili-0.6
[**2194-7-12**] 02:21AM BLOOD Lipase-26
[**2194-7-12**] 02:21AM BLOOD TotProt-6.5 Albumin-3.4 Globuln-3.1
Calcium-9.1 Phos-1.3* Mg-2.1
[**2194-7-11**] 11:39AM BLOOD Lactate-2.3*
CT HEAD: There is a small hypodense focus within the right
frontal lobe (S2, I18) that is not seen on the prior study.
Small punctate
calcifications associated with right anterior frontal cavernous
hemangioma are unchanged. Stable appearance of chronic
encephalomalacia involving the left frontal and occipital lobe
with ex vacuo dilatation of the occipital [**Doctor Last Name 534**] of the left
lateral ventricle. There is no shift of normally midline
structures, hydrocephalus, or intracranial hemorrhage. Confluent
hypodensities within the periventricular and deep white matter
consistent with chronic microvascular infarct. Hypodensity
within the right basal ganglia is unchanged. The osseous and
soft tissue structures are unremarkable. The visualized
paranasal sinuses are clear.
KUB: Consistent with the given history, a gastric tube is
present within the medial left upper quadrant. No gaseous
distention of the stomach is
appreciated. There is gas throughout the colon and nondilated
small bowel
loops. Numerous clips are seen within the pelvis. Extensive
degenerative
disease is noted in the lower lumbar spine.
Brief Hospital Course:
Mr. [**Known lastname 9995**] was initially thought to be treated as an
outpatient. However, he then developed a flurry of seizures with
head rotation to the right. He finally stopped after he
received a total of 14 mg of Ativan and 1500iv of Keppra. He had
gotten 1000mg of Keppra by mouth in the ED. He was obtunded and
difficult to arouse after the Ativan doses.
Given that he had > 3 seizures within 30 minutes without
returning to baseline, he was admitted to the MICU. In ICU, he
had a few more seizures (R UE twitching w/ L sidedspiking on
EEG). By report, no electrographic seizures w/o clinical
correlate and no clinical seizure w/o electrographic correlate.
Last seizures <1min each time [**2194-7-14**] at midnight & 3am (rec'd
LZP 2mg each time).
He finally stopped seizing with Keppra IV 2000mg [**Hospital1 **] and after
48 hrs without any seizure activity, he was transferred to
neurology floor where he was monitored and treated for 48 more
hours. He remained seizure free and his IV Keppra was changed
to Keppra per G-tube the day before discharge.
Given his hx of chronic loose stools, nutrition was consulted
who upon discussing plan of care with wife, recommended [**Name (NI) 97336**]
2.5 cans thrice daily plus 1 can at bedtime as boluses to
minimize activity restriction.
He has follow-up appt with Dr. [**Last Name (STitle) **] as outpatient. He is
discharged to home with home physical therapy plus VNA services.
Medications on Admission:
Amlodipine 5 mg once a day
Hydrochlorothiazide 25 mg once a day
Labetalol 400/600/600
Levetiracetam 500 mg twice a day
Levothyroxine 125 mcg once a day
Modafinil 200 mg qam
Ranitidine 150 mg once a day
Cyanocobalamin 250 mcg once a day
EC ASPIRIN - 325MG QD
Ferrous Sulfate 325 mg once a day
Folic Acid 0.8 mg once a day
Multivitamin once a day
Senna 8.6 mg Tablet - 2 Tablet(s) by mouth once a day as needed
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
3. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
4. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
5. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Cyanocobalamin 500 mcg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Modafinil 100 mg Tablet Sig: Two (2) Tablet PO qam ().
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. Therapeutic Multivitamin Liquid Sig: One (1) Tablet PO
DAILY (Daily).
13. Keppra 1,000 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*0*
14. tube feed
[**Last Name (STitle) 97336**] 2.5 cans per G-tube three times daily (does not need to
be set time) plus 1 can at night. Flush with 75cc of water
after each bolus feeds.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Status epilepticus likely secondary to under-medication possible
from chronic loose stools/diarrhea.
Hx of multiple strokes and cavernous angioma with known
seizures.
Discharge Condition:
Baseline - bed/chairbound
Discharge Instructions:
You were admitted initially to medical intensive care unit with
status eplilepticus likely from decreased absorption of your
anti-seizure medication (Keppra) because of your loose stools.
Your Keppra was titrated upto 2000mg twice daily then switched
to pill form once your loose stools were under control.
Nutrition consult was also obtained to ensure that you were
getting proper tube feeds/scheduling - we recommend [**Location (un) 97336**] 2.5
cans three times daily (no set time necessary) and 1 can before
bedtime per your G-tube plus 75cc of water through the tube
after each bolus of feeds.
Please take your medications as scheduled - the only change has
been your seizure medication, Keppra as noted above. Also,
please follow-up with Dr. [**Last Name (STitle) **] as scheduled and call your PCP
(Dr. [**First Name (STitle) 3510**] for a follow-up within 2 weeks of discharge.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 658**], M.D. Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2194-9-9**] 1:30
Completed by:[**2194-7-18**]
ICD9 Codes: 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1174
} | Medical Text: Admission Date: [**2183-9-15**] Discharge Date: [**2183-10-7**]
Date of Birth: [**2114-7-8**] Sex: M
Service: NEUROLOGY
Allergies:
Phenergan
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Mental status changes and headache
Major Surgical or Invasive Procedure:
-Right craniotomy to biopsy brain tissue underlying large right
IPH.
-Wound vac changes and debridement (bedside) by Gen Surgery -->
now changed by nursing (q3d)
History of Present Illness:
Initial presentation to neurosurgery:
Pt is a 69m who was found to be a little confused today at
his rehab facility. He was at rehab recovering from abdominal
wall reconstruction 10 days ago. He currently has a VAC over his
abdominal wound. He has been on Coumadin and heparin at this
facility for treatment of DVT and PE. His INR today is 1.6. CT
head at OSH showed right posterior parietal hemorrhage measuring
5mm with no report of midline shift. He did not receive FFP, Vit
K or any other agents for reversal of his INR and was noted to
be
hypertensive on arrival with SBP in the 250's. He currently
complains of headache and denies weakness/numbness of
extremities, word finding difficulty or facial weakness.
Initial Neurology Fellow's HPI:
Mr. [**Known lastname 24735**] is a 69-year-old, L-handed man with a history of
hypertension, DVT/PE on warfarin and heparin, and multiple
abdominal surgeries who was transferred to [**Hospital1 18**] from a rehab
facility yesterday ([**2183-9-15**]) with headache and confusion. CT
revealed a right fronto-parietal hemorrhage. The patient
reports
that the headache started shortly after his operation on
[**2183-8-20**], which took place at [**Hospital **] Hospital; he was
transferred to a rehab facility from [**Hospital **] Hospital. He
describes the headache as encompassing his entire head, it was
associated with nausea, but no vomiting. The patient also
describes confusion, specifically having difficulty remembering
what happened on a day-to-day basis. He reports having seen
"little furry things," brown and [**Location (un) 2452**] in color, which
sometimes
looked like sunflowers. He knew they weren't real and thought
they must be "blood clots" in his eyes. A CT was performed at
[**Hospital **] Hospital, which revealed a 5mm R posterior parietal
hemorrhage with no midline shift. He received no FFP or vitamin
K at the OSH and was found to be hypertensive on arrival to
[**Hospital1 18**]
with SBP in the 250s, INR of 1.8, and PTT of 27.7.
The patient currently denies numbness of the face or
extremities,
but reports that he's felt somewhat weak and clumsy over the
past
few days, with trouble, for example, in opening his mobile
phone.
He also reports that his speech is slower than usual, with
difficulty putting his thoughts into words. He denies headache
currently and reports that his memory has improved, but that he
still can't clearly remember the events of the past month. He
denies abnormal perceptions.
Past Medical History:
- s/p hiatal hernia repair [**2182-11-17**] c/b post-op infections,
s/p >7 surgeries for debridement
- DVT/PE following hiatal hernia repair, treated with warfarin
(and with heparin at recent stay at OSH)
- "coma" following one of above surgeries; patient denies stroke
- hypothyroidism
- HTN
- Afib
- GERD
- prostate CA s/p protatectomy 2 years ago; no hx radiation or
chemotherapy treatment
- s/p L nephrectomy and adrenalectomy ~40 years ago for renal
problem caused by congenital malformation of kidney
- chronic kidney disease
Social History:
Was at rehab prior to admission. Patient is married and lives
with his wife. [**Name (NI) **] is a non-smoker (quit when he was a
teenager). He had one alcoholic drink per month.
Family History:
No known history of strokes or heart disease. No known history
of dementia or other neurologic disease.
Physical Exam:
On Admission
T-98.2, HR-86, BP-137/72, RR-22, O2Sat-95% on 2L by NC
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally anteriorly and laterally
Abd: Wound dressing in place
Ext: no edema
Neurologic examination:
Mental status:
General: alert, awake, normal affect, occasional loss of
attention in interview with difficulty remembering topic
Orientation: oriented to person, place, date, situation
Attention: able to go backwards with DOW
Executive function: follows simple axial and appendicular
commands: closes and opens his eyes, shows me the tongue, points
to ceiling, lifts R arm and L arm
Memory: recalls current president and President [**First Name9 (NamePattern2) **] [**Last Name (un) 2450**], but
forgot that [**Hospital1 1806**] was president before [**First Name9 (NamePattern2) **] [**Last Name (un) 2450**] and after [**Last Name (un) 2450**]
senior; remembered [**3-19**] words after 5 minutes
Speech/Language: fluent w/o paraphasic (phonemic or semantic)
errors or blocking, but with occasional slowness; comprehension,
repetition, naming normal; able to read, but not able to write
with dominant L hand
Praxis/Agnosia: able to demonstrate how to brush teeth and to
use
a hammer
Patient has mild left side neglect
Cranial Nerves:
II: Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Left hemianopia
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V1-3: Sensation intact V1-V3.
VII: Facial movement symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX & X: Palate elevation symmetric. Uvula is midline.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius full strength bilaterally.
XII: Good bulk. No fasciculations. Tongue midline, movements
intact.
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
Pronator drift present on L.
Delt; C5 bic:C6 Tri:C7 Wr ext:C6 Fing ext:C7
Left 4- 4+ 4- 4 4-
Right 5 5 5 5 5
.
IP: Quad: Hamst: Dorsiflex: [**Last Name (un) 938**]:Pl.flex
Left 5 5 5 5 5 5
Right 5 5 5 5 5 5
.
Deep tendon Reflexes:
.
Biceps: Tric: Brachial: Patellar: Achilles Toes:
Right 2 2 2 2 2
DOWNGOING
Left 2 2 2 2 2
DOWNGOING
.
Sensation: Intact to light touch and pinprick on R; diminished
light touch and pinprick on L, upper and lower extremities.
.
Coordination: finger-nose-finger normal on R, slow with
overshoot
on L
Gait: deferred
Romberg: deferred
Pertinent Results:
ADMISSION LABS:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2183-9-18**] 03:41 16.0* 3.23* 10.1* 29.9* 93 31.3 33.8 16.3*
648
[**2183-9-15**] 06:00PM GLUCOSE-87 UREA N-18 CREAT-1.6* SODIUM-139
POTASSIUM-4.9 CHLORIDE-107 TOTAL CO2-23 ANION GAP-14
DISCHARGE LABS:
CT HEAD [**9-15**]
Large right frontoparietal intraparenchymal hemorrhage with
surrounding edema and mass effect. No significant shift of
midline
structures. An underlying mass lesion cannot be excluded. MRI is
pending for further evaluation.
MRI/A Brain [**9-16**]
There is a right parietal intraparenchymal lesion suggestive of
recent acute hemorrhagic episode on a background of chronic
bleed or bleeding episodes. An occult vascular malformation
would be the likely etiology. Further areas of small hemorrhages
in the right cerbral hemisphere and right cerebellum may
represent amyloid angiopathy or multiple arteriovenous
malformations or a combination of both. It would be useful to
compare any previous studies and followup imaging is advised for
assessment of evolution
Cerebral carotid arteriogram [**9-23**]:
pt underwent cerebral arteriography for evaluation of right
parietal hemorrhage. This study failed to demonstrate any
evidence of AV vascular malformations, AV fistulas,
aneurysms,vasculitis or significant vascular stenosis.The
patient withstood the procedure well and had no immediate
complications.
MRI [**9-24**]:
IMPRESSION: Right temporoparietal hemorrhagic lesion with
perilesional edema, unchanged over the short interval.
NCHCT [**9-24**]
Expected post-operative changes status post resection of right
parietal mass with a small amount of fluid, air, and
post-operative blood within the resection cavity. Stable
vasogenic edema surrounding the resection cavity causes minimal
mass effect on the atrium of the right lateral ventricle. Small
to moderate amount of right frontal pneumocephaly.
MRI [**9-26**]:
Since the previous MRI of [**2183-9-24**], patient has undergone
resection of right parietal hemorrhagic lesion with expected
post-surgical changes and blood products and pneumocephalus. No
evidence of enhancement seen in this region. Enhancement in the
left occipital lobe along the surface of the brain is unchanged.
No acute infarcts or hydrocephalus. Other findings as described
above are unchanged.
Expected post-surgical appearance after right parietal mass
resection with edema and a decreased amount of blood surrounding
the surgical site. Interval decrease in the amount of
pneumocephalus. No new hemorrhage.
***
CT Chest/Abdomen/Pelvis [**9-16**]:
No primary lesion
CT Chest/Abdomen/Pelvis [**9-27**]:
1. Decreased size of horse-shoe shaped subcutaneous fluid
collection adjacent to the anterior abdominal wall wound, which
is otherwise little changed in appearance.
2. Status post IVC filter placement, with new evidence of
thrombus in the IVC, right external iliac vein, and probably
also in the left external iliac vein.
IVC filter placement [**2183-9-23**]:
IMPRESSION:
1.IVC venogram demonstrating single IVC with no evidence of
thrombus.
2.Successful placement of an OptEase IVC filter below the level
of the renal veins via the right common femoral venous approach.
The OptEase filter can be retrieved after two weeks or can stay
as a permanent filter.
LEDs [**2183-9-29**]:
1. Incompletely occlusive thrombosis of right popliteal vein.
2. Dampening of normal respiratory variation within the right
common femoral vein compared to the left is consistent with the
right external iliac venous thrombosis previously seen on CT
TTE [**9-26**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF 65-70%). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic arch is mildly dilated. There are focal
calcifications in the aortic arch. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. The left
ventricular inflow pattern suggests impaired relaxation. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
Impression: no obvious intracardiac shunt seen on suboptimal
imaging
Brief Hospital Course:
Initial hospital course on neurosurgery service:
Patient presented to the ER at [**Hospital1 18**] as a transfer from an OSH.
He had previously been at rehab and had been complaining of a
headache since thursday as well as difficulty using his left
hand. He presented to an OSH last evening [**9-15**] with complaints
of mental status changes as well as continued headache. Imaging
was done which showed a 5cm Right posterior parietal hemorrhage.
He was then transferred to [**Hospital1 18**] for neurosurgical evaluation.
Upon arrival a repeat CT scan of the head was done which showed
stable appearance of the Right parietal blood, he had a left
pronator drift but was otherwise neurologically intact, and was
admitted to the ICU. MRI of the head with and without as well
as an MRA of the brain was done overnight which showed a right
parietal intraparenchymal lesion. His INR was 1.6 upon admission
secondary to his coumadin use and as a result he received 1 unit
fo platelets as well as 1 unit of FFP.
On the morning of [**9-16**] on rounds he was noted to be
neurologically intact except for a left pronator drift. His
wound vac dressing from his recent abdominal surgery was in
place but not connected to a vac unit. The wound care nurse
evaluated him and removed the vac and found necrotic tissue. As
a result, general surgery was consulted who removed the vac, and
debrided necrotic tissue at the bedside. They also decided to
aspirate the abdmoinal fluid collections. This was thought to be
the source of the elevated WBC.
Given the nature of his bleed and symptoms Stroke neurology was
consulted. They were highly suspicious that this was likely a
hemorrhagic stroke, and not a mass. The decision was made to
obtain an MRI which revealed a mass under the hemorrhage. He
will go to angiogram on Tuesday to have the lesion embolized and
then resected on the following day. An IVCF will also be placed
in IR by general surgery. On [**9-19**], patient was intact and no
further debridements of his abdomen were done. He will remain in
the ICU for monitoring until his angiogram. His dilantin level
was 5.0 in the morning, a 300mg bolus was given.
Pt underwent diagnostic cerebral angiogram on [**9-23**] to evaluate
for vascular malformation or other lesions. This proved to be
negative and pt was transfered to the floor in stable condition.
He was seen post angio and was doing well. His groin site was
clean and dry with no hematoma and he had good distal pulses and
no change in his neurological status. Pt was made NPO on this
night in preparation for craniotomy on [**9-24**] to evaluate for
underlying lesion as his MRI was suspicious for hemorrhagic
mass.
On [**9-24**] pt underwent R sided craniotomy for exploration of his
occiptal bleed. Tissue sent was consistent with hemorrhagic
tissue and showed no malignancy. Pt was intubated post
operatively but required re-intubation as his oxygenation was
poor. He was transfered to the ICU for post operative care
including strict blood pressure control and q1 neuro checks. On
post op exam pt was following commands and moving all
extremities. His incision was clean and dry with no active
drainage. Pt was transfered to the neurology service on [**9-25**] for
further care and medical managment of his stroke.
He was transferred to the care of Neurology on [**9-25**], finding a
bed on the floor on [**9-26**]. Surgery had signed off and signed back
on for continued care of vacuum dressings.
Floor (step-down unit) [**Hospital 878**] hospital course:
Re. Neuro issues, There were no complications after the
craniotomy; post-operative imgaing (MRI and HCT) looked good,
neurologic exam remained stable to improved, and his staples and
sutures were removed on [**2092-10-2**]. Post-op dexamethasone was
tapered by [**9-27**] and Dilantin was tapered to off prior to
discharge.
Re. ID issues, Intraabdominal wound infection continued to
improve, both radiographically and systemically, with the
patient remaining afebrile both on, and then off IV abx (vanc +
meropenem). These were stopped on [**9-30**] under the advice of the
following inpatient ID consult service. His wound dressing was
changed q3d initially by surgery, and then by wound-care nursing
after ACS signed off the case on [**10-2**].
Re. heme issues, an IVC filter was placed while the patient was
on Nsgy service. This became clotted (pt off a/c after
IPH/crani), first evidenced on CT with contrast (obtained to
trend abdominal wound), and later by RLE DVT evident on exam and
LED. Thus, he was restarted on heparin bridge to warfarin on
[**10-3**], with low-therapeutic PTT goal (40-60). INR was up to 1.5
at the time of discharge, dosing warfarin 10mg/d at that point
([**10-6**]). Per Hematology c/s, a hypercoagulability workup should
be re-initiated (prot C/S, antithromb, FactV Leiden) after
discharge; slightly abnormal levels drawn in the acute setting
are of unknown significance. Pt was started on ASA 81. Also note
that H&H trended down (Hb from 11s to [**8-25**]) gradually over the
course of this hospitalization. Guiac negative. Thought [**2-18**]
phlebotomy plus blood loss with craniotomy plus oozing with
debridment/wound vac changes. Not transfused.
Re. cardiologic issues, he was continued on 200mg [**Hospital1 **] amiodarone
for afib.
Re. endo issues, he was continued on Synthroid previous dose.
Re. psychiatric issues, the patient's Wellbutrin was held during
this admission, and should be restarted under the guidance of a
psychiatrist/Neurologist if desired (this medication has been
associated with seizures / reduced seizure threshold).
He will follow up in [**Hospital1 18**] clinics with Dr. [**Last Name (STitle) **]
(Neurosurgery) and with Dr. [**Last Name (STitle) **] (stroke/vascular Neurology).
He will transfer his ID and wound care follow up to [**Hospital **]
hospital, per his convenience. Our ID service will supply
contact information for these services.
Medications on Admission:
Coumadin 4mg daily
Ativan 1mg q6 PRN
Zinc 220mg daily
MVI 1 tab daily
Synthroid 50mcg daily
Lansoprazole 30mg daily
Imipenem 250mg q8
Vit C,
amiodarone 200mg daily
Discharge Medications:
.
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
2. Levothyroxine 50 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
3. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times
a day).
4. Ascorbic Acid 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
5. Zinc Sulfate 220 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY
(Daily).
6. Glucagon (Human Recombinant) 1 mg Recon Soln [**Last Name (STitle) **]: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
7. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
8. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day).
9. Magnesium Hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
11. Simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for
gas-discomfort/ileus.
12. Acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q12H
(every 12 hours).
13. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
14. Psyllium 1.7 g Wafer [**Hospital1 **]: One (1) Wafer PO DAILY (Daily) as
needed for constipation.
15. Warfarin 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Once Daily at 4
PM.
16. Phenytoin 125 mg/5 mL Suspension [**Hospital1 **]: One (1) PO Q24H
(every 24 hours).
17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breathe.
18. Collagenase Clostridium hist. 250 unit/g Ointment [**Hospital1 **]: One
(1) Appl Topical [**Hospital1 **] (2 times a day).
19. Oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
20. Heparin (Porcine) in D5W 12,500 unit/250 mL Parenteral
Solution [**Hospital1 **]: One (1) Intravenous ongoing: Currently at 1200
units/ hr: check ptt next time at 6:00 pm, please
Stop when INR is [**2-19**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1122**] Center - [**Hospital1 3597**]
Discharge Diagnosis:
Right Parietal Hemorrhage
Discharge Condition:
HDS/VSS. AAOx3. Afebrile without leukocytosis x greater than one
week prior to discharge, off IV abx x 6d.
Neuro exam is notable for stable mildly impaired graphesthesia
in Right hand, extiction to DSS on left (visual and
somatosensory). And left-hand clumsiness/ataxia. Somewhat
flat/depressed affect (at-home buproprion has been held [**2-18**] c/f
seizure threshold), but improving.
Wound vac packing to be changed q3d and followed up by surgery
at [**Hospital **] Hospital.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance.
Discharge Instructions:
You have had a large right frontoparietal intraparenchymal
hemorrhage with surrounding edema and mass effect that required
surgery
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Followup Instructions:
(1) Please call [**Telephone/Fax (1) 2574**] to schedule an appointment with Dr.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (Stroke Neurology, [**Hospital1 18**] [**Hospital Ward Name 23**] Clinical
Center, [**Location (un) **]).
(2) Neurosurgery:
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
******
(3)ID AND GEN SURGERY will F/U at [**Hospital 420**] HOSPITAL
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
ICD9 Codes: 431, 5185, 5859, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1175
} | Medical Text: Admission Date: [**2115-9-17**] Discharge Date: [**2115-10-9**]
Date of Birth: [**2044-5-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
Increased fatigue and dyspnea on exertion
Major Surgical or Invasive Procedure:
s/p cath
History of Present Illness:
71 yo male with 100py smoking history transferred from OSH for
cath. The patient had not seen a doctor in over 50 years. he was
seen by his wife's PCP on day of admission, and was found to
have CHF by CXR. The patient was sent to [**Hospital3 3583**] ED and
found to be hypertensive to 211/90 with EKG changes of inferior
and lateral Q waves and ST elevations, 92% on RA, and positive
cardiac enzymes (Trop I 0.038 --> 0.210). He was given NTP,
lasix, aspirin, plavix 300mg x 1, heparin gtt, and lopressor
25mg po x1. he was transferred to [**Hospital1 18**] for cath. In the Cath
lab, HD, RA 10, PC WP 27, CO2.0. He was found to have triple
[**Last Name (un) 12599**] disease with mild LAD stenosis (feeding the Cx) so
effective LM. Of note, pt had increased DOE x 2 weeks. No CP,
palpitations. Occassional cough productive of yellow sputum. No
fevers/chills, leg edema, orthopnea, PND, high salt intake or
change in diet.
Past Medical History:
None
Social History:
lives with wife
100 pack year smoking history
remote etoh
h/o asbestos exposure
Family History:
nc
Physical Exam:
HR: 78
BP: 154/71
RR: 17
92% on 4 liters
GEN: NAD
HEENT: JVP -11 cm
CV: RRR, nl s1, s2, no M/R/G
Pulm: Bibasilar crackles, expiratory wheezes
Abd: soft, NT, ND
Femoral: 2+ pulses, blt bruits
ext: no c/c/e
R TP pulse faint, dopperable R DP, L TP, L DP
Pertinent Results:
[**2115-9-17**] 09:48PM CK(CPK)-307*
[**2115-9-17**] 09:48PM CK-MB-7
[**2115-9-17**] 02:50PM TYPE-ART PO2-115* PCO2-46* PH-7.34* TOTAL
CO2-26 BASE XS--1
[**2115-9-17**] 02:40PM GLUCOSE-119* UREA N-35* CREAT-1.2 SODIUM-138
POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-24 ANION GAP-15
[**2115-9-17**] 02:40PM NEUTS-72.8* LYMPHS-18.9 MONOS-6.5 EOS-1.3
BASOS-0.5
[**2115-9-17**] 08:50AM WBC-10.4 RBC-4.54* HGB-14.3 HCT-41.4 MCV-91
MCH-31.5 MCHC-34.4 RDW-14.4
[**2115-9-17**] 08:50AM PLT COUNT-233
[**2115-9-17**] 07:00AM CK-MB-8 cTropnT-0.21*
Echo:
Conclusions:
1. The left atrium is mildly dilated.
2. The left ventricular cavity is mildly dilated. There is
severe global left
ventricular hypokinesis with apical akinesis. Overall left
ventricular
systolic function is severely depressed. (< 30 EF)
3. The aortic root is mildly dilated.
4. The aortic valve leaflets are moderately thickened. There is
a minimally
increased gradient consistent with minimal aortic valve
stenosis. Mild (1+)
aortic regurgitation is seen.
5. The mitral valve leaflets are moderately thickened. Mild (1+)
mitral
regurgitation is seen. HEMODYNAMICS RESULTS BODY SURFACE AREA:
2.06 m2
HEMOGLOBIN: 14.3 gms %
FICK
**PRESSURES
RIGHT ATRIUM {a/v/m} 11/13/9
RIGHT VENTRICLE {s/ed} 54/16
PULMONARY ARTERY {s/d/m} 54/18/30
PULMONARY WEDGE {a/v/m} 31/35/27
AORTA {s/d/m} 169/85/119
**CARDIAC OUTPUT
HEART RATE {beats/min} 80
RHYTHM SINUS
O2 CONS. IND {ml/min/m2} 125
A-V O2 DIFFERENCE {ml/ltr} 60
CARD. OP/IND FICK {l/mn/m2} 4.3/2.1
**RESISTANCES
SYSTEMIC VASC. RESISTANCE 2047
PULMONARY VASC. RESISTANCE 56
**% SATURATION DATA (NL)
SVC LOW 67
PA MAIN 68
AO 99
OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed.
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**RIGHT CORONARY
1) PROXIMAL RCA DISCRETE 60,80
2) MID RCA NORMAL
2A) ACUTE MARGINAL NORMAL
3) DISTAL RCA DISCRETE 60
4) R-PDA DIFFUSELY DISEASED 99
4A) R-POST-LAT DIFFUSELY DISEASED
4B) R-LV NORMAL
**ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM
**LEFT CORONARY
5) LEFT MAIN TUBULAR 50
6) PROXIMAL LAD NORMAL
6A) SEPTAL-1 NORMAL
7) MID-LAD DIFFUSELY DISEASED 90
8) DISTAL LAD NORMAL
9) DIAGONAL-1 NORMAL
10) DIAGONAL-2 DISCRETE 60
12) PROXIMAL CX DISCRETE 90
13) MID CX NORMAL
13A) DISTAL CX NORMAL
14) OBTUSE MARGINAL-1 DIFFUSELY DISEASED 99
15) OBTUSE MARGINAL-2 DIFFUSELY DISEASED 99
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 53 minutes.
Arterial time = 39 minutes.
Fluoro time = 7.1 minutes.
Contrast:
Non-ionic low osmolar (isovue, optiray...), vol 100
ml, Indications - Hemodynamic
Premedications:
ASA 325 mg P.O.
Anesthesia:
1% Lidocaine subq.
Anticoagulation:
Other medication:
Fentanyl 25 mcg IV
Integrilin 7.5 cc/hr IV
Furosemide 40 mg IV
TNG 40-200 mcg/min IV
Midazolam 0.5 mg IV
Cardiac Cath Supplies Used:
- ARROW, ULTRA 8, 40CC
200CC MALLINCRODT, OPTIRAY 100CC
150CC MALLINCRODT, OPTIRAY 100CC
COMMENTS:
1. Coronary angiography of this right dominant circulation
revealed
severe three vessel coronary artery disease. The LMCA had a
distal 50%
tapering. The LAD was diffusely diseased and had a 90% stenosis
in the
mid vessel between moderate sized D1 and D2 branches. D2 had a
60%
narrowing. The LCX had a 90% ostial lesion and supplied small
OM1 and
OM2 branches before terminating in the AV groove. Both OM
branches were
diffusely diseased and sub-totally occluded. The RCA was
diffusely
diseased with a 60-80% stenoses in the proximal vessel and a 60%
distal
narrowing. A moderate sized PDA was subtotally occluded and
appeared to
fill in part via L->R collaterals.
2. Resting hemodynamics revealed markedly elevated filling
pressures
with a mean PCWP of 27 mmHg in the setting of moderate to severe
systemic arterial hypertension. There was evidence of moderate
pulmonary
hypertension with PA pressures of 50/18/30. The cardiac output
was
mildly reduced at 4.3 L/min. No gradient across the aortic valve
was
detected.
3. Left ventriculography was not performed due to the patient's
elevated
filling pressures and recent non-invasive assessment of his
underlying
LVEF.
4. Distal aortography demonstrated moderate distal aortic
disease as
well as disease in the external iliacs.
5. An intra-aortic balloon pump was placed at the conclusion of
the case
without known complication.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Moderate pulmonary hypertension.
3. Successful placement of an IABP.
ATTENDING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) 900**] [**Name Initial (NameIs) **].
Brief Hospital Course:
1. Myocardial Infarction: The patient had a large ST elevation
MI. At cath, he was found to have 3VD and markedly elevated
filling pressures with a wedge of 27 and moderate pulmonary
hypertension and a IABP was placed in hopes that the patient
would go the CABG. Echo on admission revealed severe LV global
hypokinesis. During the days following the diagnostic cath, he
was not a surgical candidate given his mental status (see
below). He was taken back for high-risk catherization and
received 4 [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 10157**] to the LAD lesion. He was placed on
Plavix, BB, ASA, Statin, and Acei. He will continued the Plavix
for at least 9 months. His ACE-I and BB can be titrated up as
his blood pressure and kidney function will tolerate.
2. Congestive Heart Failure - Given patients elevated filling
pressures and chest x-ray consistent with failure, patient was
diuresed in house. He was given Lasix on a prn basis. As his
oral intake increases, he may need daily Lasix.
3. Asystole/Apnea: The patient had his first asystolic pause on
[**9-18**] which was a 7 second pause with junctional escape. This
was felt to be a vagal episode as these occurred in the setting
of sleep apnea, heavy sedation, and were presence by
bradycardia. The pauses became more frequent and EP was
consulted after the patient had an 18 second asymptomatic pause.
At that time, his BB was held and EP thought that he did not
need a pacemaker given that these were vagal episodes. Since
these were related to his sleep apnea, we decided against
starting BiPap given the patients tenuous mental status and that
he would not tolerate it. The BB was added back very slowly,
however the patient had pauses of up to 30 seconds on the days
between [**10-1**] and [**10-2**]. During these pauses, he would be awake,
bradycardic, his respirations would cease, and would be
responsive with a preserved blood pressure. However on [**10-2**] he
syncopized during a 36 second pause, he was transcutaneously
paced and went intubated for an emergent pacer placement. He
received a DDI pacer with a lower rate of 50 bpm and an ICD. He
will need to follow up in the device clinic on [**10-9**].
4. Melana - The patient had multiple episodes of melana when he
first arrived to the hospital. He was transfused twice for these
episodes. Since his mental status was unstable and it was felt
that he would not be able to corporate with a colonoscopy or
EGD, he was taken for a virtual colonoscopy which revealed a
thickened area of his sigmoid colon. By sigmoidoscopy, he had a
small polyp that was non-bleeding that likely not responsible
for this melana. He again had melana on [**10-5**] and his HCT dropped
to 26. He was transfused 1 unit and had an EGD and colonoscopy
which showed gastritis and two non-bleeding angioectasias which
were cauterized. In addition, the patient had multiple non
bleeding diverticular lesions throughout the colon. He will need
to be on a high fiber diet as an outpatient and have a repeat
colonoscopy in 5 years. If the patient continued to have GI
bleeding, he should have a push enteroscopy for cauterization of
AVMs. He should continue Protonix and have H. Pylori serologies
checked as an outpatient.
5. UTI/phimosis/Foley trauma - Patient was seen by urology in
house for severe phimosis and a Foley was blindly placed and
patient was put on Ciprofloxacin for ten days as UTI
prophylaxis. He then partially removed his Foley catheter and
had significant prostate trauma from this. Urology inserted a
second Foley and the patient passed several clots and had a good
amount of hematuria. The Foley was discontinued on [**10-7**] and the
patient was able to void without problems. The patient should
follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] as an outpatient regarding his
phimosis.
6. Mental Status: When the patient was admitted, the patient did
not have mental status changes. However, he became acutely
delirious after he returned from his first cath and had a
balloon pump in. He was unable to be restrained with IV and PO
medications. Therefore, so that he did not pull out his IABP, he
was intubated and sedated. The IABP was removed on [**9-18**] and he
was extubated on [**9-19**]. He continued to be severely delirious
requiring standing and prn Haldol. He was seen by psychiatry who
felt that this was all delerium and hypoxia. Repeat ABGs did
not revelad significant hypoxia or hypercarbia. He continued to
wax and wane with his mental status often not oriented to place
or time. This culminated to becoming unresponsive and frequently
apneic on the day of his 30 second asystolic pauses. Following
his pacemeker, his mental status dramatically improved. He no
longer needed psychoactive medications or a sitter. He continues
to have slight confusion at night which is improving with time.
7. Apnea: The patient was observed to have sleep apnea. However,
as his mental status waned, and he had more severe asystolic
episodes, he became apneic while awake for episodes for up to 30
seconds. A pulmonary consult was obtained and this was though to
be both central and obstructive in nature. The patient was tried
on BiPap and continued to have apneic pauses. In addition, as he
became more responsive, he would not tolerate the machine. After
the patient received his pacemaker, he did not have any further
witnessed events of apnea. He will need to follow up in the
pulmonary clinic for a sleep study.
8. Pneumonia: Several days after admission, the patient was
diagnosed with a retrocardiac infiltrate on chest xray. Sputum
culture demonstrated MRSA. The patient was treated with a 7 day
course of vancomycin. Following the second intubation, the
patient developed a RLL infiltrate though to be due to
aspiration. He was treated for 6 days on Zosyn and then switched
to Levofloxacin and Flagyl. His lung exam markedly improved and
he was breathing with a O2 sat in the high 90s on room air. The
levofloxacin and Flagyl will need to be continued until [**10-17**].
He will also need to have a follow up chest xray to confirm
resolution of his infiltrate.
9. Acute vs. chronic renal insufficency - The patient was
admitted with a creatinine of 1.2, with his baseline unknown.
his creatine steadidly rose to a peak of 2.5 though to be due to
intravascular depletion secondary to CHF and contrast
nephropathy. Over the last week of his hospital stay, his
creatinine decreased to 1.6. This can be monitored as an
outpatient.
10. Anemia: The patient recieved several transfusions during his
three weeks stay. His anemia was though to be due to melana and
chronic disease. This can be worked up further as an outpatient.
His hematocrit was 27 on day of discharge and he was transfused
1 unit.
Medications on Admission:
none
Discharge Medications:
1. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
2. Clopidogrel Bisulfate 75 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 Calcium 40 mg Tablet Sig: One (1) Tablet PO QD
().
5. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-30**] Sprays Nasal
PRN (as needed).
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO once a day.
9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 8 days.
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 8 days.
Discharge Disposition:
Extended Care
Facility:
Lifecare Center of [**Location (un) 3320**]
Discharge Diagnosis:
Asystole
myocardial infarction
delerium
phimosis
pneumonia
sleep apnea
acute renal failure
Discharge Condition:
good
Discharge Instructions:
Call your cardiologist if you have chest pain.
If you have another episode of dark tarry stools, call your PCP.
Take all your medications as prescribed. Never stop the Plavix
for the nest 9 months unless a cardiologist tells you to.
Followup Instructions:
You have a PCP appointment on Tuesday [**2122-10-21**]:15AM with
Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **]. Call [**Telephone/Fax (1) 18696**] for directions.
Follow up with your cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5310**] -
[**Telephone/Fax (1) 5315**]- Monday, [**11-4**] 1:30PM. Call for directions.
Call [**Telephone/Fax (1) 21817**] if you have any questions about your
pacemaker. This is the phone number to the device clinic.
Follow up with urology - Dr. [**First Name (STitle) **] [**Name (STitle) **] - appointment on
[**10-28**] at 2:00 [**Hospital **] clinic is located on [**Location (un) 470**] of [**Hospital Ward Name 23**]
Building at [**Hospital1 **] [**Last Name (Titles) 516**] ([**Street Address(2) 57460**])
Follow up with Pulmonary for a sleep study.
ICD9 Codes: 4280, 5070, 5845, 2851, 5990, 4275, 3051, 4019, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1176
} | Medical Text: Admission Date: [**2106-10-6**] Discharge Date: [**2106-11-9**]
Date of Birth: [**2065-11-8**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
Pleural biopsy
Spine stabilization surgery
History of Present Illness:
Per Resident Admit note:
HPI: 40 F with little PMH, immigrated from [**Country 16465**] 8 years ago,
admitted with markedly abnormal T/L spine MRI and low back pain.
Patient reports ongoing low back pain for over one year. She
thought it may have been related to a fall that occurred around
that time. She was also pregnant for a good portion of that
time (son is 6 months old) and also thought the pain could be
related to her pregnancy. Pain has been gradually worse over
the past several weeks. She saw her PCP and was prescribed
oxycodone and ibuprofen in the past. She reports outpatient
plain films of the L spine with unclear readings and was sent
for outpatient MRI yesterday. She was told to go the the ED and
presented to OSH, then subsequently transferred to [**Hospital1 18**]. MRI
from OSH showing marked abnormality with liquefaction from T12
to L3, L psoas abscess, and cauda equina compression. In the ED
she was given a dose of vanco and zosyn and seen by spine.
.
Denies leg weakness, but does note some vague difficulties when
first getting up from a chair, then is okay once she starts to
walk. Has also noted bilateral anterior thigh numbness for a
couple months, worse when sitting. Limited to anterior thighs,
no weakness/numbness elsewhere. No headache or neckpain. NO
bladder/bowel incontinence, saddle anesthesia. No fever,
chills, night sweats, unintentional weight loss. No chest pain,
cough, dyspnea, hemoptysis. No abd pain, diarrhea,
constipation. No hoarseness or dysphagia.
.
Patient from [**Country 16465**], moved 8 years ago. No travel back to [**Country 16465**]
since. Able to describe ?negative PPD about 4 years ago.
Negative HIV test during her pregnancy ~ one year ago. Sexually
active with boyfriend [**Name (NI) **] only. No IV drug use. No contacts
with anyone known to have TB, prison inmates, homeless. No
known BCG vaccination.
Past Medical History:
None.
Social History:
No smoking/etoh/drugs. Sister and boyfriend currently at home
with son. no hx of exposure to high risk TB populations.
Family History:
No breast cancer or other malignancy.
Physical Exam:
DSICHARGE PHYSICAL:
VS:
Pertinent Results:
[**2106-10-13**] 12:29 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2106-10-13**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2106-10-15**]): NO GROWTH.
ACID FAST SMEAR (Final [**2106-10-15**]):
REPORTED BY PHONE TO [**Last Name (LF) 16137**],[**First Name3 (LF) **] @ 08:30, [**2106-10-15**].
ACIDFAST BACILLI. 5 seen on concentrated smear.
ACID FAST CULTURE (Preliminary):
AFB GROWN IN CULTURE; ADDITIONAL INFORMATION TO FOLLOW.
[**2106-10-22**] 11:16 am SPUTUM Source: Expectorated.
ACID FAST SMEAR (Final [**2106-10-25**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACIDFAST BACILLI. MODERATE seen on concentrated smear.
REPORTED BY PHONE TO DR.[**Last Name (STitle) **],[**First Name3 (LF) **] AND [**Last Name (LF) 16137**],[**First Name3 (LF) **]
@ 13:50,
[**2106-10-25**].
[**2106-10-26**] 1:54 pm SPUTUM Source: Induced.
ACID FAST SMEAR (Final [**2106-10-27**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
[**2106-10-28**] 10:57 am SPUTUM Source: Induced.
ACID FAST SMEAR (Final [**2106-10-29**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
[**2106-10-29**] 8:18 am SPUTUM Source: Induced.
ACID FAST SMEAR (Final [**2106-11-1**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACIDFAST BACILLI. 3 seen on concentrated smear.
REPORTED BY PHONE TO [**Last Name (LF) **], [**First Name3 (LF) **] AND [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
AT 1;30PM,
[**2106-11-1**].
Cytology Report CYTOPATHOLOGY SMEARS, NON-GYN Procedure Date of
[**2106-10-17**]
REPORT APPROVED DATE: [**2106-10-20**]
SPECIMEN RECEIVED: [**2106-10-19**] [**-7/4108**] CYTOPATHOLOGY SMEARS,
NON-GYN
SPECIMEN DESCRIPTION: Received 1 Hematology slide for review.
CLINICAL DATA: None provided.
PREVIOUS BIOPSIES:
[**2106-10-11**] [**-7/3984**] SPUTUM
[**2106-10-7**] [**-7/3959**] SPUTUM
REPORT TO: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DIAGNOSIS: Pleural Fluid:
NEGATIVE FOR MALIGNANT CELLS.
Reactive mesothelial cells, lymphocytes, histiocytes, and
neutrophils.
DIAGNOSED BY:
[**First Name8 (NamePattern2) 5335**] [**Last Name (NamePattern1) 5336**], CT(ASCP)
[**Name6 (MD) 8847**] [**Name8 (MD) **], M.D.
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 80443**],[**Known firstname **] [**2065-11-8**] 40 Female [**-7/3980**]
[**Numeric Identifier 80444**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] GOODELL/mtd
SPECIMEN SUBMITTED: left psoas abcess, CORPECTOMY.
Procedure date Tissue received Report Date Diagnosed
by
[**2106-10-12**] [**2106-10-12**] [**2106-10-15**] DR. [**Last Name (STitle) **]. BROWN/mb????????????
Previous biopsies: [**-7/3979**] (Not on file)
[**-7/3938**] RIGHT PLEURAL PARIETAL BIOPSY - RUSH (1 JAR).
************This report contains an addendum***********
DIAGNOSIS:
I) Left psoas (A):Fibroadipose tissue and skeletal muscle with
chronic inflammation and necrotic debris.
II) Soft tissue and bone, T12-L2, corpectomy (B-C):
Granulomatous inflammation and necrosis involving bone.
Note: Special stains for AFB and fungi are pending.
ADDENDUM: A rare AFB is seen on special stain. Special stain for
fungi is negative with appropriate positive control.
Addendum added by: DR. [**Last Name (STitle) **]. BROWN/lfb Date: [**2106-10-28**]
Clinical: Lesion of T12, L1, L2.
Gross: The specimen is received fresh in two parts, both labeled
with "[**Known lastname **], [**Known firstname 19904**]" and the medical record number.
Part 1 is additionally labeled "left psoas abscess". It consists
of multiple fragments of pink, tan and yellow soft tissue
measuring 3.5 x 1.9 x 0.9 cm in aggregate. The fragments of soft
tissue are soft and grossly necrotic. The specimen is
represented in cassette A.
Part 2 is additionally labeled "corpectomy". It consists of
multiple fragments of pink-tan soft tissue and bone measuring
8.9 x 6 x 1.4 cm in aggregate. There are focal areas of
hemorrhage but the specimen is otherwise grossly unremarkable.
The specimen is represented as follows: B = soft tissue, C =
bone for decalcification.
[**2106-10-6**] CT of L spine
IMPRESSION:
1. Destructive vertebral body changes from T12 through L2 are
consistent with tuberculosis infection. These findings are
suggestive of spinal instability with posterior propulsion of
osseous fragments that causes severe spinal canal stenosis,
though evaluation of the spinal canal is limited CT. Recommend
correlation with recently performed outside hospital MRI for
further evaluation of the spinal canal.
2. Chronic left psoas muscle abscess supports a diagnosis of
tuberculosis.
3. Limited evaluation of biapical and right upper and lower
lower lobe lung consolidations with hyperdense calcified right
pleural thickening and right effusion which is in keeping with
TB infection. Dedicated chest CT is recommended for further
evaluation.
Findings discussed with the infectious disease team.
Brief Hospital Course:
40 you F admitted from OSH with low back pain and MRI showing
destruction of T12-L3 vertebrae. CT L/T spine showed pleural
thickening and calcification in the right lung. High concern
for TB/Pott's disease. Pleural biopsy negative for AFB or
granulomas. Induced sputum negative. Give marked spinal
instability [**1-30**] to vertebral destruction, patient underwent
spine stabilization surgery on [**2106-10-13**] & [**2106-10-18**] and tissue
biopsies were obtained at that time which showed were positive
for AFB. Secondary to acute blood loss due to multiple surgical
procedures, pt was transfused two units of blood on [**2106-10-15**] and
[**2106-10-19**]. ID consulted, placed on quadruple TB regimen.
Thoracics followed for CT and pigtail catheter which were d/c'd
w/o difficulty. Subsequent AFBs showed. Worked with physical
therapy who cleared patient for home. Plan for d/c to home with
follow with infectious disease.
Medications on Admission:
Ibuprofen 600 mg, average TID
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
6. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
7. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Rifampin 300 mg Capsule Sig: Two (2) Capsule PO Q24H (every
24 hours).
9. Pyrazinamide 500 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily). Tablet(s)
10. Pyridoxine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Ethambutol 400 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
14. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
Discharge Disposition:
Home With Service
Facility:
publich health nurse
Discharge Diagnosis:
TB spine
Discharge Condition:
stable
Discharge Instructions:
[**Name8 (MD) **] MD or go to ED if you have fever/drainage from incision
site, resume home meds, take TB meds as prescribed, take pain
meds as prescribed, activity as tolerated
Physical Therapy:
activity as toleated
Treatments Frequency:
change dressing daily, if not drainage, leave open to air
staples/sutures to be d/c'd in 14d
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 1007**], 2 weeks from time of surgery
Completed by:[**2106-11-2**]
ICD9 Codes: 5119 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1177
} | Medical Text: Admission Date: [**2200-1-23**] Discharge Date: [**2200-1-31**]
Date of Birth: [**2149-3-13**] Sex: M
Service: SURGERY
Allergies:
Bactrim
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Liver transplant failure
Major Surgical or Invasive Procedure:
liver transplant [**2200-1-24**]
History of Present Illness:
50 M here for repeat OLT. He is s/p deceased donor liver and
kidney transplant c/b hepatic artery thrombosis leading an
ex-lap, resection of distal CBD and debridement of segments 4
and
5. The graft ultimately failed and he was relisted. He has no
complaints and denies any recent fevers, chills, nausea,
vomiting, or general malaise. He also denies any erethema or
purulent drainage from his multiple drains.
Past Medical History:
hepatitis C ([**2184**]) c/b cirrhosis, salmonella gastroenteritis
with acute renal failure, chronic kidney disease with renal
stones s/p lithotripsy ([**2192**]), DM (dx [**2188**], off medications,
diet-controlled), HTN ([**2196**], well-controlled, off medications),
ITP s/p splenectomy ([**2173**]), asthma
PSH: splenectomy [**2173**], lithotripsy [**2192**], Combined liver/kidney
transplant [**2199-10-17**], repeat liver transplant [**2200-1-24**]
Social History:
SH: Lives with sister, has two children. Prior heroin user,
sober for two years, on methadone program.
Family History:
FH: His family history is significant for an aunt and uncle with
diabetes.
Physical Exam:
Phx: 96.6 61 149/76 20 100RA
GEN: A&O, NAD
HEENT: mild ly jaundiced, thin male, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses, incision CDI well
healed, G tube capped, medial and lateral drains ss, PTC capped
Ext: No LE edema, LE warm and well perfused
Brief Hospital Course:
50 M s/p CKT/OLT c/b hepatic artery thrombosis, and graft
failure underwent repeat liver transplant on [**2200-1-24**]. Surgeon
was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to operative note for
details. Postop, he went to the SICU intubated. [**Doctor Last Name 406**] drain
outputs were non-bilious. LFTs decreased daily. Initial liver
duplex noted abnormal vascularity seen proximal to the porta
hepatis with a color thrill and high velocity within the
extrahepatic main portal vein suggestive of an AV fistula.
Parvus tardus waveforms were seen within the right and left
hepatic arteries with very low resistive indices. Hepatic veins
were patent. There was no biliary dilatation and no hepatic
collections were seen within the transplanted liver. Duplex was
repeated on [**1-25**] that revealed interval improvement in waveforms
within the main hepatic artery and portal vein. Portal vein had
focal
area of considerable acceleration but was improved. An ABD CTA
was done to evaluate vasculature. This demonstrated patent
arterial anastomosis with an arterial conduit extending from the
infrarenal abdominal aorta to the donor liver. Stenosis at the
site of insertion of the arterial conduit into the aorta was
noted. There was no convincing CT evidence of an arterial-portal
fistula. Marked narrowing of the portal vein at the level of the
porta hepatis adjacent to one of the surgical drains,was noted,
however no thrombosis of the portal vein was seen.
LFTs continued to decrease. He required blood products on postop
day 1 and 2 then Hct and coags remained stable. He was
extubated on [**1-25**]. IV Dapto, Micafungin and Unasyn were
continued given past micro data and the plan was to continue for
a 2 week course. Diet was slowly advanced. J tube feedings were
started.
Creatinine was 2.0 on [**1-27**]. Renal transplant US was wnl. He
transferred out of the SICU on postop day 4. Renal function
improved with creatinine decreasing to normal. Lasix was given
for generalized edema. Blood cultures were drawn on [**1-27**] and
isolated GNR. Unasyn was switched to Meropenum which was given
for 3 days until blood culture speciated Klebsiella Oxytoca
sensitive to Cefepime. Meropenem was switched to Cefepime on
[**1-29**]. The plan was to continue all antibiotics (Micafungin,
Cefepime and Dapto until [**2-4**]. Daily surveillance blood cultures
were drawn and remained negative to date ([**1-28**], [**1-29**], [**1-30**], [**1-31**]).
A right IJ picc line was inserted on [**1-30**].
Dietary intake improved. Tube feeds were switched to cycled
feeds (6p to 6a) . He became more ambulatory. Medial JP was was
removed on [**1-30**]. Lateral JP was removed on POD 7.
Physical therapy worked with him. He did well ambulating and was
independent by postop day 6. The plan was to transfer to rehab
when a bed was available given need for multiple antibiotics and
tube feed.
Immunosuppression consisted on Cellcept, steroid taper per
transplant protocol and Prograf which was adjusted up to 6mg [**Hospital1 **]
for trough level of 5.9 (goal of [**10-10**]). Pentamidine (PCP
prophylaxis was given on [**1-30**]).
Medications on Admission:
FK 4'', MMF 500'', micafungin 100', daptomycin 500', valcyte
450'', pentamidine 300' Q month, dilaudid 1 Q3H PRN, lantus 14'
HS, SSI, methadone 40', metoprolol 25'', zofran 4''' PRN,
trazadone 50' HS, albuterol 90 HFA 2 puffs PR
All: bactrim
Discharge Medications:
1. prednisone 5 mg Tablet [**Month/Day (2) **]: Four (4) Tablet PO DAILY (Daily):
follow printed taper schedule.
2. mycophenolate mofetil 500 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO
BID (2 times a day).
3. docusate sodium 100 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO BID (2
times a day).
4. aspirin 81 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: One
(1) Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. trazodone 50 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
7. hydromorphone 2 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
8. amlodipine 5 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY (Daily):
hold for sbp <110 or HR <60 .
9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
10. dextrose 50% in water (D50W) Syringe [**Month/Day (2) **]: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
11. ondansetron HCl (PF) 4 mg/2 mL Solution [**Month/Day (2) **]: One (1)
Injection Q8H (every 8 hours) as needed for nausea/vomiting.
12. methadone 10 mg Tablet [**Month/Day (2) **]: Four (4) Tablet PO DAILY
(Daily).
13. metoprolol tartrate 25 mg Tablet [**Month/Day (2) **]: 1.5 Tablets PO TID (3
times a day): hold for sbp <110 or HR <60.
14. acetaminophen 325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: no more than 2000mg per day.
15. glucagon (human recombinant) 1 mg Recon Soln [**Month/Day (2) **]: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
16. insulin regular human 100 unit/mL Solution [**Month/Day (2) **]: follow
printed sliding scale Injection ASDIR (AS DIRECTED).
17. valganciclovir 450 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO Q24H
(every 24 hours): cmv prophylaxis.
18. cefepime 2 gram Recon Soln [**Month/Day (2) **]: One (1) Recon Soln Injection
Q12H (every 12 hours): for Klebsiella bacteremia.continue until
[**2-7**]
.
19. micafungin 100 mg Recon Soln [**Month/Year (2) **]: One (1) Recon Soln
Intravenous Q24H (every 24 hours): continue until [**2-7**].
20. daptomycin 500 mg Recon Soln [**Month/Year (2) **]: One (1) Recon Soln
Intravenous Q24H (every 24 hours): continue until [**2-7**].
21. Outpatient Lab Work
Stat every Monday and Thursday for
cbc, chem 10, ast, alt, alk phos, t.bili, albumin, UA and trough
prograf level
Fax to [**Telephone/Fax (1) 697**] attention Transplant Coordinator
22. tacrolimus 1 mg Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO twice a day.
23. tacrolimus 5 mg Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO twice a day.
24. furosemide 40 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times
a day): stop if weight decreases by 5kg. wt 68kg on [**1-31**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]/ [**Hospital1 8**]
Discharge Diagnosis:
h/o liver and kidney transplant c/b HA thrombosis with hepatic
abscesses s/p liver transplant.
re-transplanted liver
malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You will be transferring to [**Hospital **] [**Hospital 8**] Rehab
Call the Transplant Office [**Telephone/Fax (1) 673**] if you have any of the
warning signs listed below
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2200-2-6**] 2:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14254**], [**Name12 (NameIs) 1046**] Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2200-2-6**] 3:00
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2200-2-13**] 1:45
Completed by:[**2200-1-31**]
ICD9 Codes: 9971, 2851, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1178
} | Medical Text: Admission Date: [**2120-8-21**] Discharge Date: [**2120-8-25**]
Date of Birth: [**2066-10-13**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / Lisinopril
Attending:[**First Name3 (LF) 358**]
Chief Complaint:
Chest pain, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 53yo female with PMH significant for OSA, obesity
hypoventilation, and pulmonary HTN who is being transferred to
the MICU for dyspnea requiring BiPAP. The patient presented to
her PCP earlier today with chest pain and SOB. In the ED, her
chest pain resolved quickly and the initial plan was to admit
her to the cardiology service for ROMI. Upon further questioning
the patient was more short of breath than she has been at
baseline. Per daughter, her SOB has gotten worse over the past 2
weeks especially on exertion. The patient has been also feeling
more fatigued. She also admits to some production of green
sputum. No associated PND, orthopnea, lower extremity swelling,
fevers, or chills. Of note, the patient has been admitted to the
MICU multiple times for hypercarbic respiratory failure. She was
noted to become more somnolent and ABG showed an elevated PC02.
She was then placed on BiPAP and then transferred to the MICU.
Of note, the patient has missed several of her appointments with
her pulmonologist and endocrinologist.
In the ED, initial vitals were T 98.0 BP 120/56 AR 62 RR 14 O2
sat 94% on 2L NC. She received Lasix 20mg IV, Kayexelate 30 gm,
and ASA 325mg.
Past Medical History:
1)Obstructive Sleep Apnea on home CPAP, 16cm H20
2)Obesity Hypoventilation
- Multiple admissions for hypercarbic respiratory failure; PFT's
consistent with a restrictive defect
- PFTs: FVC 39%, FEV1 37%, FEV1/FVC 96%, TLC 59%, DLCO reduced
3)ASD with right-left shunt (12% shunt fraction documented in
nuclear study from [**2116-3-30**])
4)Pulmonary artery hypertension: Echo in [**10/2118**] demonstrated a
TR gradient of 33mmHg ?????? followed by [**Location (un) 4507**]
5)Hypertension
6)Pan-hypopituitarism with partially empty sella on
desmopressin, levothyroxine, prednisone ?????? followed by Dr.
[**Last Name (STitle) **]
7)Diastolic CHF with dilated RA/LA on previous echo
8)Angioedema (unclear history, possibly related to ACE-I)
Physical Exam:
vitals T 97.4 BP 166/89 AR 106 68 RR 18 O2 sat 100%
CPAP + PS FIO2 0.50 [**1-3**]
Gen: Awake and alert
HEENT: Puffy face
Heart: RRR, ? 2/6 systolic murmur
Lungs: CTAB, poor air movement
Abdomen: Soft, NT/ND, +BS
Extremities: No edema, 2+ DP/PT pulses bilaterally
Pertinent Results:
[**2120-8-21**] 03:35PM BLOOD WBC-12.5* RBC-3.75* Hgb-10.0* Hct-34.1*
MCV-91 MCH-26.6* MCHC-29.3* RDW-16.5* Plt Ct-216
[**2120-8-23**] 03:56AM BLOOD WBC-11.2* RBC-4.09* Hgb-10.7* Hct-36.2
MCV-89 MCH-26.3* MCHC-29.7* RDW-15.4 Plt Ct-170
[**2120-8-21**] 03:35PM BLOOD Neuts-89.5* Lymphs-6.8* Monos-3.5 Eos-0.2
Baso-0
[**2120-8-21**] 03:35PM BLOOD PT-13.2 PTT-25.9 INR(PT)-1.1
[**2120-8-21**] 03:35PM BLOOD Glucose-140* UreaN-21* Creat-0.9 Na-142
K-6.4* Cl-101 HCO3-35* AnGap-12
[**2120-8-21**] 03:35PM BLOOD CK(CPK)-83
[**2120-8-21**] 03:35PM BLOOD CK-MB-NotDone proBNP-1117*
[**2120-8-21**] 03:35PM BLOOD cTropnT-<0.01
[**2120-8-22**] 04:14PM BLOOD Calcium-9.7 Phos-4.5# Mg-2.3
[**2120-8-22**] 04:22AM BLOOD Osmolal-298
[**2120-8-22**] 04:22AM BLOOD T4-6.9 T3-67* calcTBG-0.97 TUptake-1.03
T4Index-7.1
[**2120-8-21**] 08:41PM BLOOD Type-ART pO2-107* pCO2-81* pH-7.32*
calTCO2-44* Base XS-11 Intubat-NOT INTUBA
Relevant Imaging:
1)Cxray ([**8-21**]): There is gross cardiomegaly with upper lobe
venous diversion consistent with CHF. There is acute kyphosis
and extensive degenerative change in the lower thoracic spine as
well as the thoracolumbar junction.
2)ECHO ([**8-22**]): Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Left atrial dilation with moderate diastolic LV dysfunction.
Moderate mitral regurgitation. Moderate tricuspid regurgitation.
Moderate pulmonary hypertension.
Brief Hospital Course:
Ms. [**Known lastname **] is a 53yo female with PMH as listed above who presents
with 2 week history of worsening dyspnea and chest pain.
1)Hypercarbic respiratory failure: Patient presented with 2 week
history of worsening shortness of breath. She was found have an
elevated PC02 of ~80 on an ABG. Baseline pCO2 is in the 60's.
She has been hospitalized multiple times for hypercarbic
respiratory failure. She has been compliant with CPAP at home
(which has not been the case in the past per OMR). She does not
appear to volume overloaded on exam. She does admit to some
daily green sputum production, which was suggestive of a
possible underlying infection. She was started on BiPAP in the
emergency room which was continued when she came to the MICU.
She was also started on Levofloxacin and Mucinex for
tracheobronchitis. Over the course of 24 hours her respiratory
status significantly improved and she was transitioned to 1-2L
nasal cannulus.
2)Chest pain: She presented with 2 week history of chest pain,
which resolved quickly in the ED. No history of CAD. Cardiac
enzymes were negative x3, ECG was normal, and there were no
events on telemetry.
3)Leukocytosis: Patient presented with mild leukocytosis of of
12.5. She has history of UTIs on prior admissions but U/A on
this admission was w/o WBCs. She also denies any urinary
frequency or burning. No evidence of pneumonia on cxray but
given history of green sputum production, she may have some
tracheobronchitis. She was placed on 5d course of Levaquin.
4)Diastolic CHF: Last ECHO in [**2118**] with EF>55%. She does not
appear volume overloaded on exam. She received Lasix in the ED;
she is also on Lasix as an outpatient but unclear why. She
underwent an ECHO which showed an increase in her pulmonary
pressures from 33-->50. Her ejection fraction remained the same.
Lasix was held in the MICU and the floor team should call her
PCP to discuss why this was started.
5)Panhypopituitarism: Thought to be secondary to "empty sella".
She is followed by Dr. [**Last Name (STitle) **] but has missed several
appointments with him. The last time she was hospitalized she
was on Prednisone 15mg PO daily; she was started on 60mg per PCP
notes but after talking with her daughter she had actually been
on 5mg. Endocrinology was consulted to help determine her
regimen. She was continued on Prednisone 5mg, Levoxyl, and
Desmopressin.
6)Hypertension: Continued on outpatient regimen of Lopressor and
Diovan.
Addendum by Dr. [**Last Name (STitle) **] after discharge [**2120-8-26**]: Appointments
were arranged with Dr. [**Last Name (STitle) **] (endocrine) on [**9-17**] at
10:30 am and Dr. [**Last Name (STitle) 4507**] (sleep) on [**10-14**] at 9am. I called
patient and advised her daughter (English speaking) of the
dates/time and that she must keep these appointments.
Medications on Admission:
Aspirin 81mg PO daily
Omeprazole 20mg PO daily
Lasix 40mg PO daily
Prednisone 60mg PO daily
Clonidine 0.1mg Po daily
Famotidine 20mg PO BID
Lopressor 25mg PO BID
Valsartan 80mg PO QHS
Valsartan 40mg PO QAM
Albuterol nebs
Levothyroxine 150mcg PO daily
Desmopressin 0.2mg PO BID
Bisacodyl 10mg PO PRN
Vitamin D3 800 unit PO daily
Calcium Carbonate 500mg PO daily
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. Synthroid 150 mcg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Desmopressin 0.2 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer treatment Inhalation Q6H
(every 6 hours) as needed for shortness of breath or wheezing.
9. Valsartan 40 mg Tablet Sig: One (1) Tablet PO QAM (once a day
(in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
10. Valsartan 80 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
Disp:*30 Tablet(s)* Refills:*2*
11. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Hypercarbic respiratory failure
Obstructive sleep apnea
Diastolic heart failure
Secondary Diagnoses:
Pan-hypopituitarism
Discharge Condition:
Stable-- breathing more comfortably on room air; feeling better
and less short of breath.
Discharge Instructions:
You were admitted to the hospital with difficulty breathing.
You should make sure you take all the medications on the list.
You should use the CPCP breathing machine at night-- it will
help your lungs and breathing and will help you not feel short
of breath. If you should find bright red blood in your stool,
please contact your primary care provider (Dr. [**Last Name (STitle) 6680**] and come
back to the hospital. If you have severe chest pain, shortness
of breath, loss of consciousness, severe
lightheadedness/dizziness, please come back to the hospital.
Followup Instructions:
Please see your doctor in 7 - 10 days. You can call Dr. [**Last Name (STitle) 6680**]
at [**Telephone/Fax (1) 608**].
Completed by:[**2120-8-28**]
ICD9 Codes: 4280, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1179
} | Medical Text: Admission Date: [**2105-11-21**] Discharge Date: [**2105-12-11**]
Date of Birth: [**2053-3-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7299**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 87792**] is a 52 year old gentleman with a pmh of DMII,
CRI, multiple neck abscesses, and traumatic brain injuries (SDH)
of unknown etiology who presents after a seizure and fall from
bed at his nursing home.
.
Mr [**Known lastname 87792**] is a Haitian earthquake survivor, who originally
presented to his dentist in [**Country 2045**] with a tooth abscess. He had
the wound opened and required skin grafting for healing. He was
found to have multiple abscesses in his neck. The abscesses
were opened, and after the earthquake he was transferred to an
airport that had been set-up as a health care facility. He
developed a stage IV decubitus ulcer on her coccyx as well as
around his penis from an indwelling catheter. He also was unable
to swallow so a PEG was placed.
.
He was transferred to [**Location (un) 2848**], for better care since [**Country 2045**] did not
have adequate resources. He was stabilized and transferred to a
NH in the [**Location (un) 86**] area in [**Month (only) 205**]. He was progressing and improving,
however he had multiple falls that were not told to the family,
and he developed a foot drop on Friday. In the past few weeks
he was more lethargic than usual. On [**11-20**] he was observed
having a tremor w/ teeth gringding, lasting several minutes.
When EMS arrived he was observed twisting on the right side. At
OSH he was loaded w/ dilantin, treated for hyperkalemia (5.9),
and treated w/ unasyn with concern for aspiration pneumonia.
When head CT and MRI showed small SAH (left parietal) and
subdural hematoma (left frontal, parietal, bilat occipital) he
was transferred to [**Hospital1 18**].
Past Medical History:
DM type 2
CRI (w/ hx hyperkalemia)
anemia
s/p I and D of Left neck abscess
multiple UTI's
Decubitus ulcer
chronic brain injury of unknown nature
G-tube placement (for malnutrition)
Social History:
Patient is a surviver of the Haitian earthquake, who was
transferred to [**Location (un) 2848**] for management of his multiple medical
problems. [**Name (NI) **] was living in a nursing home in Mass prior to
admission.
Family History:
HTN, DMII
Physical Exam:
Admission Exam:
Vitals: T:97.9/97.7 BP:118/75 (108-124/58-86) P: 68 (68-76) R:16
O2:100% on RA
General: Alert,lying in bed in no acute distress, cacchectic
HEENT: Sclera anicteric
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Normal rate and regular rhythm, normal S1 + S2, II/VI SEM
murmur at the RUSB, no rubs or gallops
Abdomen: soft, non-tender, PEG tube in place with dressing C/D/I
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses in radials and DPs
bilaterally, no clubbing, cyanosis or edema
Skin: warm, dry
Neuro: Moving all four extremities in bed, but unable to assess
strength this am
Pertinent Results:
[**2105-11-21**] 10:26PM BLOOD WBC-10.5 RBC-2.86* Hgb-8.6* Hct-25.9*
MCV-91 MCH-30.2 MCHC-33.2 RDW-15.7* Plt Ct-330
[**2105-11-21**] 10:26PM BLOOD PT-12.8 PTT-26.5 INR(PT)-1.1
[**2105-11-21**] 10:26PM BLOOD Plt Ct-330
[**2105-11-22**] 06:19AM BLOOD Ret Aut-0.7*
[**2105-11-21**] 10:26PM BLOOD Glucose-88 UreaN-43* Creat-2.0* Na-147*
K-4.3 Cl-113* HCO3-24 AnGap-14
[**2105-11-23**] 09:00AM BLOOD Glucose-124* UreaN-34* Creat-1.8* Na-142
K-4.8 Cl-112* HCO3-21* AnGap-14
[**2105-11-21**] 10:26PM BLOOD ALT-47* AST-32 LD(LDH)-209 AlkPhos-292*
TotBili-0.3
[**2105-12-10**] 05:55AM BLOOD ALT-85* AST-59* AlkPhos-329* TotBili-0.1
[**2105-11-22**] 06:19AM BLOOD CK(CPK)-136
[**2105-11-23**] 09:00AM BLOOD CK(CPK)-110
[**2105-11-21**] 10:26PM BLOOD cTropnT-0.19*
[**2105-11-22**] 06:19AM BLOOD CK-MB-6 cTropnT-0.17*
[**2105-11-23**] 09:00AM BLOOD CK-MB-4 cTropnT-0.15*
[**2105-11-22**] 06:19AM BLOOD calTIBC-203* Ferritn-573* TRF-156*
[**2105-11-22**] 06:39AM BLOOD %HbA1c-6.2* eAG-131*
[**2105-11-22**] 06:19AM BLOOD TSH-1.6
.
[**2105-12-8**] C. Diff toxin negative
.
Imaging:
NON-CONTRAST HEAD CT, WITH MULTIPLANAR REFORMATS.
There is hyperdense thickening of the falx to the left of
midline, compatible with a thin subdural hematoma, measuring no
more than 3 mm. Equivocal slightly larger idodense component is
also noted, measuring up to 4 mm (2a:22). There is no further
subdural collection identified. There is no subarachnoid,
intraparenchymal or intraventricular blood identified. There is
no parenchymal edema or mass effect. Ventricles and sulci are
prominent, compatible with atrophy, and there are
periventricular white matter hypodensities, compatible with
sequelae of chronic small vessel ischemic disease. The
[**Doctor Last Name 352**]-white matter differentiation is otherwise preserved,
without CT evidence of acute territorial infarction. The
visualized bones are free of fracture. There is scattered
opacification of the mastoid air cells, and mucosal thickening
in the left ethmoids. Remainder of the paranasal sinuses are
clear. The extracranial soft tissues, including the globes and
orbits, are unremarkable.
IMPRESSION:
1. Thickening of the falx, compatible with a subdural hematoma.
A thin
hyperdense component measures no more than 3 mm, with a possible
slightly
larger isodense component also noted, as above. No further
intracranial
hemorrhage is identified.
2. Global atrophy and sequelae of chronic small vessel ischemic
disease are noted.
Comparison with prior imaging reportedly performed at an outside
hospital
would be helpful for evaluation of stability of these findings.
EEG [**11-25**]:
IMPRESSION: This in an abnormal continuous EEG due to the
presence of
frequent brief periods of rhythmic delta activity occurring
maximally
over the bifrontal regions seen more frequently during sleep.
This
pattern is most consistent with FIRDA which is consistent with a
mild
to moderate diffuse encephalopathy or a deep midline structural
defect.
However, given the reduction in frequency and duration of these
events
after the administration of antiepileptic medication yesterday,
these
events could also represent atypical frontal lobe seizures.
EEG [**11-26**]:
IMPRESSION: This in an abnormal modified EEG telemetry due to
the
presence of frequent brief periods of rhythmic delta activity
occuring
maximally over the bifrontal regions. This pattern is most
consistent
with FIRDA which is consistent with a mild to moderate diffuse
encephalopathy or a deep midline structural defect. However,
these may
also represent atypical frontal lobe seizures. While a
comparison with
the previous tracing is limited given that the patient remains
mostly
awake, these periods of rhythmic delta activity appear to be
less
frequent than in the previous tracing.
Liver US [**12-8**]:
IMPRESSION: No focal liver lesion or biliary dilatation seen.
Cholelithiasis
with no sign of cholecystitis. Scant trace of ascites.
CXR [**12-8**]:
SINGLE PORTABLE UPRIGHT VIEW OF THE CHEST: The cardiomediastinal
contour is
normal. The heart is not enlarged. Lung volumes are somewhat
low,
accentuating perihilar vascular crowding. Left upper lobe
consolidation is
slightly more prominent. There is no pleural effusion. The bony
thorax is
unremarkable.
IMPRESSION: Left upper lobe consolidation somewhat more
prominent
URINE CULTURE (Final [**2105-12-7**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
| PROTEUS MIRABILIS
| |
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- =>32 R <=2 S
CEFAZOLIN------------- <=4 S 8 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN--------- =>4 R 1 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- 64 I <=4 S
TOBRAMYCIN------------ =>16 R <=1 S
TRIMETHOPRIM/SULFA---- 2 S <=1 S
[**2105-12-10**] 05:55AM BLOOD ALT-85* AST-59* AlkPhos-329* TotBili-0.1
[**2105-11-27**] 01:28PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 Polys-0
Lymphs-87 Monos-13
[**2105-11-27**] 01:28PM CEREBROSPINAL FLUID (CSF) TotProt-29 Glucose-69
All CSF cultures were negative for growth and cytology did not
reveal any malignant cells
Brief Hospital Course:
52 year old gentleman with a pmh of DMII, CRI, multiple neck
abscesses, and traumatic brain injuries (SDH) of unknown
etiology who presents after a seizure and fall from bed at his
nursing home.
#Neuro/Mental status changes: Pt was intially admitted to
neurosurgery and it was felt that no surgical intervention was
indicated. Serial head CTs showed stable SDHs. Seizures were
thought most likely related to multiple SDH/trauma. MRI was
obtained to evaluate vasculature for aneurysm given concern for
SAH on CT. Prior images were uploaded for comparison. Pt was
initially started on phenytoin 100mg TID for seizure ppx and
dose was later increased to 200mg PO TID after EEG raised
concern for frontal seizures. An MRI was performed to further
characterize ICH and the previously seen subtle signal
abnormality in the frontal cortical region on diffusion images
was confirmed to be artifactual. Pt was found to have a
persistent encephalopathy and an LP was performed which was
negative (cultures, smear & cytology). Pt has had an early
onset dementia of unclear etiology for the last year and MRI
showed global atrophy and ventricles enlarged out of proportion
to global atrophy. Pt was evaluated for possible NPH, however a
large volume tap was unsuccessful. In the setting of multiple
SDHs, UTI, seizures and renal insufficiency, neuro team
recommended that a dementia work up should be postponed until
medically stable and recovered from multiple SDHs. Pt will
require cognitive neurology outpatient evaluation at [**Hospital1 18**],
number [**Telephone/Fax (1) 50382**].
.
# Acute Change in Mental Status: Pt was transfered to Medicine
around [**11-27**] at which time he was not responding to commands.
The patients Dilantin was titrated down and he was given 1pRBC
for persistent anemia. Hypernatremia (hypovolemic in nature)
was corrected by increasing his free water boluses and IVF. Pt
was found to have a UTI that was treated with Ceftriaxone.
Encephalopathy improved after these interventions. Given the
persistent transaminitis on dilantin, pt was transitioned to
Keppra 500mg [**Hospital1 **] for seizure prophylaxis. Pt was also started
on seroquel qhs for intermittent agitation and by the time of
discharge, he was responded to questions with one word answers,
naming common objects and tolerating some oral diet.
# Chronic renal insufficiency: Stable creatinine of 1.8-2.1
while an inpatient. Urine lytes showed a FeNa of 3.9%, suspected
to be from diabetic nephropathy, apparently diagnosed back in
[**Country 2045**].
# Anemia: Likely secondary to chronic renal insufficiency and
ACD. Iron level was normal, ferritin was high, TIBC was low.
Reticulocyte count was low.
# DMII: Newly diagnosed in [**Month (only) 956**] according to his sister. Hgb
A1c was 6.2. Pt was on lantus and sliding scale insulin at
home. He had hypoglycemia while in house initially and as intake
improved, his blood sugars became more stable.
# Sacral decubitus ulcer stage II: This was noted on admission
and wound care was consulted. Pt was treated with barrier
dressing, regular position changes and nutrition support with
TFs. Ulcer was healing well.
# Iatrogenic hypospadias: Urology was consulted for urethral
erosion [**3-10**] chronic indwelling foley catheter, needed to heal
sacral decub ulcers (stage IV). Family members, were [**Name2 (NI) 87793**]
about the procedure and decision to follow-up in [**Hospital 159**] clinic
to discuss the need for a suprapubic catheter (SPC) was made.
Given improved mental status in [**12-16**] and healing penile ulcer,
a voiding trial was attempted which was successful. However, a
condom catheter was applied for incontinence and risk of
contaminating sacral decub. Urology follow up was scheduled for
ongoing management of this issue.
# UTI: Urine Cx grew Klebsiella resistant to Cipro/Unasy and
pansensitive Proteus mirabilis. Pt. was treated with
ceftriaxone IV starting on [**2105-12-4**] and was written to complete
a 10 day course given the indwelling cath/condom cath.
# Transaminitis. Mild on arrival w/ elevated AP and nl Bili.
RUQ US was negative, Hepatitis serologies were negative,
including Hep BsAb, for which he will require immunization. Hep
C was negative. Hep A Ab was positive. The LFT abnormalities
were thought possibly due to dilantin which was discontinued on
[**12-8**]. LFTs should be followed up on [**2105-12-21**].
# Hypothermia episode. Pt. was triggered for an episode of
hypothermia to [**Age over 90 **]F and infectious w/u revealed an aspiration
PNA. Pt was empirically treated with Ceftriaxone/Flagy (started
on [**2105-12-8**]), IVF and warming blanket. Hemodynamics normalized
after 6 hrs of treatment and there were no further episodes of
hypothermia. He was treated for presumed aspiration PNA x 7
days (last day [**2105-12-15**])
# Loose stools. Onset after TF restarted. C.Diff negative x 2
as were common stool cultures, O/P. Amylase/Lipase were normal.
Atrributed due to osmotic load from TF, may need readjustment
while at [**Hospital1 1501**].
Medications on Admission:
Omeprazole 20mg PO daily
Colace 100mg [**Hospital1 **] via G-tube
Lantus 8 units SC daily
Novolin R insulin sliding scale
Heparin 5000 units SC TID
Remeron 15mg PO QHS
Seroquel 75mg PO QHS
Discharge Medications:
1. Lantus
8 units injected subcutaneously once a day in the morning
2. Novolin R insulin
Please take according to your sliding scale
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) 5000
units Injection TID (3 times a day). 5000 units
4. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. epoetin alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
6. quetiapine 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime): give at 6pm daily please .
7. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID PRN () as
needed for agitation.
8. levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day).
9. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): Day 1 = [**2105-12-8**], total of 8 days, last day
[**2105-12-15**].
10. ceftriaxone 1 gram Piggyback Sig: One (1) gram Intravenous
once a day for 3 days: Day 1 = [**12-4**]
Duration 10 days
Last day [**12-14**].
11. Outpatient Lab Work
Please perform CBC, Chem 7 and LFTs upon arrival.
Please recheck within one week prior to clinic appointments.
12. appointments
Please ensure patient follows up with appointments as listed
above, changed from discharge summary time of writing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare of [**Location (un) **]
Discharge Diagnosis:
Primary:
Seizure
Intracranial Bleed
Secondary:
Chronic renal insufficiency
Diabetes type 2
Anemia
Pre-existing decubitus and urethral ulcer
Discharge Condition:
Mental Status:
Alert, oriented to hospital and city at best, other times only
to name. Able to perform DOW backwards at best, at other time
unable.
Names high frequency objects at best. Follows 2 step commands
at best. His mental status improves with family presence,
requires a translator for appropriate communication.
CNs: EOMi, PERRL, face symmeetric, tongue midline, palate
elevates symmetrically.
Motor: Increased tone in UEs, mild cogwheeling at b/l wrists and
biceps, mild spasticity as well.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. [**Known lastname 87792**], it was a pleasure taking part in your care. You
were admitted to [**Hospital1 18**] because you had a seizure. We did a CT
scan of your head which showed signs of a bleeding. It was not
operable and remained stable throughout your hospital stay.
.
For seizures, you were evaluted by neurology and started on
medications to suppress seizures.
Because of the dilantin use (antiseizure medicine) you developed
abnormal liver enzymes. Your seizure medicine was changed to
Keppra.
We had wound care evaluate your ulcers and they recommended
urology follow-up.
.
We made the following changes to your medications (please refer
to your discharge medication list for details).
You were discharged to a nursing home facility for further
rehabilitation and because you required 24 hr care.
Followup Instructions:
Please follow-up with your Nursing Home Care doctors
Please set-up an appointment with a primary care physician when
you leave your nursing home
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2106-1-27**] at 9:00 AM
With: UROLOGY UNIT [**Telephone/Fax (1) 164**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: COGNITIVE NEUROLOGY UNIT
When: WEDNESDAY [**2106-1-13**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8384**], MD [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage Please ensure family
member is present for appointment.
Please follow up with the Liver Clinic on [**2106-1-26**] with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 18**] Liver Center, LMOB [**Location (un) **], Please call
([**Telephone/Fax (1) 1582**] to confirm the appointment. Please ensure family
member is present for appointment.
Department: LIVER CENTER
When: TUESDAY [**2106-1-26**] at 1 PM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2105-12-10**]
ICD9 Codes: 5070, 2760, 5990, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1180
} | Medical Text: Admission Date: [**2186-7-28**] Discharge Date: [**2186-8-1**]
Date of Birth: [**2105-2-15**] Sex: M
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
left sided weakness, left sided facial droop transferred from
OSH for eval for intra-arterial tPA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 111885**] is an 81 year-old right-handed gentleman with a
history of hyperlipidemia, a-fib s/p ablation currently on
coumadin, essential tremors, who presents after he fell in the
bathroom and found to have dense right sided weakness.
.
Mr. [**Known lastname 111885**] reports having been in his usual state of health last
night. He went to bed at 10:30pm, which is when he was last well
seen by his wife. [**Name (NI) **] also reports waking up this morning at
06:27am and walking to the bathroom. He again did not notice
anything wrong (this however is not reliable as he does not
believe there is any weakness now as part of his right MCA
syndrome).
He said he fell on the bathroom floor but was not sure why, and
his wife heard him about 5-10 minutes later and called 911
immediately. He was taken to [**Hospital6 3105**], where he
received an NIHSS of 9 (breakdown not available on the provided
notes) and his head CT did not show acute infarcts by report.
.
Patient is on coumadin which was stopped on Tuesday due to an
elevated INR. His INR yesterday was 2.6, and today's was 2.7 at
the OSH. He was therefore not an IV rTPA candidate, and was
transferred to [**Hospital1 18**] for possible IA rTPA.
Of note, Mr. [**Known lastname 111885**] had 2 cataract surgeries, over the last 2
weeks and has been taking the coumadin on and off. There were
instances in the past where his INR was very elevated (up to
16), and his PCP was considering making the switch to Pradaxa.
.
On arrival to [**Hospital1 18**] ED, a CODE STROKE was called. NIHSS by
neurology was 12 (1 for best gaze, 2 for visual palsy, 4 for
left motor arm, 4 for left motor leg, and 1 for dysarthria).
Exam was notable for dense L flaccid plegia,
nosoagnosia, visual extinction on the L, R gaze preference,
impaired body position sensation on the L. Patient immediately
was sent for CTA for further characterization of his stroke.
Past Medical History:
-AFib s/p ablation (on coumadin)
-Hyperlipidemia
-Essential tremor
-CAD s/p angioplasty (no h/o MI, only prior angina)
-Carotid ultrasound obtained day prior to admission. Per PCP,
[**Name10 (NameIs) **] was for routine follow up.
-Had TTE in the last year, which showed preserved EF (per PCP)
Social History:
He is a retired electrical engineer, lives with his wife and is
completely independent in his ADLs. He smoked a long time ago
but the duration and quantity are unclear. [**Name2 (NI) **] very rarely drinks
a beer or a scotch.
Family History:
His father had a stroke at age [**Age over 90 **] years.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: P: 72 R: 16 BP: 117/70 SaO2: 100%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to spell "earth" backwards.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors. Pt. was able
to name both high and low frequency objects. Able to read
without difficulty. Speech was mildly dysarthric. Able to
follow
both midline and appendicular commands on the right side of his
body. He has at least a partial left sided neglect and denies
any
weakness on that side. He is able to recognize his own left
hand,
able to count the correct number of people in the room on both
sides of his bed. He has a right gaze preference.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch with no extinction on
double simultaneous stimulation.
VII: left sided facial droop.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 1 0 0 0 0 0 0 0 0 0 0 0 0 0
-Sensory: No deficits to light touch, pinprick, No extinction
to
DSS. He has loss of proprioception on the left side.
Graphestesia
and object recognistion are impaired on the left.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 3 3 3 1 1
R 2 2 2 1 1
Plantar response was mute on the right and extensor on the left.
-Coordination: No dysmetria ( only tested on the right)
-Gait: unable to stand.
.
DISCHARGE PHYSICAL EXAM:
-Vitals: 98.4, 150/84 [109-150/68-84], 66-85, 18, 96% RA
-Neuro: AAOx3, pt somewhat abullic. Dense hemiplegia affecting
left face, left arm and left leg. Can occasionally wiggle left
toes.
Pertinent Results:
ADMISSION LABS:
-WBC-10.1 RBC-4.63 HGB-15.3 HCT-46.5 MCV-100* MCH-33.0*
MCHC-32.9 RDW-14.4
-GLUCOSE-135* NA+-142 K+-4.0 CL--104 TCO2-24, UREA N-24*,
CREAT-1.0
-PT-34.2* PTT-37.6* INR(PT)-3.3*
-Serum tox: ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
-Urine tox: bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG
amphetmn-NEG mthdone-NEG
-Urinalysis: BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG
KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5 LEUK-NEG RBC-2
WBC-1 BACTERIA-FEW YEAST-NONE EPI-0
-VIT B12-383
.
MODIFIABLE STROKE RISK FACTOR LABS:
-Triglyc-93 HDL-62 CHOL/HD-2.4 LDLcalc-66
-%HbA1c-6.5* eAG-140*
-TSH-1.5
.
LABS ON DISCHARGE:
-WBC-8.2 RBC-4.37* Hgb-14.4 Hct-43.2 MCV-99* MCH-33.0* MCHC-33.4
RDW-14.5 Plt Ct-167
-PT-18.3* PTT-34.6 INR(PT)-1.7*
===================================
Imaging:
.
NONCONTRAST HEAD CT ([**7-28**]): There is a hyperdense middle
cerebral artery on the right with obscuration of the lentiform
nucleus on the right consistent with infarction. There is no
evidence of hemorrhage, edema, or mass effect. The ventricles
and sulci are normal in size and configuration. No fracture is
identified.
.
CT PERFUSION ([**7-28**]): There is a matched perfusion defect in the
right MCA territory with delayed transit time and reduced blood
flow and blood volume.
.
HEAD AND NECK CTA ([**7-28**]): There is abrupt termination of the
right superior M2 division of the MCA consistent with an
occlusion. There is an early branching pattern of the right MCA.
The left carotid and bilateral vertebral arteries and their
major branches are patent with no evidence of stenosis. There
is a calcified plaque at the proximal right internal carotid
artery with 25% stenosis. On the right, the proximal internal
carotid artery measures 3 mm in diameter on the right and the
distal internal carotid artery measures 4 mm in diameter. On
the left, the proximal internal carotid artery measures 5 mm in
diameter, and the distal cervical internal carotid artery
measures 4 mm in diameter. There is no evidence of aneurysm
formation.
CONCLUSION: Right MCA infarct with occlusion of the superior M2
division of the right MCA.
.
TTE: The left atrium is mildly dilated. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). No atrial septal defect or patent foramen
ovale is seen by 2D, color Doppler or saline contrast with
maneuvers. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Right
ventricular chamber size and free wall motion are normal. The
aortic arch is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Mild (1+)
aortic regurgitation is seen. Mild to moderate ([**12-19**]+) mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild moderate mitral regurgitation with normal valve
morphology. Mild aortic regurgitation. Normal biventricular
cavity sizes with preserved regional and global biventricular
systolic function. No patent foramen ovale identified.
CHEST X-RAY ([**7-28**]): No focal infiltrate.
.
NONCONTRAST HEAD CT ([**8-1**], our read): expected evolution of
right MCA infarct with known hemorrhagic conversion. No new
acute intraparenchymal hemorrhage.
Brief Hospital Course:
Mr. [**Known lastname 111885**] is an 81 year-old right-handed gentleman with a
history of hyperlipidemia, a-fib s/p ablation currently on
coumadin, essential tremors, who presented to an OSH after he
fell in the bathroom and had severe left sided weakness.
.
# NEURO: Patient's initial CT at OSH was normal. His exam was
concerning for a dense
right MCA infarct. Repeat head CT in our ED showed the right MCA
infarct. CTA revealed a right M2 superior division cutoff. Even
with the assumption that he was last well seen at 6:30 am as he
reports he had no trouble then (which is not reliable due to
presence of neglect), he was not an IV tpa candidate due to an
elevated INR. Given the infarct progression and finding on his
head CT, he was
also not a candidate for IA intervention as the risks outweighed
the benefits. Most likely, infarct was embolic in setting of
afib despite appropriate INR.
.
Mr. [**Known lastname 111885**] was initially admitted to the neurology ICU because
his systolic blood pressures were in the low 100s and it was
thought he may need vasopressors to attain adequate cerebral
perfusion. However, once A-line was placed, saw that MAPs were
~100, so patient never requited pressors. His coumadin was
stopped because embolic stroke despite being on coumadin for
afib indicated coumadin failure. In ICU he underwent stroke risk
factor workup including TTE (showed no PFO/ASD), full lipid
panel (showed LDL 66) and A1C (mildly elevated to 6.4%).
.
On HD #3, patient was transferred from ICU to floor. MRI was
performed, confirming presence of right MCA infarct. Of note,
the MRI also showed some hemorrhagic conversion of the stroke,
but regardless it was decided to continue anticoagulating
patient as his neuro exam was stable. Repeat head CT on day of
discharge showed no increase in hemorrhage. Once his INR drifted
below 2, he was started on therapeutic Lovenox 70mg SC BID. Plan
is for him to stay on Lovenox until INR <1.5, and then switch to
Pradaxa 150mg [**Hospital1 **]. INR on day of discharge was 1.7. His home
cilostazole should also be continued, as patient has CAD and
requires anti-platelet therapy. He was also started on
Fluoxetine, which has been shown to help with motor recovery
after cortical strokes.
.
On discharge, neuro exam was stable to mildly improved from
admission: patient AAOx3 with abullic affect, and dense left
face/arm/leg hemiplegia. He is able to briefly wiggle his toes
at times. Per PT recs, he was discharged to an acute rehab
facility. He continues to require a dysphagia diet on discharge.
He will follow up with Dr. [**First Name (STitle) **] in outpatient neurology clinic
in 2 months.
.
# CV: patient's home propranolol 120mg PO daily (for essential
tremor) was temporarily decreased to 1/2 dose during
hospitalization due to need to maintain adequate cerebral
perfusion pressure after stroke. Restarted on home dose at
discharge.
.
=====================
TRANSITIONS OF CARE:
- please D/C Foley when pt arrives to rehab facility, and check
post-void residuals
- please HOLD morning dose of Lovenox until INR is checked on
[**2186-8-2**]. If INR is >1.5, give AM dose of Lovenox and recheck INR
on [**2186-8-3**]. If INR is <1.5, STOP Lovenox and START Dabigatran.
- will follow up in stroke clinic with Dr. [**First Name (STitle) **]
- Full Code, HCP is [**Name (NI) 501**] [**Name (NI) **], daughter, and number is
[**Telephone/Fax (1) 111886**].
=====================
[ AHA/ASA Core Measures for Ischemic Stroke and Transient
Ischemic Attack ]
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
() Yes - () No
4. LDL documented? (x) Yes (LDL = 66) - () No
5. Intensive statin therapy administered? (for LDL > 100) () Yes
- (x) No (if LDL >100, Reason Not Given: )
6. Smoking cessation counseling given? () Yes - (x) No (Reason
(x) non-smoker - () unable to participate)
7. Stroke education given? (x) Yes - () No
8. Assessment for rehabilitation? (x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No (if LDL >100,
Reason Not Given: )
10. Discharged on antithrombotic therapy? (x) Yes (Type: (x)
Antiplatelet - (x) Anticoagulation) - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A
Medications on Admission:
-Cilostazole 100mg daily
-Propranolol ER 120mg daily
-Atorvastatin 20mg daily
-Eye drops:
Durezol 0.05% 1gtt TID (remaining 1 day for right eye, 1 wk for
left eye)
Nevanac 0.1% 1gtt TID (remaining 1 day for right eye, 1 wk for
left eye)
Vigamox 0.5% 1gtt TID (remaining 1 day for right eye, 1 wk for
left eye)
Discharge Medications:
1. Vigamox *NF* (moxifloxacin) 0.5 % OS TID Duration: 1 Weeks
* Patient Taking Own Meds *
2. Durezol *NF* (difluprednate) 0.05 % OS TID Duration: 1 Weeks
* Patient Taking Own Meds *
3. Fluoxetine 20 mg PO DAILY
4. Propranolol LA 120 mg PO DAILY
5. Atorvastatin 20 mg PO DAILY
6. Durezol *NF* (difluprednate) 0.05 % OS TID Duration: 1 Weeks
* Patient Taking Own Meds *
7. Nevanac *NF* (nepafenac) 0.1 % OS TID Duration: 1 Weeks
* Patient Taking Own Meds *
8. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
9. Enoxaparin Sodium 70 mg SC BID
Please STOP enoxaparin once INR is <1.5. Pt will then be
switched to dabigatran.
10. Dabigatran Etexilate 150 mg PO BID
To be started AFTER INR is <1.5 (pt should remain on Enoxaparin
until then).
11. Outpatient Lab Work
Please check INR on [**2186-8-2**]:
---If INR is <1.5, please STOP enoxaparin and START dabigatran
(Pradaxa).
---If INR is >1.5, please CONTINUE enoxaparin and recheck INR
daily until INR <1.5.
12. PleTAL *NF* (cilostazol) 100 mg ORAL DAILY Reason for
Ordering: Wish to maintain preadmission medication while
hospitalized, as there is no acceptable substitute drug product
available on formulary.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
ACUTE ISSUES:
1. Stroke
CHRONIC ISSUES:
1. Atrial fibrillation
2. Hyperlipidemia
3. Essential tremor
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neuro exam on discharge: dense hemiplegia affecting left face,
left arm, and left leg.
Discharge Instructions:
Dear Mr. [**Known lastname 111885**],
You were admitted to the hospital for weakness in your left
face, arm and leg. You were found to have a large stroke on the
right side of your brain. This stroke was likely due to your
atrial fibrillation, which can cause blood clots to form in the
heart and travel to the brain. We made some changes to your
blood thinner medications to help prevent another blood clot
from forming and leading to a stroke in the future.
.
Please attend the outpatient neurology appointment listed below
to follow up on your hospitalization.
.
We made the following changes to your medications:
1. STOPPED Coumadin
2. STARTED enoxaparin (Lovenox) 70mg subcutaneous injection
twice daily -- this will be replaced with a stronger blood
thinner called dabigatran (Pradaxa) once the Coumadin is out of
your system.
3. STARTED Fluoxetine 20mg by mouth daily
Followup Instructions:
Department: NEUROLOGY
When: MONDAY [**2186-10-2**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
ICD9 Codes: 431, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1181
} | Medical Text: Admission Date: [**2137-5-28**] Discharge Date: [**2137-5-31**]
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
leg swelling, PE, tachycardic
Major Surgical or Invasive Procedure:
IVC filter placement
History of Present Illness:
Pt is an 86 yo F with history of HTN, HLD, R humerus fracture in
cast, who presents from [**Hospital1 18**] [**Location (un) 620**] for LLE swelling DVT seen
on u/s. Pt states that for the last week since discharge from
[**Hospital1 18**] Needhamd she has had increasing LLE swelling, but denies
warmth, redness or pain. Denies fever or chills. Pt denies CP,
no SOB, no complaints, except frequent urination from lasix. She
has had a cough that was dry, now more "loose," with sensation
of something "stuck in her lungs." She says that doctors [**First Name (Titles) **] [**Name5 (PTitle) 6787**] [**Name5 (PTitle) 620**] thought she may have had an aspiration PNA, for
which she was taking abx. Pt taken to [**Hospital1 **] from [**Hospital 11622**]
rehab today given the leg swelling, where an u/s showed DVTs in
L CFV, L SFVP, L SFVM, L [**Doctor Last Name **] V, L calf vein. She was transferred
here for further care pending possible need for surgical
intervention.
.
In the ED, initial vs were: 98.4 109 158/76 18 96% RA. Exam was
notable for right humerus fracture in splint, no ecchymoses,
abdomen soft, non-tender. Pt was guaiac negative. ECG: 115,
NANI, sinus, Q waves III, aVF all c/w prior, V1-V3, no changes
compared to prior. Labs were notable for HCt of 26 from previous
34. Resident unsure if she received IVF's at [**Location (un) 620**] prior to
transfer here. She was becoming increasingly tachycardic, and
was given 2 boluses 500cc NS. Still tachycardic. Pt also found
to have increasing O2 requirement, initially high 90s RA, now
99% on 3LNC. Per the resident, CTA showed PE obstructing all 3
branches of pulm artery No bedside echo done to assess for RHS.
Vascular consulted, and stated will follow if team wants IVC
filter. Pt with 2 PIV's (size unknown to resident).
.
Vital signs prior to transfer HR 114, 153/68, 98% on 3L NC. w/ L
hand 20g IV.
.
Currently, she feels dry, but denies SOB, chest pain.
.
She was recently admitted at [**Hospital 18**] [**Hospital3 **] for syncope.
Her syncope was attributed to multiple BP meds and volume
depletion. Pt had new acute stroke MRI/MRA of brain revealed
small areas of acute infarcts in both posterior temporal lobes
and subcortical location.
Ventricular blood products and subarachnoid blood products as
well as
inferior right frontal lobe hemorrhage and contusion, minor
changes of small-vessel ischemic disease and brain atrophy,
chronic infarcts in the pons and middle cerebral pedicle. She
had a possible aspiration PNA for which she was treated with
Levaquin.
.
Review of systems:
(+) Per HPI. Also positive for poor appetite and emesis over the
last 4 weeks. She also reports non-bloody diarrhea at OSH, that
has since resolved. Also endorses fast heart rate and
palpitations for the last week, when she was at [**Hospital1 **].
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
-Hypertension
-Hyperlipidemia
-Osteoporosis
-Diverticulosis
-Sarcoid (not active and no history of chronic lung disease)
-Cataracts
-Previous right forearm fracture and left humerus fracture
([**2113**], treated at [**Hospital **] Hospital)
-S/p hemicolectomy for a benign polyp
-S/p total abdominal hysterectomy
-SAH
-recent infarct
Social History:
She is widowed. She drinks occasional alcohol. No tobacco or
illicit drug use.
Family History:
Non-contributory
Physical Exam:
Vitals: T: 97.7 BP: 165/68 P: 112 R: 23 O2: 99% 3LNC
General: pleasant, elderly female, Alert, oriented, no acute
distress
HEENT: EOMI, cataracts present, Sclera anicteric, dry MM
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: no use of access mm, Clear to auscultation anteriorly, no
wheezes, rales, ronchi
CV: tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: NABS, soft, non-tender, non-distended, no rebound
tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, left lower extremity with
increased circumference compared to right, no erythema,
non-tender
Neuro: A&Ox3, CN II-XII grossly intact, [**3-28**] handgrip
bilaterally, 5/5 strength in LE's, gait deferred
Pertinent Results:
Labs:
CBC:
[**2137-5-27**] 09:00PM BLOOD WBC-9.1 RBC-3.03* Hgb-9.0*# Hct-26.6*
MCV-88 MCH-29.7 MCHC-33.9 RDW-14.0 Plt Ct-362
[**2137-5-28**] 03:43AM BLOOD WBC-9.2 RBC-3.04* Hgb-8.9* Hct-26.6*
MCV-88 MCH-29.3 MCHC-33.4 RDW-13.8 Plt Ct-372
[**2137-5-29**] 03:35AM BLOOD WBC-7.5 RBC-2.62* Hgb-7.7* Hct-23.1*
MCV-88 MCH-29.3 MCHC-33.2 RDW-13.8 Plt Ct-330
[**2137-5-30**] 03:30AM BLOOD WBC-6.5 RBC-2.79* Hgb-8.2* Hct-24.0*
MCV-86 MCH-29.4 MCHC-34.2 RDW-13.7 Plt Ct-367
Diff:
[**2137-5-27**] 09:00PM BLOOD Neuts-79.2* Lymphs-15.7* Monos-2.7
Eos-2.1 Baso-0.3
INR:
[**2137-5-27**] 09:00PM BLOOD PT-12.4 PTT-25.0 INR(PT)-1.0
[**2137-5-28**] 10:10PM BLOOD PT-13.3 PTT-89.8* INR(PT)-1.1
[**2137-5-29**] 03:35AM BLOOD PT-13.9* PTT-150* INR(PT)-1.2*
[**2137-5-30**] 03:30AM BLOOD PT-13.4 PTT-102.3* INR(PT)-1.1
[**2137-5-30**] 07:35AM BLOOD PT-14.0* PTT-78.9* INR(PT)-1.2*
[**2137-5-31**] 07:45AM BLOOD PT-13.6* PTT-73.3* INR(PT)-1.2*
Retic:
[**2137-5-28**] 03:43AM BLOOD Ret Aut-1.9
Electrolytes:
[**2137-5-27**] 09:00PM BLOOD Glucose-114* UreaN-13 Creat-0.7 Na-139
K-3.3 Cl-101 HCO3-26 AnGap-15
[**2137-5-28**] 03:43AM BLOOD Glucose-109* UreaN-10 Creat-0.6 Na-138
K-3.5 Cl-101 HCO3-24 AnGap-17
[**2137-5-29**] 03:35AM BLOOD Glucose-165* UreaN-9 Creat-0.7 Na-140
K-3.8 Cl-107 HCO3-23 AnGap-14
[**2137-5-30**] 03:30AM BLOOD Glucose-107* UreaN-5* Creat-0.5 Na-140
K-3.8 Cl-106 HCO3-25 AnGap-13
[**2137-5-31**] 07:45AM BLOOD Glucose-117* UreaN-6 Creat-0.7 Na-141
K-3.4 Cl-104 HCO3-28 AnGap-12
Enzymes and Bilirubin:
[**2137-5-28**] 03:43AM BLOOD LD(LDH)-301* TotBili-0.3
Elements:
[**2137-5-28**] 03:43AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.6 Iron-22*
[**2137-5-29**] 03:35AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.2
[**2137-5-30**] 03:30AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.8
[**2137-5-31**] 07:45AM BLOOD Calcium-9.0 Phos-3.3 Mg-1.9
Iron studies:
[**2137-5-28**] 03:43AM BLOOD calTIBC-153* Hapto-538* Ferritn-885*
TRF-118*
Urine:
[**2137-5-28**] 01:30AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.015
[**2137-5-28**] 01:30AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
Microbiology:
[**2137-5-28**] 3:24 am MRSA SCREEN No MRSA isolated.
Imaging:
CXR [**2137-5-27**]
IMPRESSION: Small right pleural effusion with associated
atelectasis,
although an underlying pneumonia cannot be excluded.
CT ABD & PELVIS WITH CONTRAST Study Date of [**2137-5-28**] 12:03 AM
STUDY: Chest CTA and CT of the abdomen and pelvis with contrast;
MDCT images were generated through the chest without IV
contrast. Subsequent MDCT images were generated through the
chest after the administration of 130 cc of Optiray intravenous
contrast in the pulmonary arterial phase. Coronal, sagittal as
well as right and left oblique reformatted images were also
generated. Subsequent MDCT images were generated through the
abdomen and pelvis using the same contrast bolus in the venous
phase. Coronal and sagittal reformatted images of the abdomen
and pelvis were also generated.
COMPARISON: None.
FINDINGS:
CHEST: The visualized portion of the thyroid demonstrates a
hyperdense nodule at the junction of the left lobe and the
isthmus that measures 17 x 9 mm (5A; 6). There is no axillary,
hilar or mediastinal lymphadenopathy. The aorta is of normal
caliber along its course and shows no intramural hematoma or
dissection.
The branches of the left pulmonary artery showed no filling
defects down to the subsegmental level. In the right main
pulmonary artery, there is a
filling defect that extends into the right upper, right middle,
and right
lower lobe branches. It is partially occlusive as some contrast
is able to
make its way by the obstruction. The heart demonstrates
straightening of the intraventricular septum, but there is no
bowing into the left ventricle to suggest right heart strain.
The heart demonstrates calcified atherosclerotic disease of the
coronary arteries, but no pericardial effusion. A small simple
right-sided pleural effusion is seen with associated
atelectasis. The lungs demonstrate ground-glass opacity of the
inferolateral portion of the right upper lobe, which may
represent an area of infarct (5A; 56). The left lung is largely
clear with minimal atelectasis.
ABDOMEN: The liver shows multiple hypodensities, most of which
are too small to characterize, but likely represent simple
cysts; the largest of which measures 9 x 10 mm in segment VIII
(5B; 104). Clips in the gallbladder fossa are compatible with
prior cholecystectomy. The spleen, pancreas and adrenal glands
appear normal. The kidneys enhance with and excrete contrast
symmetrically. A hypodensity in the right mid pole is too small
to characterize, likely represents a cyst. Small and large
intestine show no signs of obstruction. Calcified
atherosclerotic disease is seen throughout the abdominal aorta.
There is no filling defect of the IVC. There is no
lymphadenopathy, free air, or free fluid.
PELVIS CT: The bladder, uterus, and rectum appear unremarkable.
There is no free air or lymphadenopathy. A filling defect is
noted involving the left deep and superficial femoral veins
extending into the common femoral vein and into the left
external iliac vein, after which it resolves.
BONES: Mild degenerative changes are seen throughout the
thoracic spine. A
severe compression deformity is seen at the T12 vertebral body
and to a lesser extent at the T10 vertebral body. At the T12
level, there is approximately 8 mm of retropulsed material.
These are of indeterminate age, but the degree of sclerosis and
degenerative changes around them suggests that they are chronic.
IMPRESSION:
1. Large PE involving the right upper, right middle, and right
lower
pulmonary arterial branches, partially occlusive. No evidence of
right heart strain.
2. Filling defect extending from the left superficial and deep
femoral veins all the way up to the left external iliac vein; no
evidence of more central DVT.
The above findings were discussed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] at 00:59 on
[**2137-5-28**] by [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 11623**] over the phone.
3. Compression deformities of T12 and T9, while chronic
appearing, no
comparison study is available to assess for stability; correlate
with exam.
- CT HEAD W/O CONTRAST Study Date of [**2137-5-28**] 2:07 AM
IMPRESSION:
1. Decreased intraventricular hemorrhage.
2. Near complete resolution of subarachnoid hemorrhage.
3. Decreased right paratentorial subdural hematoma.
4. Interval resolution of subdural fluid collections.
- CT HEAD W/O CONTRAST Study Date of [**2137-5-28**] 11:38 PM
Final Report
INDICATION: 86-year-old female with traumatic subarachnoid
hemorrhage, now on heparin for pulmonary embolus. Evaluate for
worsening intracranial hemorrhage.
COMPARISON: Serial CT examinations between [**2137-5-7**] and [**2137-5-28**] at
2:07. TECHNIQUE: Contiguous non-contrast axial images were
obtained through the brain. 5-mm axial, 2-mm coronal, and 2-mm
sagittal multiplanar reformats were generated.
FINDINGS: There has been near-complete resolution of
subarachnoid hemorrhage, with tiny residual hyperdense foci
along the parietal sulci (2:19). Trace subdural hemorrhage also
persists along the right tentorium cerebelli (401B:64). A small
amount of blood is seen layering in the bilateral occipital
horns (2:15). No new foci of hemorrhage, edema, or vascular
territorial infarction are identified. The ventricles and sulci
remain prominent, consistent with age-related involutional
changes. Periventricular and subcortical white
matter hypodensities are consistent with small vessel ischemic
disease. Dense calcifications are present in the cavernous
carotid arteries. There is no shift of the normally midline
structures.
The paranasal sinuses and mastoid air cells are clear. Orbits
and intraconal structures are preserved.
IMPRESSION:
1. Stable trace subarachnoid, right subdural, and
intraventricular
hemorrhage. No evidence of new intracranial hemorrhage.
2. Chronic involutional changes.
- HUMERUS (AP & LAT) RIGHT Study Date of [**2137-5-30**] 6:01 PM
Preliminary Report !! WET READ !!
Oblique fx of mid-humeral diaphysis with continued 2 shaft width
anterior, [**11-26**] shaft width medial displacement of distal
fragement. Interval resorption of fx lines and heterotopic
ossification, but no successfully bridging callus.
Brief Hospital Course:
Primary Reason for Hospitalization:
Pt is an 86 yo F with history of HTN, HLD, R humerus fracture in
cast, SAH, who presents from [**Hospital1 18**] [**Location (un) 620**] for LLE swelling DVT
seen on u/s. Pt found to have PE in partially occlusive PE
involving R upper, mid, and lower PA.
Active Issues:
#. Pulmonary embolism, lower extremity DVT: Significant clot
burden. No RHS seen on CT, however, no echo done. ECG shows some
signs of RHS, but c/w prior, CTA without signs of RH strain.
Neurosurgery okay with starting anticoaggulation given SAH has
resolved. Patient given a bolus of heparin but then held for IVC
filter placement. Patient underwent filter placement on [**2137-5-28**]
without complication. Heparin gtt was restarted on [**2137-5-28**] after
procedure. The patient was then started on warfarin 5 mg daily
(started on [**2137-5-30**]) and received her dose of 5 mg warfarin
prior to her discharge on [**2137-5-31**]. Hypercoagulable studies were
not sent given that this was a provoked DVT likely secondary to
her immobility. She will need to continue to remain on a heparin
gtt with a goal PTT between 60-100 until her INR has been stable
between [**12-27**] fofr 48 hours.
# Previous Intra-ventricular hemorrhage, SAH: Per neurosurg
recs, benefits of anti-coagulation outweigh risk since bleed
appeared stable on repeat head CT on [**2137-5-28**]. ASA held initially,
and restarted once Hct stable and guaiac negative. She is
scheduled for a repeat head CT and a follow up appointment in
the neurosurgery clinic after discharge.
# Right humeral fracture: Pt sustained R humeral fracture after
fall in [**4-3**], had closed treatment with splint and followed by
ortho service as outpatient. The ortho service re-evaluated her
fracture while she was in the hospital and recommended....
#. Normocytic Anemia: Hct drop from baseline low 30s to 26 on
admission but then stabilized. Iron studies were consistent with
anemia of chronic disease/inflammation. Her Hct was monitored
and was stable at 26 on the day of discharge.
.
#. HTN: Hypertensive on admission to systolic 160s. Recently
with hypotension at OSH, and new stroke thought to be [**12-26**]
hypovolemia & multiple BP meds. Metoprolol was continued
throughout hospitalization, lisinopril was initially held for
renal protection after CT with IV contrast and then resumed. BP
was stable in 130s-140s on day of discharge.
.
Inactive issues:.
#. HLD: Continued simvastatin 40mg daily
.
# Osteoporosis: Continued Calcium, vitamin D
Transitions:
On discharge Ms. [**Known lastname **] was well-appearing, breathing
comfortably on room air. She should continue coumadin with
heparin bridge and will need anti-coagulation monitoring. She
should continue anticoagulation for three months. She should
continue physical therapy to encourage ambulation. She is
scheduled to follow up with the neurology and neurosurgery
services (with an appointment for a repeat head CT). She also
has a follow-up appointment with our orthopedic clinic to
reevaluate her right humerus. She should also have an
appointment scheduled to follow up with her PCP [**Name Initial (PRE) 176**] 1-2 weeks
of leaving the hospital. In addition, she may benefit from
outpatient follow up in our hematology/oncology clinic. She can
schedule an appointment by calling their clinic at ([**Telephone/Fax (1) 11624**]. Please also follow-up in the final imaging report of
the patient's right humerus performedon [**2137-5-31**].
Medications on Admission:
- Levaquin 500 mg a day for 4 more days
- Neutra-Phos 1 packet a day for 3 days
- metoprolol 25 mg twice per day, hold if BP under 100, pulse
under
- Zocor 40 mg a day
- coated aspirin 81 mg daily
- Fleet enema rectally every day as needed
- Remeron 7.5 mg at nighttime
- milk of magnesia 30 mL a day as needed
- senna 2 tablets twice per day as needed
- Colace 100 mg every 8 hours as needed
- Tylenol 650 every 6 hours as needed
- Lisinopril 5 mL a day, hold if BP under 100
- mag oxide 400 mg a day if needed if magnesium is under 1.8.
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Remeron 15 mg Tablet Sig: [**11-25**] Tablet PO qHS:prn as needed for
insomnia.
6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for Constipation.
10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. heparin (porcine) in NS 10,000 unit/1,000 mL Parenteral
Solution Sig: Per attached sliding scale Intravenous Per
sliding scale: Continue until therapeutic INR on warfarin for 48
hours.
12. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Please continue to monitor INR daily, therapeutic goal
2.0-3.0.
13. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal
once a day as needed for constipation.
14. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ml
PO once a day as needed for constipation.
15. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO once a
day as needed for needed if magnesium is under 1.8.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary diagnosis:
Pulmonary embolus
Deep vein thrombosis
.
Secondary diagnoses:
Subarachnoid hemorrhage
Interventricular hemorrhage
R humerus fracture
Anemia
Hypertension
Hyperlipidemia
Osteoporosis
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 [**Hospital1 18**] because you had left leg swelling and
evidence of a blood clot in your leg on ultrasound. You had a
CT scan of your chest which showed a blood clot in your lungs.
You were seen by the neurology service because of your history
of a head bleed, and a repeat CT scan of your head showed that
this bleed was stable. You were evaluated by the vascular
surgery service, who placed an filter in a blood vessel called
the inferior vena cavae. You were started on heparin and then
coumadin. You will need to continue the heparin until the
coumadin reaches therapeutic levels. At that time, your heparin
can be stopped but you will need to continue to take the
coumadin for a total of 3 months at least.
Unfortunately the orthpedic team was unable to see you while you
were in the hospital, but you have an appointment in the very
near future to have your shoulder re-evaluated.
We made the following changes to your medications:
-STARTED IV heparin drip (per sliding scale instructions) --
continue until INR therapeutic (2.0-3.0) on warfarin for 48
hours
-STARTED warfarin by mouth 5mg daily or adjusted as needed for
therapeutic INR (2.0-3.0) -- continue for 3 months
-STARTED Calcium Carbonate 500 mg by mouth twice a day
-STARTED Vitamin D 800 UNIT by mouth daily
-CHANGE you dose of Remeron to 7.5 mg at nighttime as needed for
sleep (previously you had been taking it every night)
We made no other changes to your medications. Please continue
taking the rest of your medications as prescribed by your
physician.
Please see below for information about upcoming appointments
with your physicians.
It has been a pleasure taking care of you at [**Hospital1 18**], and we wish
you a speedy recovery.
Followup Instructions:
You should ask your rehab facility to schedule an appointment to
follow up with your primary care provider (Dr. [**First Name (STitle) 860**] within
1 to 2 weeks of leaving the hospital. Her clinic phone number
is [**Telephone/Fax (1) 8506**].
.
You have the following appointments scheduled at [**Hospital1 18**]:
In case you are unable to be seen by Orthopedics prior to your
discharge, you have the following appointment; please cancel
this appointment if you see them prior to your discharge:
Department: ORTHOPEDICS
When: TUESDAY [**2137-6-4**] at 12:20 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: TUESDAY [**2137-6-4**] at 12:40 PM
With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: TUESDAY [**2137-6-11**] at 3:00 PM
With: DRS. [**Name5 (PTitle) **] & [**Doctor Last Name 11625**] [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RADIOLOGY
When: WEDNESDAY [**2137-6-12**] at 8:15 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: WEDNESDAY [**2137-6-12**] at 9:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1669**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1182
} | Medical Text: Admission Date: [**2108-1-31**] Discharge Date: [**2108-2-15**]
Date of Birth: [**2044-3-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Dyspnea.
Major Surgical or Invasive Procedure:
Endoscopy, colonoscopy, right and left cardiac catheterization
with bare metal stent placement
History of Present Illness:
This is a 63 year old gentleman with CAD s/p CABG (SVG-D,
SVG-RCA and LIMA-LAD SVG-RCA which was occluded on [**12/2107**]
catheterization), diastolic CHF, atrial fibrillation/flutter,
type II diabetes presented to an OSH with worsening dyspnea over
one day. Of note patient was recently admitted to [**Hospital1 18**] with an
acute MI in [**2107-12-9**], at that time PCI was performed with
SVG to the diag was performed. The patient was to return for PCI
on the native OM.
Also of note, the pt's post-cath course on prior admission was
complicated by large groin hematoma; he required 3 units pRBC
and repair by vascular surgery. Pt also noted to have one guaiac
positive stool.
.
Since that time the patient has developed worsening shortness of
breath over several weeks associated with non-productive cough.
He denies any chest pain, or fever. Over the last few days he
has been using his wife's oxygen with some relief. He could only
move a few feet before becoming short of breath.
.
On admission to OSH on [**1-31**], he found to have +2 pedal edema, O2
sats 85-90% on RA. No mention is made of other vital signs. The
patient was briefly on Bipap, transitioned to 4L NC maintaining
sats between 97-100%. He was diagnosed with CHF exacerbation. He
was treated with lasix 60 IV and nebulizers. His respiratory
status improved. The patient had a leukocytosis to 20,000 but
this was not commented on in the notes. There was some concern
for abscess and mention is made of obtaining MRI, per the
patient this was not done because of his heart monitor. In
general the course at the OSH is poorly documented, with no
discharge summary and confusing, at times, illegible notes.
.
The patient reported currently feeling somewhat better. He
denies any chest pain and feels his breathing is improved.
.
ROS: Chronic back pain since [**Month (only) 359**]. No nausea/vomiting, but he
did have some diarrhea this morning. No abdominal pain except
with coughing. No dizziness, weakness, imbalance, loss of
continence. A total of 10 of 14 systems were reviewed and, other
than those mentioned, were negative.
Past Medical History:
Myasthenia [**Last Name (un) 2902**]
CAD s/p CABG [**2091**]
Hypertension
Dyslipidemia
Atrial flutter/fibrillation
Diabetes Mellitus
Ventral abdominal hernia s/p MVA in [**2092**].
Lower back pain, has l-spine compression fractures
GI bleed
Social History:
Quit tobacco [**2094**]; rarely drinks alcohol; lives with his wife;
Currently on disability, former director of an exercise company
Family History:
Grandmother with pacemaker, no other known heart disease
Physical Exam:
T 98.6; HR 60-65; BP 112/62; RR 19; O2 99% on 4L
Gen: Obese male Caucasian, no acute distress.
HEENT: Clear OP, MMM
Neck: Supple, obese neck, JVP about 10 cm.
CV: irregularly, irregular, NL rate. Distant heart sounds. No
murmurs, rubs, gallops.
Lungs: Fair air movement, occasional crackles, no wheezes.
Abd: obese; [**5-14**] inch ventral hernia - easily reducible,
nontender; Soft, NT, ND. NL BS.
Ext: 1+ pedal edema, improved per patient.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Normal
coordination. Gait assessment deferred
Pertinent Results:
WBC 20.4 Hct 31.7 (baseline around 30) Plt 434
90 neutophils, 4 bands
P-BNP 1650 CK 24 Trop 0.06
INR 0.9 PTT 21.8
Na 141 K 4.1 Cl 107 BUN 26 Cr 1.4 Gluc 182
Digoxin 1.2
.
EKG: Atrial fibrillation, rate 65, low voltage
.
CXR: OSH (image unavailable) no pulmonary edema, "R lower lobe
opacity"
[**Hospital1 **] (my read) mild pulm congestion, R costophrenic angle missing,
no focal infiltrates seen, no effusions.
.
[**2107-2-1**] echocardiogram
1.The left atrium is moderately dilated. The left atrium is
elongated.
2.There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Left ventricular systolic function is hyperdynamic
(EF>75%).
3. Right ventricular chamber size is normal. Right ventricular
systolic function is normal.
4.The ascending aorta is mildly dilated.
5.The aortic valve is not well seen. There is no aortic valve
stenosis. No aortic regurgitation is seen.
6.The mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen.
7.The estimated pulmonary artery systolic pressure is normal.
8.There is no pericardial effusion.
Bleeding Study [**2108-2-7**]:
Following intravenous injection of autologous red blood cells
labeled with Tc-[**Age over 90 **]m, blood flow and dynamic images of the
abdomen for 120
minutes were obtained. A left lateral view of the pelvis was
also obtained.
Blood flow images show no sites of abnormal radiotracer uptake.
Dynamic blood pool images show no active gastrointestinal
bleeding.
IMPRESSION: No active gastrointestinal bleeding after 2 hours.
Bleeding Study [**2108-2-8**]:
Following intravenous injection of autologous red blood cells
labeled with Tc-[**Age over 90 **]m, blood flow and dynamic images of the
abdomen from 0-79 minutes and from 150-180 minutes were
obtained. A left lateral view of the pelvis was also obtained.
Blood flow images show a normal pattern of tracer distribution.
Dynamic blood pool images show somewhat heterogeneous blood pool
throughout the abdomen, most prominent in the left lower
quadrant. The activity does change in distribution throughout
the examination but does not appear to collect. The changing
pattern could reflect physiologic bowel movement.
IMPRESSION: No definite evidence of GI bleeding.
[**2108-2-6**] Upper Endoscopy:
Findings:
Esophagus: Normal esophagus.
Stomach: Mucosa: Erythema of the mucosa with no bleeding was
noted in the stomach body and antrum. These findings are
compatible with gastritis.
Duodenum: Protruding Lesions A single small non-bleeding polyp
was found in the second part of the duodenum.
Impression: Erythema in the stomach body and antrum compatible
with gastritis Polyp in the second part of the duodenum
Otherwise normal EGD to second part of the duodenum
[**2108-2-10**]: Colonoscopy:
Findings:
Contents: Red blood, with some clots was seen in the whole
colon.
Flat Lesions Many angioectasias that were not bleeding were seen
in the cecum. Mono-Polar Cautery Unit was applied for
hemostasis. The AVMs did not bleed on cauterization.
Protruding Lesions Four sessile 3-4mm polyps of benign
appearance were seen. 2 in the cecum and 2 distally (descending
and sigmoid colon). They were not removed at this time.
Excavated Lesions Multiple diverticula were seen in the whole
colon. No active bleeding was seen in the diverticuli.
Other Few small ulcerations were seen in the ileum. They were
not bleeding. There was no blood in the ileum.
Impression:
Blood in the whole colon
Diverticulosis of the whole colon
Angioectasias in the cecum (thermal therapy)
Polyps in the cecum
Few small ulcerations were seen in the ileum. They were not
bleeding. There was no blood in the ileum.
Otherwise normal colonoscopy to cecum and terminal ileum
Brief Hospital Course:
This is a 63 year old gentleman with CAD s/p CABG, CHF
(diastolic) and atrial flutter/fibrillation who presented to an
outside hospital for dyspnea and found to be hypoxic on room
air. He was diagnosed with CHF exacerbation and this improved
after diuresis. He was transferred here for CHF management and
for repeat catheterization. On transfer his oxygen status
appeared improved after diuresis and patient seemed more
comfortable. He did have some jugular vein distention,
scattered rales and LE edema. He was therefore diuresed on HD1.
Further diuresis was stopped as his creatinine trended upward
the following day.
.
Of more importance was that his troponin was noted to trend
upward and he ruled in for MI. Heparin was started. The
patient was therefore started on heparin on HD 2. Subsequent to
this the patient was noted to have brown, guaiac positive stools
with his HCT trending downward. Heparin was discontinued for
this reason. His hematocrit trended further downward and the
patient developed BRBPR, melena was not noted. Planned
catheterization on HD 3 was therefore deferred. GI was
consulted and they planned for endoscopy to be done on [**2-6**]
prior to his catheterization.
On HD [**4-12**] patient had multiple episodes of BRBPR; however his
hematocrit remained stable. BP and pulse remained stable until
the afternoon of HD 5.
.
At this time when the patient became tachycardic to the 130's
with SBP to 70's after another episode of BRBPR. NG lavage was
negative and stat blood draw revealed no change. EKG revealed
ST depressions in inferolateral leads consistent with posterior.
Posterior lead EKG was also consistent with posterior territory
ischemia The blood pressure spontaneously trended to the 90's
range systolic. The patient received one 250 cc bolus and a
unit of pRBC. His blood pressure stabilized for the next two
days. It was believed the hypotension was secondary to
posterior ischemia given the anatomy of his CAD and his EKG
changes
.
On HD 7 the patient underwent catheterization with DES to the
OM1. Of note the patient was briefly hypotensive in the cath
holding area. This resolved spontaneously (pt was on pre-cath
fluids). Importantly, the pt was found to have a melanotic
stool movement the prior night and had an additional melanotic
movement the afternoon after catheterization. This was not
reported to the medical team until the afternoon of HD 7. His
blood pressure and pulse remained unchanged. GI consult was
notified and he was taken to the intensive care unit for
endoscopy and further monitoring.
Upper endoscopy revealed gastritis but no active source of
bleeding. He continued to have melanic stools, and his HCT
continued to trend down although vital signs remained stable.
He required 1-2units PRBCs daily. Bleeding scan was negative
x2. A colonoscopy was preformed which was filled with blood.
It also showed diverticula and AVMS (which were cauterized)
although no active source of bleeding was noted. The ileum
showed ulcers but since there was no blood seen on colonoscopy
in the ileum, this is likely not the source of the bleed. He
was treated with PPI IV. He was continued on aspirin and plavix
given recent MI and s/p cardiac cath with stent placement which
likely contributed to persistent bleeding. Eventually, the
melanic stools and BRBPR resolved and HCT remained stable.
## Cardiovascular disease, s/p PCI to OM1
a) Ischemia: CAD s/p CABG. He is s/p BMS to OMI and was treated
with aspirin and plavix, metoprolol and lisinopril.
.
b) PUMP: CHF, diastolic, initially presented with volume
overload and responded to diuresis. He was treated with
lisinopril, metoprolol, diuresis. Daily weights, O2 sats and
symptoms improved.
c) Rhythm: Atrial fibrillation/flutter, the patient had
episodes of PAF and atrial flutter and responded to metoprolol.
He was also on digoxin. He is not on anticoagulation given
history of groin hematoma and GIB.
## Leucocytosis, noted at OSH but no action taken. Range 12,00
20,000 now [**Numeric Identifier 2686**]. Likely secondary to long term steroid use. He
remained afebrile, negative cultures, negative c.diff.
.
## Elevated creatinine--1.4 on admission, baseline 1.1, climbed
to 2.1 after diuresis. Back to baseline prior to discharge.
.
## Myasthenia [**Last Name (un) 2902**], continue home regimen of imuran,
prednisone, and mestinon. The patient had previously been on
cell cept instead of prednisone for myasthenia [**Last Name (un) 2902**] but due to
insurance coverage issues, cellcept was discontinued. The
patient required intubation in [**2-/2107**] after first stopping
cellcept and had to be started on prednisone. Given the
increased risk the prednisone has on heart disease, GIB and
diabetes (all of which the patient suffers), we contact[**Name (NI) **] his
insurance company regarding the need for cellcept coverage. The
insurance company agreed to cover a generic form of cellcept and
the patient has a follow-up appointment with his neurologist to
change his outpatient regimen.
.
## Diabetes mellitus type 2: Glyburide was initially held for
elevated creatinine and he was covered with insulin. His
outpatient regimen was eventually restarted and his creatinine
remained at baseline at the time of discharge.
.
## Full code.
Medications on Admission:
Aspirin 325 daily
Plavix 75 daily
Metoprolol 75 [**Hospital1 **]
Lisinopril 5 daily
Lasix 10 daily PRN swelling
Prednisone 60 daily
Azathioprine 50 [**Hospital1 **]
Crestor 10 daily
Percocet 325-5 1-2 tablets PRN q4-6 hours
Iron 325 daily
Protonix 40 once a day
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. Rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*28 Tablet(s)* Refills:*0*
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO
Q3H (every 3 hours).
9. Pyridostigmine Bromide 180 mg Tablet Sustained Release Sig:
One (1) Tablet Sustained Release PO qHS (2300-2400) ().
10. Aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable
PO DAILY (Daily).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
11. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
13. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day.
14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day as
needed for leg swelling: Take once daily as needed for leg
swelling. .
Disp:*30 Tablet(s)* Refills:*0*
15. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: Two (2)
Tablet Sustained Release 24HR PO once a day.
Disp:*60 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Primary diagnosis:
Congestive heart failure exacerbation
gastrointestinal bleeding
.
Secondary diagnosis:
Coronary artery disease
hypertension
diabetes mellitus
myasthenia [**Last Name (un) 2902**]
atrial fibrilation/flutter
dyslipidemia
Discharge Condition:
Good, respiratory status stable, ambulatory
Discharge Instructions:
Please take all medications as prescribed. Continue to take your
aspirin and plavix for at least 6 months and speak with your
cardiologist before stopping these medications. Do not start
taking Mycophenolate Mofetil until you speak with your
neurologist.
Please keep all follow-up appointments.
Please call your primary care doctor or return to the Emergency
department if you experience weight gain greater than 3 pounds,
shortness of breath, chest pain, blood in your stools, light
headedness, dizziness, feeling faint.
Followup Instructions:
Please call your primary care doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 29561**] to schedule a follow-up appointment within 1-2 weeks of
discharge. You will need to continue plavix and aspirin for at
least 6 months from [**2107-12-19**] for the Drug eluting stent that was
placed.
.
Follow up with your neurologist Dr. [**First Name (STitle) **], to transition from
prednisone to generic cellcept. Please do not change your
prednisone dose or start cellcept prior to discussing this with
Dr. [**First Name (STitle) **]. Let you doctor know that the prior authorization
request number is 1-[**Telephone/Fax (1) 39248**]. Additionally you should
discuss imaging for your lower back pain, including MR for
further evaluation.
ICD9 Codes: 4280, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1183
} | Medical Text: Admission Date: [**2167-4-9**] Discharge Date: [**2167-4-18**]
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Neck pain
Major Surgical or Invasive Procedure:
Central line placement
Chest tube placement
History of Present Illness:
HPI: 88M s/p mechanical fall 1 wk ago, presented to OSH had
negative CT head and discharged. Presented today to an OSH and
second head CT still negative but with CT c-spine showing C1
fracture. Transferred for further management.
Past Medical History:
PMHx: dementia, CAD, HTN, GERD, COPD
Social History:
Social Hx: unable to obtain
Family History:
Family Hx: n/c
Physical Exam:
ON ARRIVAL
PHYSICAL EXAM:
O: T: 97.7 BP: 151/85 HR:86 R16 O2Sats 98%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: R=3-->2 brisk, L=3-->2.5, sluggish EOMs: full
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: Reg rate
Abd: Soft, NT
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, affect of
dementia, poor historian
Orientation: Oriented to person, "[**Hospital **] hospital", "[**2167**]"
Motor:
D B T FE FF IP Q AT [**Last Name (un) 938**] G
R 5 5- 4 5 5 5 5 5 5
L 5 5 5 5 5 5- 5 5 5
Sensation: Intact to light touch
Reflexes: B T Br Pa Ac
Right 1+ 1+
Left 1+ 1+
Toes downgoing bilaterally
Rectal exam normal sphincter control
ON DISCHARGE
Brief Hospital Course:
Pt was admitted to the neurosurgery service after ED eval for
c/o neck pain revealed C1 fracture. Pt placed in a rigid collar
for stabilization. Medicine consult obtained for risk
assessment for pre-operative planning. Medicine eval
demonstrates that pt is a high surgical risk and had no further
recommendations for medical optimization.
Cardiothoracic eval was obtained for Thoracic aortic aneurysm.
They did not recommend operative intervention.
He was seen by Nutrition as well as speech and swallow. They
are concerned with pts poor nutritional status and sugggest the
following. 1 Pureed with nectar thickened lquids / they also
feel that he may benefit from NGT or Dobhoff for supplementation
as his appetite is so poor. A Dobhoff placement was attempted
but was unsuccessful. Shortly afterward the patient was made
[**Last Name (un) 3225**].
Dr [**Last Name (STitle) **] spoke with the family regarding the surgical case and
it was decided to undergo posterior stabilization. On morning
of [**4-15**] pt desaturated and ended up requiring intubation and
transfer to ICU. He had central line placed with resultant
pneumothorax requiring chest tube placement. His grave
situation was discussed with the family. On [**4-16**] there was a
family meeting with social work and neurosurgery. His son
decided that he would make the patient [**Month/Day (4) 3225**] the following day
after other family members were able to come in. There was
another family meeting [**2167-4-17**] in the early afternoon with the
ICU team and neurosurgery. The son decided to make the patient
[**Name (NI) 3225**] at that time. He was extubated and ultimately expired at
[**2167-4-18**] at 12:25am.
Medications on Admission:
albuterol, prolosec, simvastatin, lantus, MOM, folic acid,
bupropion, ASA 81, docusate
Discharge Medications:
Not applicable.
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory failure
C1 fracture status post fall
Discharge Condition:
Expired
Discharge Instructions:
Not applicable
Followup Instructions:
Not applicable
ICD9 Codes: 5070, 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1184
} | Medical Text: Admission Date: [**2189-7-15**] Discharge Date: [**2189-7-19**]
Date of Birth: [**2120-1-7**] Sex: M
Service: MICU, KURLA
CHIEF COMPLAINT: Found down in setting of gastrointestinal
bleed.
HISTORY OF PRESENT ILLNESS: This is a 69-year-old male with
history of mental retardation with IQ of 60, peptic ulcer
disease, with a history of gastrointestinal bleed and
guaiac-positive stools, as well as asthma, depression with
psychotic seizures, and hospitalization for suicidal ideation
with plan who was brought to the Emergency Room by Emergency
Medical Service after being found down by brother in pool of
red blood around face and mouth the morning of admission.
Brother reports has a history of falls over the last two to
three years ago but none recent. Was in usual state of
health until found bleeding this morning. Says that his
brother was able to converse appropriately, and en route to
hospital family reports that patient vomited black material
and shortly became obtunded.
In the Emergency Room vital signs included a temperature of
96.1 F, a pulse of 112, a blood pressure of 170/65,
respiratory rate of 12, and he was satting 94%. The patient
was somnolent to following commands. Orogastric lavage was
done with return of coffee grounds which cleared with 400 cc.
Patient was intubated thereafter for airway protection and
transfused two units of red cells for an initial hematocrit
of 31 and bolused with three liters of normal saline. He was
transiently hypotensive to the systolic 80s after intubation
in the setting of some rigors with a tympanic temperature of
92. He was bolused with warm fluids and started on a warming
blanket. He also received Clindamycin for question
aspiration.
PAST MEDICAL HISTORY:
1. Mental retardation, IQ of 60.
2. Chronic constipation with multiple admissions.
3. Hypercholesterolemia.
4. Asthma.
5. Hiatal hernia.
6. GERD with Barrett's esophagus as well as peptic ulcer
disease with history of UGVI and history of guaiac-positive
stools.
7. History of [**Female First Name (un) 564**] esophagitis.
8. Depression with psychotic features and suicidal ideation.
9. Iron-deficiency anemia.
10. BPH status post TURP.
11. DJD.
12. Nasal polyps.
PAST SURGICAL HISTORY:
1. Hernia repair bilaterally.
2. Wedge resection of benign right apical lung mass.
3. TURP.
SOCIAL HISTORY: Patient lives with brother, who also has
mental retardation. No tobacco, alcohol, or drugs.
Independent with activities of daily living. Health care
proxy is [**Name (NI) 3065**] [**Name (NI) **] at [**Telephone/Fax (1) 9603**].
MEDICATIONS ON ADMISSION:
1. Accolate 20 b.i.d.
2. Lipitor 10.
3. Carafate 1 gram b.i.d.
4. Celexa 80 q. h.s.
5. Colace 100 t.i.d.
6. Fleet enema.
7. Flovent inhaler.
8. Lactulose b.i.d.
9. Lasix 10 b.i.d.
10. Protonix 40 q.d.
11. Serax 30 h.s.
12. Serevent MDI.
13. Vitamin C.
14. Volmax 4 mg b.i.d.
15. Wellbutrin 150 mg b.i.d.
16. Zyprexa 2.5 mg b.i.d. and 2 mg q. h.s.
17. Niferex 150 b.i.d.
ALLERGIES: He has no known drug allergies.
PHYSICAL EXAMINATION: Initial physical exam was significant
for the patient being intubated, disheveled, with some
rigors. Pupillary exam was normal. Patient was in a
C-collar. He had poor air movement bilaterally with
inspiratory and expiratory wheezes throughout. Cardiac and
abdominal exams were unremarkable. Toes were downgoing. He
was unresponsive to voice. He had no gag reflex but did have
corneal reflexes. Gastrointestinal fellow exam in ER showed
a finding of brown stool which was heme negative; however, it
was guaiac positive per the Emergency Room physician.
INITIAL LABORATORY DATA: Hematocrit 31.6, near his baseline;
MCV of 67, platelets of 220; normal coagulation studies,
unremarkable chemistry panel, negative urinalysis, and serum
and urine toxicity negative for benzodiazepines.
EKG showed down sloping ST depression in 2, L, and T-wave
inversion in 3, but otherwise unremarkable.
Chest x-ray showed minimal atelectasis at left lung base,
questionable mild congestive heart failure.
There is no bowel obstruction on KUB.
Head CT was negative except for maxillary sinus mucosal
thickening.
Recent EGD [**2188-8-14**] showed Barrett's esophagus and
nodularity in duodenum.
HOSPITAL COURSE: The patient was treated with Protonix, was
stabilized overnight, then underwent EGD. The patient had a
large hiatal hernia with short segment of Barrett's
esophagus, ulcers in the lower third of the esophagus, fluids
in stomach. EGD was otherwise normal to the third part of
the duodenum. Recommendations were Protonix 40 mg
intravenous b.i.d. until on POs, Carafate one gram q.i.d.
when able, and repeat EGD in six weeks to document clearance
and support the biopsy.
By [**2189-7-16**] the patient was ready for transfer to the floor
and had been extubated. Was having no respiratory
difficulties. Hypokalemia was treated. Diet was advanced to
full. Patient had some mild abdominal pain thereafter which
was felt to be consistent with his chronic constipation which
was treated in the usual fashion with his home medications.
Patient did spike to 101.4 F degrees the evening of
[**2189-7-16**]. Sputum culture showed gram positive cocci.
Chest x-ray was unremarkable. Urinalysis was negative with
blood cultures pending. The patient's fevers resolved
without intervention. He began to have guaiac-negative
stools. His abdominal pain improved. He was therefore felt
safe for discharge on [**2189-7-19**].
Discharge medications were not recorded by the discharging
physician but probably included his home medications and:
1. Carafate as directed by the GI fellow, one gram q.i.d.
2. Protonix 40 mg b.i.d.
[**First Name4 (NamePattern1) 9604**] [**Last Name (NamePattern1) 9605**], M.D.
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2189-10-2**] 09:13
T: [**2189-10-2**] 21:54
JOB#: [**Job Number 9606**]
ICD9 Codes: 4280, 5070, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1185
} | Medical Text: Admission Date: [**2151-6-4**] Discharge Date: [**2151-6-30**]
Date of Birth: [**2151-6-4**] Sex: M
Service: NB
HISTORY: Baby is a 32-2/7 week gestational age triplet
number 2 admitted to the NICU for prematurity. Mom is a 33-
year-old G1, P0 to 3 woman with past OB history notable for
primary infertility. She has a past medical history notable
for telangiectasia/epistaxis with negative brain and
abdominal MRI and investigation for Osler-[**Doctor Last Name 11586**]-Rendu.
PRENATAL SCREENS: Blood type A positive, antibody negative, hep
B surface antigen negative, RPR nonreactive, rubella immune,
GBS unknown.
ANTENATAL HISTORY: [**Last Name (un) **] [**2151-7-28**], for estimated
gestational age of 32-2/7 weeks at delivery. Babies were an
IVF dichorionic, triamniotic triplet gestation with
concordant growth and normal full fetal survey in all
triplets. Pregnancy was complicated by preterm labor,
hypertension and thrombocytopenia leading to admission on
[**5-22**] through [**5-24**] at which time she received Nifedipine
and a full course of betamethasone. She was subsequently
discharged on bed rest. She underwent elective C-section
under spinal anesthesia. There was no intrapartum fever or
other clinical evidence of chorioamnionitis. Artificial
rupture of membranes occurred at delivery and yielded clear
amniotic fluid. The infant was vigorous at delivery. He was
orally and nasally bulb suctioned and dried. Apgars were 8
and 5.
PHYSICAL EXAM ON ADMISSION: Birth weight [**2078**] grams (25th-
50th percentile). Head circumference 30.5 cm (50th-75th
percentile). Length 44 cm (50th-75th percentile). Heart rate
166, respiratory rate 60-70, temp 98.4, BP 69/27 (42), O2
saturation 95% on room air. HEENT, anterior fontanel open and
flat, nondysmorphic. Palate intact. Neck/mouth normal.
Normocephalic. No nasal flaring. Red reflexes normal
bilaterally. Chest, no retractions, good breath sounds
bilaterally. No adventitious sounds. Cardiovascular, well
perfused, regular rate and rhythm. Femoral pulses normal. S1,
S2 normal. No murmur. Abdomen soft, nondistended, no
organomegaly. No masses. Bowel sounds active. Anus patent.
Three vessel umbilical cord. GU, normal phallus. Testes
descended bilaterally. Neuro, active, alert, responding to
exam. Tone AGA and symmetric. Suction, root, gag reflex
intact. Facies symmetric. PERRL. Skin normal.
Musculoskeletal, normal spine, limps, hips, clavicles.
PHYSICAL EXAM AT DISCHARGE: Discharge weight 2720 grams.
Discharge head circumference 33 cm. Discharge Length 48 cm.
SUMMARY OF HOSPITAL COURSE:
1. Respiratory. The baby was admitted on room air and
continued on room air throughout his stay. He had
occasional apnea of prematurity. He has been greater than
5 days without a spell.
2. Cardiovascular. Vital signs on admission were normal
including blood pressure and heart rate. Baby has had no
murmur and has been stable.
3. Fluids, electrolytes and nutrition. Baby was started on
IV fluids and feeds. Feeds were advanced as tolerated to
full feeds and calories were advanced. He currently is
taking Enfacare 24 ad lib.
4. GI. Baby was found to have hyperbilirubinemia on day of
life 3 with a peak bilirubin of 10.4/0.3. He was on
phototherapy for 2 days and has not had any issues since
that time.
5. Hematology. On admission, baby had a CBC which had a
hematocrit of 55.9 and platelets of 22.7. No current
issues.
6. Infectious disease. On admission, the baby's white count
was 9.1 with 15 polys, 0 bands and 75 lymphs. A blood
culture was done, but no antibiotics were started. He has
had no issues.
7. Neurology. [**Known lastname **] has never needed a head ultrasound. Has a
normal neurologic exam. She was started in an isolette.
He was then put in an open crib on day of life 13. He has
been holding his temperatures appropriately.
8. Sensory. An audiology hearing screen was performed with
automated, auditory brain stem responses on [**2151-6-29**], which [**Known lastname **] passed.
9. Ophthalmology. Because of gestational age, the patient
did not need ophthalmology exam.
CONDITION ON DISCHARGE: Excellent.
DISCHARGE DISPOSITION: Home.
PRIMARY CARE PEDIATRICIAN: Dr. [**Last Name (STitle) **] at [**Hospital **] Pediatrics
RECOMMENDATIONS:
1. Feeds at discharge. Please continue Enfacare 24. We
recommend that premature babies continue preemie formula
until 6-9 months corrected age.
2. Medications. None.
3. Iron and vitamin B supplementation. (a) Iron
supplementation is recommended for premature and low
birth weight infant until 12 months corrected age. (b)
All infants that predominantly eat breast milk should
receive vitamin D supplementation at 200 international
units (may be provided as a multivitamin preparation)
daily until 12 months corrected age.
4. Car seat position screening. A car seat position
screening test was done on [**2151-6-29**], which was
passed.
5. State newborn screening status. The baby has had state
newborn screening through the [**State 350**] state newborn
screening lab on [**6-7**] and [**6-12**] which were normal.
6. Immunizations received. [**Known lastname **] received hepatitis B
vaccination on [**2151-6-18**].
7. Immunizations recommended. A Synagis RSV prophylaxis
should be considered from [**Month (only) **] through [**Month (only) 958**] for
infant to meet any of the following for 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; (3) chronic
lung disease; (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 contact out of
home caregivers. (c) This infant has not received
rotavirus vaccine. The American Academy of Pediatrics
recommends initial vaccination of preterm infant at or
following discharge from the hospital if they are
clinically stable and at least 6 weeks, but fewer than 12
weeks of age.
8. Follow-up appointment schedule recommended: 1.
Pediatrician appointment is scheduled for Friday. VNA
will be visiting the house on Thursday.
DISCHARGE DIAGNOSES:
1. Prematurity at 32-2/7 weeks.
2. Triplet gestation.
3. Rule out sepsis, resolved.
4. Hyperbilirubinemia, resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) 74288**]
MEDQUIST36
D: [**2151-6-30**] 07:28:39
T: [**2151-6-30**] 08:05:17
Job#: [**Job Number 74289**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1186
} | Medical Text: Admission Date: [**2102-9-18**] Discharge Date: [**2102-9-30**]
Service:
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old
man with history of dilated cardiomyopathy since [**2094**] which
was diagnosed in [**Hospital6 1129**], at which
time his catheterization revealed an ejection fraction of 38%
with no coronary artery disease. Over the last several years
he has been followed with echocardiogram which has revealed
worsening of his congestive heart failure. He also has 3+
aortic regurgitation, 3+ mitral regurgitation and had
pacemaker placement in [**2101-12-7**] for marked AV conduction
delay. He has had several admissions for congestive heart
failure between [**12/2101**] and [**6-6**] and did reasonably well for
approximately 6-8 weeks in regimen of Hydralazine and
diuretics. Over the last 5 months had deterioration with
several visits to the Emergency Room at CCH. Major reason
for the Emergency Room visits was shortness of breath. He
had a sleep study which revealed obstructive sleep apnea and
therefore was started on C-PAP approximately two weeks prior
to admission but did not tolerate it well. On [**9-16**] he was
transferred from CCH to [**Hospital3 4527**] and had pacemaker
interrogation which showed conversion from normal sinus
rhythm to atrial fibrillation. The patient was started on
Heparin and received one dose of Coumadin. Now he has been
transferred to [**Hospital1 69**] for
transesophageal echo and plan for cardioversion biventricular
pacing.
PAST MEDICAL HISTORY: Significant for atrial fibrillation
with recent onset, cardiomyopathy diagnosed in [**2094**] with an
EF of 38%. Echocardiogram in [**2097**], [**Month (only) 404**], revealed an EF
of 45% with mild aortic regurgitation and mitral
regurgitation with diffuse hypokinesis. In [**2100-10-6**] he
had an EF of 45% with severe mitral regurgitation. In [**2102-5-7**] ejection fraction of less than 20% with severe aortic
regurgitation and mitral regurgitation as well as left
ventricular dilatation. In [**2101-10-7**] he had a DDD
pacemaker placed for AV synchrony. He had an abdominal
aortic aneurysm repair in [**2093**], history of anemia, combined
iron deficiency and chronic disease and he is status post
cholecystectomy. Also has a history of severe pulmonary
hypertension, obstructive central mixed sleep apnea, gout.
MEDICATIONS: On admission, Reglan 10 mg q d, Heparin 1,000
units per hour, Iron Sulfate 325 mg q d, Ambien 5 mg q d,
Probenecid 250 mg [**Hospital1 **], Vitamin E 400 IV q d, K-Dur 40 mEq q
d, Spironolactone 25 mg [**Hospital1 **], Lasix 80 mg [**Hospital1 **], Zaroxolyn 5 mg
[**Hospital1 **], Hydralazine 50 mg tid, Imdur 60 mg q h.s., Digoxin 0.125
mg q d, Carvedilol 25 mg [**Hospital1 **], Colchicine 0.6 mg [**Hospital1 **], Lescol
30 mg q d, Protonix 20 mg q d and Mag Oxide 400 mg [**Hospital1 **].
REVIEW OF SYSTEMS: Positive for shortness of breath,
anorexia over the past two days prior to admission. He
denied chest pain, headache, nausea, vomiting, diarrhea,
fever, chills, numbness.
PHYSICAL EXAMINATION: On admission he was afebrile with
blood pressure of 102/48, pulse 64, respirations 18 to 20.
He appeared comfortable, with no distress. HEENT: Pupils
are equal, round, and reactive to light, bilateral ptosis
which is noted to be longstanding. Neck, positive JVD but no
carotid bruits. Cardiac, S1 and S2, normal with a [**3-14**]
holosystolic murmur at the apex and a 1-2/6 diastolic murmur
at the left lower sternal border. No gallops. Lungs were
clear to auscultation. Abdomen soft, nontender, non
distended with active bowel sounds. Extremities, positive
for edema, positive pedal pulses. Neuro exam, normal motor
exam, 1+ DTRs bilaterally and [**Name2 (NI) 14451**] toes.
LABORATORY DATA: On admission were notable for hematocrit
approximately 32.4, potassium approximately 3.2 and T3 of 35
with TSH of 1.3. Dig level 1.8. Echocardiogram done on [**9-19**]
revealed an EF of 15% with marked left atrial enlargement and
right atrial enlargement with patent foramen ovale, left
ventricular dilatation and 2+ aortic regurgitation, moderate
to severe mitral regurgitation, no major changes since the
echocardiogram done in [**2102-5-7**].
HOSPITAL COURSE: The patient was admitted to the C-Med
service and then transferred from the C-Med service to the
CCU on [**9-20**] for invasive hemodynamic monitoring and
optimization of his cardiovascular status. He had a
transesophageal echocardiogram and subsequent unsuccessful
cardioversion, was started on Amiodarone with plan to
reattempt cardioversion in [**5-12**] weeks. The decision was made
to delay biventricular pacing at that time given his atrial
fibrillation and suboptimal hemodynamics. Instead he was
brought to the CCU for invasive hemodynamic monitoring with
Milrinone therapy.
Throughout his hospital course, as far as his pump function
was concerned, he was put on a Milrinone drip which was
increased to 5 mcg/minute and successfully increased his
cardiac output and cardiac index in the [**6-11**] and 2-3 range.
He was able to then be given Lasix intravenously and often
Diuril followed by Lasix with successful diuresis and lost
approximately 2 liters per day while he was on the Milrinone
drip. He was then switched to Captopril and his Coreg was
started as well as low dose Digoxin. His Captopril was
increased to a max dose of 100 mg tid and then it was changed
to Mavik 4 mg po for once a day dosing. His cardiac function
remained stable, however, he became dry last few days of
admission with decreased po intake and continued po diuresis
with Lasix and his Lasix dose was held on [**2102-9-19**] and po
intake was encouraged to keep him euvolemic. As far as his
coronaries were concerned, he remained AV paced for most of
his stay in CCU with his DDD pacemaker. He was switched to
Amiodarone po 400 mg q d and was given Heparin until the date
of discharge at which point his Coumadin became therapeutic
and that was stopped.
Pulmonary wise he had severe pulmonary edema on admission and
had an oxygen requirement, however, this improved markedly
with his diuresis and over the last few days of his hospital
course he had no oxygen requirement whatsoever, was satting
well on room air.
Renal, his BUN and creatinine decreased to 1.9 creatinine and
this later increased after being transferred from the unit up
to 2.7, most likely secondary to dehydration and
intravascular depletion. However, remained stable on
discharge with move towards euvolemic status.
GI, he had occasional bouts of loose bowel movements.
Because of this his Reglan was held at times. He continued
to have poor po intake and for this reason a swallowing study
was done which revealed no abnormalities in swallowing except
for some poor chewing and suggestion was made for soft diet
with lots of fluid supplement.
As far as his gout was concerned he was treated initially
with Probenecid and Colchicine. The Probenecid was stopped
because of his renal function. Colchicine was continued for
treatment of his gout.
Other issues: Insomnia, he was given Trazodone because
Ambien was ineffective in inducing sleep in this patient.
The patient was started on Effexor because of depression and
was seen by physical therapy and case management because of
decreased strength compared to his baseline. Plan was made
for transfer to rehab facility.
DISCHARGE STATUS: Stable.
DISCHARGE PLAN: Transfer to [**Hospital **] Rehab Facility on [**2102-9-30**]
on the following medications: Amiodarone 400 mg po q d,
Lipitor 20 mg po q d, Mag Oxide, Vitamin E, K-Dur, Iron
Sulfate, Reglan, Coreg 3.125 mg po bid, Digoxin 0.0625 mg po
q d, Lasix 80 mg po bid, Colchicine, Zaroxolyn 2.5 mg three
times a week, Effexor, Metamucil, Mavik 4 mg po q d, and
Coumadin 2.5 mg po q d. His attending will be contact[**Name (NI) **] and
he will have follow-up with him and his primary care
physician.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Name8 (MD) 6069**]
MEDQUIST36
D: [**2102-9-29**] 16:08
T: [**2102-9-29**] 21:15
JOB#: [**Job Number 31395**]
cc:[**Hospital 33158**]
ICD9 Codes: 4254, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1187
} | Medical Text: Admission Date: [**2170-5-29**] Discharge Date: [**2170-6-11**]
Date of Birth: [**2128-3-18**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
42 y.o. female smoker with COPD, HTN, sleep apnea, CHF, and
HTN, on home O2, transferred from OSH for "possible open lung
biopsy." Patient was initially admitted to [**Hospital 882**] Hospital on
[**5-26**] with DOE, SaO2 of 67%, low-grade fevers to 100.1, and
palpitations [**1-18**] anxiety after three days of medication
non-compliance. Patient is not able to give any reason for her
non-compliance. She denies chest pain, dysuria, lower extremity
swelling or pain, or any rashes. She does report that she had a
bout of diarrhea, vomiting, and nausea lasting approximately
three weeks which ended suddenly this past Friday. She has had
a normal formed BM x 1 since then, and denies any abdominal
pain, melana, BRBPR, hemetemesis, or hematochezia. She saw her
PCP who put her on the BRAT diet but did not recommend any
further work-up. She denies any recent travel, sick contacts,
or changes in her routine.
.
At the OSH pt became hypoxic on the floor, unable to maintain
her sats even on 100% by NRB so she was transferred to the ICU.
She was started on BiPAP with significant improvement in her
oxygenation and treated with solumedrol 80 mg IV. She was found
to have a RLL infiltrate concerning for PNA and she was started
on Levaquin. She had a chest CT with significant new findings
as described below and was transferred to [**Hospital1 18**] for further
work-up and management.
Past Medical History:
Asthma: h/o multiple hospitalizations and intubations x1
([**2167-12-17**]) - no prednisone x 8 months [**1-18**] ?allergy, has been
getting solumedrol without difficulty
HTN
pulmonary HTN
tobacco use
sleep apnea
CHF
anxiety attacks w/palpitations
allergic rhinitis
Hypothyroidism
HTN
endometriosis, s/p hysterectomy 97
BPD/Depression
GERD
Migraines
DJD
morbid obesity
chronic lower back pain - on narcotics
osteoporosis
h/o elevated right heart pressures on angiogram performed
in [**2168-8-17**] for suspicious stress test. Clean Cs
.
Past surgical Hx:
cholecystectomy
foot surgery
shoulder surgery
s/p two c-sections
Social History:
She smokes 1.5 PPD x 25 years. Husband also smokes. No
alcohol, no IVDU. Homemaker on disability. She has three
children (22, 20, 14.) No environmental exposures.
Family History:
Father has diabetes with coronary artery disease, angina, and
hypertension. Mother, history of breast cancer and ultimately
died of lung cancer at age 61. She has a brother and fraternal
twin sister who are healthy.
Physical Exam:
VS: 83 111/64 33 95% on 15L by NRB
Gen: middle-aged obese woman in NAD
HEENT: EOMI, OP thick yellow-brown coating on tongue
Chest: coarse breath sounds throughout, harsh crackles, wheezes,
squeaks, gurgles
CVS: RRR, no m/r/g, JVD flat
Abd: soft, NT, ND, + BS, no HSM, erythema beneath pannus
Extrem: no c/c/e, + 2 DP pulses
Neuro: alert, oriented, CN II - XII grossly intact
Pertinent Results:
Relevant labs (OSH)Ddimer: 1.6
WBC: 20, left-shift
ABG (6L by NC) 7.36/51/53
ECG: SR, rate 113, normal axis & intervals, no acute ST changes
.
Relevant imaging (OSH)
CXR: no cardiomegaly, + bilateral honeycomb appearance c/w
interstitial lung disease, + RLL infiltrate, cannot rule out LLL
infiltrate
.
Chest CT ([**5-26**]): no evidence of PE; mediastinal and hilar LAD;
relatively diffuse confluent alveolar opacities throughout the
lungs BL, new since previous CT of [**4-24**]
.
Pathology review of consult slides from [**Hospital3 **] Hospital from
date wedge resection [**11-20**]: RUL with hemorrhagic infarct and RLL
with focal, acute organizing pneumonitis
Brief Hospital Course:
A/P: 42 y.o. woman with [**Hospital 2182**] transferred from OSH for unclear
reasons after presenting with COPD exacerbation in the setting
of medication non-compliance and possible PNA.
.
#Respiratory Distress/COPD: Patient was transferred from the
[**Hospital1 1562**] ICU directly to the [**Hospital Unit Name 153**]. The differential was wide.
She is not neutropenic but her chest CT is most consistent with
an infection, especially given the acute onset. Infectious
etiologies include viral (RSV, parainfluenza, influenza,
adenovirus), bacterial (mycoplasma), and less likely fungal.
Also on the differential are allergic bronchopulmonary
aspergillosis and less common interstitial pneumonias such as
acute eosinophilic pneumonia; however, preliminary CT read by
[**Hospital1 18**] radiologists seemed to indicate an alveolar process.
Studies were sent: legionella antigen (negative),
mycoplasma titer (pending), IgE level ([**2169**], high), nasal swab
for viral cx (pending), HIV (pending), and DFA for influenza
(negative.) Patient was unable to produce a specimin for sputum
culture. She was continued on Levofloxacin for likely atypical
versus viral pneumonia and treated with her usual home
medications including atrovent, singulair, and xopinex, which
was subsequently changed to albuterol without ill effect. She
was treated with steroids at the OSH, and these were continued,
initially as 80 mg solumedrol Q8H, which was then transitioned
to medrol, and the plan is to do a long, slow medrol taper over
the course of about 1 month. She remained stable on 100% by
non-rebreather and she was started on BiPap at night, which she
tolerated reasonably well. This was started to decrease her
work of breathing and because she has known sleep apnea and has
only been waiting for insurance approval before beginning home
BiPap. Her respiratory status continued to improve with
treatment and patient now has stable oxygen saturations on 4L by
NC. After review of her case at pulmonary conference it was
decided that a biopsy after several weeks on steroids would be
non-diagnostic, therefore the decision was to keep her on a slow
steroid taper and if she recurrs biopsy her at that time. She
will go home on 2 weeks of 48 mg medrol, and taper by 6 mg every
week for a total of 7 more weeks of steroids. She will follow up
with her regular pulmonologist, Dr. [**Last Name (STitle) 47851**], of [**Hospital 1562**]
hospital, and arrange to have PFTs in [**Month (only) 205**]. She will then follow
up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] here at [**Hospital1 **] [**2170-7-3**] in clinic. If she
develops recurrent disease/symptoms she will likely need a
biopsy at that time.
.
#HTN: Currently normotensive; held cardizem while an inpatient,
and was never hypertensive. Follow up with PCP regarding
restarting this medication.
.
#Elevated blood glucose: Does not currently carry a diagnosis of
diabetes but had some notably high sugars at OSH; HgA1C was 5.7.
While in [**Hospital Unit Name 153**], patient was covered with a regular insulin
sliding scale. She was sent home on a sliding scale regular
insulin. She likely will not need this when she comes off
steroids.
.
#Anxiety: cont ativan TID PRN
.
#BPD/Depression: stable, cont abilify, effexor, lamictal
.
#Hypothyroidism: stable
- cont levothyroxine
.
#Migraines: stable, cont imitrex PRN
.
#lower back pain: stable; cont ultram
.
#FEN: Cardiac diet; replete lytes PRN
.
#PPX: Heparin SQ TID, PPI, pneumoboots
.
#ACCESS: PIV
.
#COMM: patient; husband
.
#CODE: FULL - confirmed with patient.
.
#DISPO: ICU
Medications on Admission:
Meds at Home:
Aciphex 20 QD
Lasix 80 PO QD
Zyflo 600 TID
Abilify 5 QD
Imitrex injection 6 mg p.r.n.
Loratidine 10 QHS
Singulair 10 mg h.s.
Effexor XR 112 mg p.o. QD
Lamictal 150 mg QD
Levoxyl 100 mcg QD
Potassium 10 mEQ QD
Actonel 35 Q Sunday
Oxycodone 10 mg Q6H
Ativan 1 mg t.i.d.
Xolair 375 Q 2 weeks
Atrovent QID and Q2H PRN sob
Xopenex QID
oxygen 3 liters h.s. and p.r.n. (about [**1-19**] x per day)
.
Meds on Xfer:
Aciphex 20 QD
Lasix 80 PO QD
Zyflo 600 TID
Abilify 5 QD
Imitrex injection 6 mg p.r.n.
Loratidine 10 QHS
Singulair 10 mg h.s.
Effexor XR 112 mg p.o. QD
Lamictal 150 mg QD
Levoxyl 100 mcg QD
Potassium 10 mEQ QD
Actonel 35 Q Sunday
Oxycodone 10 mg Q6H
Ativan 1 mg t.i.d.
Xolair 375 Q 2 weeks
Atrovent QID and Q2H PRN sob
Xopenex QID
oxygen 2 liters h.s. and p.r.n.
Discharge Medications:
1. One Touch UltraSoft Lancets Misc Sig: qs 1 month Miscell.
four times a day: Please give lancets qs 1 month.
Disp:*qs 1 month* Refills:*3*
2. One Touch Ultra Test Strip Sig: One (1) strip Miscell.
four times a day: qs 1 month.
Disp:*qs 1 month* Refills:*3*
3. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale
sliding scale Injection four times a day.
Disp:*qs 1 month* Refills:*3*
4. Aripiprazole 10 mg Tablet Sig: 0.5 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).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Sumatriptan Succinate 6 mg/0.5 mL Solution Sig: Six (6) mg
Subcutaneous X1 (ONE TIME) as needed for migraines.
7. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
9. Lamotrigine 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
10. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Risedronate 35 mg Tablet Sig: One (1) Tablet PO Q sunday ().
12. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Disp:*qs 1 month* Refills:*3*
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
16. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
Disp:*qs 1 month* Refills:*2*
17. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*qs 1 month* Refills:*0*
18. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
Disp:*qs 2 weeks* Refills:*0*
19. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
Disp:*qs 2 weeks* Refills:*3*
20. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours): Can also take prn q2h as needed.
Disp:*qs 1 month* Refills:*2*
21. Venlafaxine 37.5 mg Capsule, Sust. Release 24HR Sig: Three
(3) Capsule, Sust. Release 24HR PO DAILY (Daily).
22. Methylprednisolone 8 mg Tablet Sig: Six (6) Tablet PO DAILY
(Daily) for 7 weeks: Take 6 tabs daily for the next 2 weeks,
then take 5 tabs daily for 1 week, then take 4 tabs daily for
one week, then take 3 tabs daily for one week, then take 2 tabs
daily for one week, then 1 tab daily for one week, then stop.
Disp:*189 tablets* Refills:*0*
23. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
Disp:*90 Tablet(s)* Refills:*2*
24. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
25. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
26. CALCIUM 500+D 500-400 mg-unit Tablet, Chewable Sig: One (1)
Tablet, Chewable PO twice a day: Please take at least 3 hours
apart from your levothyroxine.
Disp:*60 Tablet, Chewable(s)* Refills:*2*
27. Insulin Syringe [**12-18**] mL 29 x [**12-18**] Syringe Sig: One (1)
syringe Miscell. four times a day.
Disp:*qs 1 month* Refills:*3*
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Interstitial Lung Disease NOS
Chronic Obstructive Lung Disease
Asthma
Pneumonia
Discharge Condition:
stable, satting well on 4L NC
Discharge Instructions:
Please continue using your oxygen at 4-5L NC continuous. Please
continue your solumedrol dose for another 2 weeks at the current
dose and begin to taper by one pill each subsequent week. If you
feel that your breathing worsens while tapering this please call
your PCP or Dr. [**Last Name (STitle) **]. Follow up with your pulmonologist and
PCP. [**Name10 (NameIs) 357**] also weigh yourself daily and call your PCP if you
gain more than 3 lbs. Please also quit smoking.
Followup Instructions:
1. Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], your new
pulmonologist, on [**8-3**] at 11:30 am, please arrive at 11:10
for your breathing tests before your appointment. Located in
[**Last Name (un) 469**] Building [**Location (un) 436**]. You can call [**Telephone/Fax (1) 612**] if you
have questions/concerns.
2. Please follow up with your PCP in the next week.
3. Please also follow up with your regular pulmonologist, Dr.
[**Last Name (STitle) 47851**], and arrange to have pulmonary function tests done with
him in [**Month (only) 205**]. Please bring the results of these to your visit
with Dr. [**Last Name (STitle) **].
ICD9 Codes: 4280, 486, 4019, 4168, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1188
} | Medical Text: Admission Date: [**2180-4-1**] Discharge Date: [**2180-4-7**]
Service: [**Hospital1 212**]
CHIEF COMPLAINT: Back pain.
HISTORY OF PRESENT ILLNESS: A [**Age over 90 **]-year-old female with a
history of myocardial infarction, hypertension, and
congestive heart failure who was in her usual state of health
until the evening of admission when she developed sudden
severe back pain. She states that the pain came as spasms
radiating once to her left arm. She has had this back pain
in the past, but nothing as severe as this episode. She
denies any strain or lifting. She denies chest pain,
shortness of breath, pleuritic pain, fevers, chills, cough,
diaphoresis, nausea, vomiting, or palpitations.
She has had a history of a myocardial infarction
approximately 10 years ago, and her symptoms then did not
resemble her current symptoms. She reported to [**Hospital3 **], and a chest CT scan was performed which was read as
having a small dissection in her descending abdominal aorta.
She was started on nitroglycerin and responded well. She was
transferred to [**Hospital1 69**] for
further management.
In the Emergency Department, she received 10 mg of
intravenous labetalol, and her vital signs were stable. She
continues to have intense back pain on arrival, but otherwise
is asymptomatic.
PAST MEDICAL HISTORY:
1. Chronic urinary tract infections of unclear etiology.
2. Pyelonephritis.
3. Splenomegaly.
4. Hypertension.
5. Congestive heart failure.
6. Diarrhea.
7. Urinary retention.
8. Hypokalemia.
9. Anemia.
10. Hemorrhoids.
11. Diverticulosis.
12. Achilles tendinitis.
13. History of intestinal obstruction.
14. Coronary artery disease status post myocardial infarction
in [**2169**].
MEDICATIONS ON ADMISSION:
1. Procardia XL 60 mg po q day.
2. Zestril 40 mg po q day.
3. Imdur 60 mg po q day.
4. Potassium chloride 20 mg po q day.
5. Aspirin 81 mg po q day.
6. Dyazide 1 tablet q day.
7. Sublingual nitroglycerin prn.
8. Iron.
9. Magnesium.
ALLERGIES: Sulfa and Celecoxib.
SOCIAL HISTORY: The patient denies any tobacco, no alcohol,
and she lives alone.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Temperature is 99.3, blood pressure
95/38, heart rate of 84, respiratory rate of 18, and 98% on
room air. In general, this patient has paroxysmal episodes
of intense back pain. HEENT: Pupils are equal, round, and
reactive to light. Extraocular muscles are intact. Mucous
membranes dry. Neck reveals no jugular venous distention.
Lung examination had bibasilar crackles and diffuse
expiratory wheezes. Cardiovascular examination: Regular,
rate, and rhythm, [**4-6**] holosystolic murmur radiating
throughout her thorax. Her abdomen is soft, nontender,
nondistended and normoactive bowel sounds. Back: No spinal
or paraspinal tenderness. Extremities: [**2-3**]+ pitting edema
right greater than left. No calf tenderness. Neurologic is
alert and oriented times three.
LABORATORY DATA: White count 5.6, 76% neutrophils, 21%
bands, 2% lymphocytes. Hematocrit 30.9, platelets 204.
Chem-7: Sodium 142, potassium 2.8, chloride 112, CO2 19, BUN
33, and creatinine of 1.2. CK of 31, troponin of less than
0.3.
Electrocardiogram revealed sinus arrhythmia at 82 beats per
minute and a left bundle branch block that is old.
Chest x-ray reveals congestive heart failure with mild
pulmonary edema, bilateral small pleural effusions, and
underlying consolidation in the right lower lobe.
A CTA of the chest was performed which revealed no evidence
of aortic dissection and bilateral pleural effusions,
bilateral atelectasis with near total collapse of the left
lower lobe and an atrophic left kidney.
HOSPITAL COURSE:
1. Aortic dissection/left lower lobe pneumonia: The patient
was admitted directly to the Medical Intensive Care Unit for
close observation for aortic dissection. However, based on
her CT scan of her chest, it was determined that there was no
evidence of aortic dissection and rather her back pain was
due to a left lower lobe pneumonia. She was started on
levofloxacin 250 mg po q day for a 14 day course. She was
transferred out of the Medical Intensive Care Unit the
following hospital day and transferred to the floor. Her
oxygenation requirements continued to improve throughout her
hospital course, and clinically she remained afebrile and
continued to improve while on levofloxacin.
2. Coronary ischemia/CHF: The patient was noted to have a
mild troponin leak at admission with a troponin level of 1.5.
Her CK enzymes, however, remained flat under 100. Her
troponin levels rose to a peak of 4.3 on hospital day #3. A
Cardiology consult was obtained for further evaluation of her
troponin leak as well as possible cardiac catheterization.
She was placed on a Heparin drip for approximately 48 hours.
After reviewing the case, Cardiology recommended cardiac
catheterization, however, the patient declined this
intervention at this time. A cardiac stress test was also
recommended, but based on the patient's codiagnosis of
pneumonia, it was felt that her stress test would be
suboptimal and should be pursued as an outpatient should she
decide to pursue invasive procedures such as cardiac
catheterization in the future.
It was felt that her troponin leak was secondary to increased
demand secondary to a pulmonic process as well as being in
mild congestive heart failure. She was diuresed gently with
Lasix intravenously 40 mg with optimal results and her blood
pressure medications were optimized upon discharge.
A transthoracic echocardiogram was performed which revealed
an ejection fraction of 20-25%, mildly dilated left atrium,
severe global left ventricular hypokinesis as well as
moderate-to-severe aortic stenosis with a peak velocity of
4.2 meters/second and a valve area of 0.8. There was also
moderate-to-severe mitral regurgitation and no evidence of
aortic dissection. Again it is unclear whether the patient
wanted to pursue invasive procedures such as possible surgery
and cardiac catheterization, regardless, she will follow up
with her primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5057**] for
further evaluation and possible outpatient stress test.
Conjunctivitis: The patient was noted to have increased
purulent discharge coming from both eyes as well as an
inflamed sclerae and conjunctiva. She was started on
erythromycin ointment for a total of seven days with marked
clinical improvement.
DISCHARGE DIAGNOSES:
1. Community acquired pneumonia.
2. Congestive heart failure.
3. Coronary artery disease.
4. Aortic stenosis.
5. Hypertension.
6. Chronic urinary tract infections.
7. Conjunctivitis.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home with VNA services and home
Physical Therapy.
DISCHARGE MEDICATIONS:
1. Aspirin 81 mg po q day.
2. Lisinopril 40 mg po q day.
3. Lipitor 10 mg po q day.
4. Lopressor 25 mg po bid.
5. Levofloxacin 250 mg po q day x7 days.
6. Erythromycin ointment one ribbon in each eye twice a day
for a total of five days.
[**Doctor Last Name **] [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 5712**]
Dictated By:[**Name8 (MD) 5406**]
MEDQUIST36
D: [**2180-4-7**] 10:21
T: [**2180-4-7**] 10:28
JOB#: [**Job Number 49821**]
ICD9 Codes: 486, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1189
} | Medical Text: Admission Date: [**2188-6-10**] Discharge Date: [**2188-6-17**]
Date of Birth: [**2123-7-19**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: This 64 year old female has a
history of chronic myelogenous leukemia and had three to four
day history of chest pain with shortness of breath. An
echocardiogram revealed severe aortic stenosis with an aortic
valve area of 0.6 centimeter squared and an ejection fraction
of 40 to 50 percent. She underwent cardiac catheterization
which revealed normal coronaries and confirmed her severe
aortic stenosis. She is now admitted for aortic valve
replacement.
PAST MEDICAL HISTORY: History of chronic myelogenous
leukemia.
History of hypertension.
History of gastroesophageal reflux disease.
History of hiatal hernia.
Status post cerebrovascular accident times two.
History of insulin dependent diabetes mellitus.
Status post total thyroidectomy.
History of hypothyroidism.
Status post total abdominal hysterectomy.
Status post cholecystectomy.
Status post benign breast mass excision times two.
MEDICATIONS ON ADMISSION:
1. Synthroid 125 mcg p.o. once daily.
2. Allopurinol 100 mg p.o. once daily.
3. Lopressor 75 mg p.o. twice a day.
4. Carafate two tablespoons four times a day p.o.
5. Nexium 40 mg p.o. once daily.
6. Zyrtec 10 mg p.o. once daily.
7. Captopril combined with Hydrochlorothiazide 50/15 p.o.
once daily.
8. Lantus 6 units subcutaneously q.h.s.
9. Multivitamin one p.o. once daily.
10. Vitamin D 50,000 units subcutaneously q.Wednesday
and Sunday.
11. Magnesium Oxide 64 mg p.o. once daily.
12. Danazol 200 mg p.o. q.h.s.
13. Hydroxyurea 1000 mg p.o. q.Monday, Wednesday and
Friday and 500 mg p.o. q.Saturday, Sunday, Tuesday and
Thursday.
14. Prednisone 5 mg p.o. q.a.m. and 7.5 mg p.o. q.h.s.
ALLERGIES: She is allergic to Codeine, Aspirin and Plavix.
SOCIAL HISTORY: She does not smoke cigarettes and does not
drink alcohol. She lives with her husband.
FAMILY HISTORY: Significant for coronary artery disease.
REVIEW OF SYMPTOMS: Unremarkable.
PHYSICAL EXAMINATION: On physical examination, she is a well-
developed, well-nourished white female in no apparent
distress. Vital signs are stable and afebrile. Head, eyes,
ears, nose and throat examination is normocephalic and
atraumatic. Extraocular movements are intact. The
oropharynx is benign. The neck was supple with full range of
motion, no lymphadenopathy or thyromegaly, carotids two plus
and equal bilaterally without bruits. The lungs are clear to
auscultation and percussion. Cardiovascular examination -
regular rate and rhythm, with a III/VI holosystolic murmur
best heard at the apex. The abdomen was soft, obese,
nontender, nondistended with positive bowel sounds, no
masses, hepatosplenomegaly. Extremities had two plus
bilateral pitting pedal edema. Pulses were one plus and
equal bilaterally throughout. Neurologic examination was
nonfocal.
HOSPITAL COURSE: On [**2188-6-10**], she underwent an aortic valve
replacement with a number 21 mosaic porcine [**Company 1543**] valve,
cross-plant time was 78 minutes, total bypass time 108
minutes. She was transferred to the CSRU in stable condition
on Neo-Synephrine and Propofol. She was extubated her
postoperative night. Postoperative day number one, she had
her chest tubes discontinued. She was followed by her
hematologist while she was here. She was restarted on her
preoperative medications. On postoperative day number two,
she was transferred to the floor in stable condition. She
had her epicardial pacing wires discontinued. She continued
to have a stable postoperative course. She did have some
postoperative atrial fibrillation. She was started on
Lopressor and Amiodarone and then she was anticoagulated with
Heparin and Coumadin. On postoperative day number seven, she
was discharged to home in stable condition. She was also
discharged on Levofloxacin for cold symptoms that she usually
treats with antibiotics. Her laboratories on discharge were
white blood cell count 9.2, hematocrit 36.1, hemoglobin 11.2,
platelet count 124,000. Sodium 139, potassium 3.8, chloride
98, CO2 30, blood urea nitrogen 13, creatinine 0.9, blood
sugar 100. Prothrombin time 21.3, INR 3.0.
MEDICATIONS ON DISCHARGE:
1. Lopressor 25 mg p.o. twice a day.
2. Lasix 40 mg p.o. twice a day for seven days.
3. Potassium 20 mEq p.o. twice a day for seven days.
4. Colace 100 mg p.o. twice a day.
5. Percocet one to two tablets p.o. q4-6hours p.r.n. pain.
6. Nexium 40 mg p.o. once daily.
7. Amiodarone 400 mg p.o. twice a day for seven days and then
decrease to 400 mg p.o. once daily for seven days and then
down to 200 mg p.o. once daily.
8. Vitamin D 50,000 units subcutaneously q.Wednesday and
Sunday.
9. Hydroxyurea 1000 mg p.o. q.Monday and Friday and 500 mg
p.o. q.Saturday, Sunday, Tuesday, Wednesday and Thursday.
10. Allopurinol 100 mg p.o. once daily.
11. Danazol 200 mg p.o. once daily.
12. Levoxyl 125 mcg p.o. once daily.
13. Prednisone 7.5 mg p.o. q.a.m. and 5 mg p.o. q.p.m.
14. Levofloxacin 500 mg p.o. q24hours for seven days.
15. Lantus 6 units subcutaneously q.p.m.
16. Coumadin hold tonight and then 1 mg on [**2188-6-18**], and
it will be titrated by Dr. [**Last Name (STitle) **].
DISCHARGE DIAGNOSES: Aortic stenosis.
Chronic myelogenous leukemia.
Hypertension.
Gastroesophageal reflux disease.
Hiatal hernia.
Postoperative atrial fibrillation.
Insulin dependent diabetes mellitus.
Hypothyroidism.
FOLLOW UP: She will be followed in two weeks by Dr. [**Last Name (STitle) **]
and in six weeks by Dr. [**Last Name (STitle) 70**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) 18588**]
MEDQUIST36
D: [**2188-6-17**] 15:43:59
T: [**2188-6-17**] 19:22:58
Job#: [**Job Number 48687**]
ICD9 Codes: 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1190
} | Medical Text: Admission Date: [**2142-2-10**] Discharge Date: [**2142-2-14**]
Date of Birth: [**2092-11-24**] Sex: F
Service: [**Company 191**] Medicine
HISTORY OF PRESENT ILLNESS: (Per admitting ICU house staff):
[**First Name8 (NamePattern2) **] [**Known lastname **] is a 49-year-old woman with a past medical history
significant for diabetes mellitus type 1 with triopathy, as
well as history of DKA, end stage renal disease, CAD, and
CABG, who presented with loose bowel movements and abdominal
discomfort from her nursing home. The patient was dialyzed
on the Friday before presentation and reported that
approximately 8 lbs had been dialyzed off of her. The
history from the patient was limited by her sleepiness
(although she was arousable); the patient was responsive to
questions when prompted repeatedly. According to records,
the patient had eaten a tuna [**Location (un) 6002**] during her above noted
dialysis session and had felt "bad" afterwards, with
increased abdominal discomfort, loose stools. The patient
denied history of blood or mucus in her stools. She also
denied history of fevers, chills, cough, shortness of breath,
chest pain.
PAST MEDICAL HISTORY: 1) Diabetes mellitus type 1:
Complicated by neuropathy, retinopathy, blindness; end stage
renal disease. 2) End stage renal disease, status post
failed renal transplant ([**2126**]); on hemodialysis three times a
week; left AV fistula placed in [**2140-3-28**]. 3) Coronary artery
disease: Status post CABG ([**2132**]); status post MI in [**9-28**],
status post cardiac catheterization in [**11-28**], which revealed
three vessel disease, with patent LIMA to LAD. 4) Systolic
dysfunction: Echocardiogram in [**9-28**] revealed left
ventricular ejection fraction of 20-30% with 3+ MR, 1+ TR,
mild pulmonary hypertension, and global hypokinesis. 5) Left
bundle branch block. 6) Squamous cell carcinoma. 7)
Hepatitis C: Diagnosed in [**2-26**]. 8) MRSA bacteremia
(attributed to fistula in [**9-28**]). 9) VRE in urine. 10)
Acute on chronic cholecystitis diagnosed [**10-28**]; no
cholecystectomy was performed. 11) Peripheral vascular
disease, status post left femoral tibial bypass. 12)
Hypercholesterolemia.
ALLERGIES: Demerol, ? IV Ciprofloxacin, ? Ambien (as of this
current admission).
MEDICATIONS: Outpatient medications: Vicodin, Compazine,
Neurontin, Insulin, Nepro, Prevacid, Celexa, Nephrocaps.
SOCIAL HISTORY: The patient is a disabled nurse. She lives
in a skilled nursing facility. She denied any history of
tobacco or alcohol use.
HOSPITAL COURSE: [**First Name8 (NamePattern2) **] [**Known lastname **] was admitted to the ICU from her
skilled nursing facility on [**2142-2-10**] with diabetic
ketoacidosis; also she subsequently ruled in for a non Q wave
MI.
To summarize, the patient presented with an approximate 24
hour history of gastroenteritis which included diarrhea; the
patient was somewhat somnolent though arousable on arrival.
Her anion gap on presentation was 27 and subsequently closed
to 25 and then 20 shortly after arrival. The patient's
troponin was 9.4 on arrival and rose to a peak of 13.8 before
trending downward. The patient's CKs were negative, although
MB index was 12.7. The patient's glucose was 699 on arrival.
The patient was treated with IV fluid and an insulin drip,
and subsequently her anion gap closed within approximately 24
hours; thereafter, the patient's outpatient insulin regimen
was resumed and her fingerstick blood sugars remained for the
most part stable (although on occasion, the patient did
refuse to take her insulin). The patient was able to advance
her diet without difficulty.
Regarding the patient's non Q wave MI, the cardiology service
was consulted. Cardiology staff felt that the patient would
benefit most from medical management; thus the patient was
maintained on Aspirin and Lopressor. For a brief period, the
patient was on a Heparin drip which was subsequently
discontinued once her enzymes were convincingly trending
downward, and she remained without chest pain. (It should be
noted that the patient remained chest pain free during her
hospitalization).
The patient's ICU course was, for the most part, uneventful.
She did exhibit some mild hypotension; and chest x-ray on
[**2142-2-11**] at 2 p.m. revealed some new CHF as well as some small
bilateral pleural effusions. The patient was eventually felt
to be somewhat fluid overloaded, and thus she had
approximately 5 kg of fluid removed at dialysis on [**2142-2-14**],
with much improvement and feeling bloated.
Also of note, the patient was given Ambien on one evening, to
help her sleep; the next morning the patient was somewhat
confused on awakening and this was attributed to her having
taken Ambien.
On [**2142-2-12**] the patient was transferred from the ICU to the
medicine floor. Thereafter the patient's course remained
fairly stable. Her insulin regimen was maintained, although,
as noted above, the patient did on occasion refuse to take
her insulin. It should also be noted that the patient had
refused telemetry as well on transfer to the medicine floor.
Ultimately, the patient did well with hemodialysis, and her
fingersticks improved on the morning of discharge.
Of note, the patient's potassium was somewhat elevated on
[**2142-2-14**] (6.3 and then 5.6); patient's potassium will be
checked at 1 p.m. on [**2-14**] prior to discharging her to skilled
nursing facility.
Also of note, on transfer to the medicine floor a urinalysis
revealed that the patient did have significant number of
white cells in her urine; thus patient was prescribed renal
dose of Levofloxacin.
CONDITION ON DISCHARGE: Vital signs stable, afebrile, free
of chest pain and shortness of breath, anxious to be
discharged to her skilled nursing facility.
DISCHARGE DIAGNOSIS:
1. Diabetic ketoacidosis.
2. Non Q wave myocardial infarction.
3. Diabetes mellitus type 1.
4. End stage renal disease on hemodialysis three times a
week.
5. Coronary artery disease.
6. Hepatitis C.
7. Ejection fraction of 20-30%.
8. Left bundle branch block.
9. Urinary tract infection.
DISCHARGE MEDICATIONS: Levofloxacin 250 mg po q o day (next
dose to be given on [**2142-2-16**]), times four more doses, Heparin
5,000 units subcu [**Hospital1 **], Protonix 40 mg po q day, enteric
coated Aspirin 325 mg po q day, Lopressor 25 mg po bid,
Reglan 5 mg po before meals and q h.s., Pravachol 10 mg po q
day, Percocet 1-2 tabs (5/325 mg strength) po q 6 hours prn,
Benadryl 25 mg po q h.s. prn for insomnia, NPH insulin 10
units subcu q a.m. and 4 units subcu q p.m., Regular insulin
4 units subcu q a.m. and 2 units subcu q p.m. Regular
insulin sliding scale for qid fingersticks, as follows: for
fingerstick of 201-250 give 2 units regular insulin subcu,
for fingerstick 251-300 given 4 units regular insulin subcu,
for 301-350 given 6 units regular insulin subcu, for 351-400
give 8 units regular insulin subcu, for greater than 400 give
fingerstick less than 60, give [**Location (un) 2452**] juice and/or one amp of
D50, and notify M.D.
DISCHARGE DIET: The patient should be maintained on a renal
diet, a well as [**First Name8 (NamePattern2) **] [**Doctor First Name **] and low sodium diet, also, it is
important that the patient remain fluid restricted to one
liter of fluid per day.
FOLLOW-UP: The patient is to continue follow-up at dialysis
three times per week. Also, the patient is to follow-up with
her cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], on [**2142-2-21**] at 9:20 a.m.
Dr. [**Last Name (STitle) **] may decide to adjust the patient's cardiac regimen
further. Also, ultimately, the patient may benefit from
cardiac rehabilitation.
DR.[**First Name (STitle) **],[**First Name3 (LF) 251**] 11-692
Dictated By:[**Last Name (NamePattern1) 1550**]
MEDQUIST36
D: [**2142-2-14**] 13:36
T: [**2142-2-14**] 13:45
JOB#: [**Job Number **]
ICD9 Codes: 5990, 2765, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1191
} | Medical Text: Admission Date: [**2150-12-29**] Discharge Date: [**2151-2-13**]
Date of Birth: Sex:
Service:
PREOPERATIVE DIAGNOSIS: Esophageal perforation.
POSTOPERATIVE DIAGNOSIS: Esophageal perforation.
OPERATIONS:
1. Left thoracotomy, repair of esophagus with intercostal
muscle flap [**2150-12-29**].
2. Thoracentesis, right chest, [**2151-1-7**].
3. Bronchoscopy [**2151-1-12**].
4. Tracheostomy, bronchoalveolar lavage, open jejunostomy
tube placement [**2151-1-13**].
HISTORY OF PRESENT ILLNESS: The patient is an 87-year-old
female who presented to an outside hospital with fever and
abdominal pain. On CT scan, the patient was found to have
evidence of esophageal perforation. She was transferred to
our hospital for care.
HOSPITAL COURSE: The patient, upon arrival to the hospital,
had a left thoracotomy and repair of her esophagus. There was
seen to be a large size hole in the distal aspect of her
esophagus. Given the amount of necrosis and the amount of
fibrinous exudate and debris in the left chest, it was felt
that the perforation had occurred some time ago. The patient
had some debridement and buttressing of the esophageal repair
site with intercostal muscle flap.
The patient was sent to the intensive care unit. She had a
prolonged and difficult postoperative course. Attempts at
extubation were made several times; however, the patient was
unable to remain extubated for prolonged periods and required
reintubation each time.
X-rays and CT scans of the chest showed that the patient had
developing pleural effusions, especially on the right side.
The left side seemed to be fairly well evacuated with the
chest tubes which were in place. She needed a right
thoracentesis performed on [**2151-1-7**] under ultrasound
guidance. This returned a fair amount of serosanguineous
fluid. A bronchoscopy performed approximately 5 days later
showed that the patient had significant copious secretions,
and it was thought that she would not be a good candidate for
extubation. Given the copious secretions and the numerous
failed extubations previously, the patient underwent a
tracheostomy and open jejunostomy tube on [**2151-1-13**].
The patient's pleural fluid on several occasions grew out
Enterococcus. Eventually, the speciation came back as
vancomycin resistant enterococcus. The patient's white count
had risen to 34,000 and remained elevated for several days.
Upon beginning linezolid, however, the patient's white count
began to decrease. Approximately 10 days after the linezolid
was begun, the white count went down to normal.
The patient had a continued difficult postoperative course.
She continued to have copious secretions from her
tracheostomy site and required suctioning several times a
day. Her cultures intermittently grew enterococcus but her
white count did stay down with the antibiotic regimen that
she was on.
Eventually, the patient had all other systems resolved except
for her kidneys. She stopped making any urine and had
increasingly rising creatinine. The patient had been on
intermittent and continuous hemodialysis. After discussion
with the family, it was thought that the patient would need
lifetime dialysis for supplementation of her kidneys. Given
the fact that the patient had requested not to be on chronic
support such as chronic dialysis, and after discussion with
the family, it was decided to withdraw support. Support was
withdrawn, and the patient expired approximately 48 hours
thereafter. The family was present at the bedside for this.
[**Name6 (MD) 4667**] [**Name8 (MD) **], M.D. [**MD Number(2) 39921**]
Dictated By:[**Name8 (MD) 67551**]
MEDQUIST36
D: [**2151-10-18**] 15:56:43
T: [**2151-10-18**] 22:56:17
Job#: [**Job Number 71100**]
ICD9 Codes: 0389, 5119, 5180, 5845, 2761, 4280, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1192
} | Medical Text: Admission Date: [**2134-4-6**] Discharge Date: [**2134-6-4**]
Date of Birth: [**2071-1-2**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal pain, nausea and vomiting
Major Surgical or Invasive Procedure:
Thoracentesis
Sub-clavian central line placement
Intubation
R radial Arterial line placement
History of Present Illness:
HPI:
The patient is a 63 yoF w/ h/o Type II DM, HTN presents from OSH
w/ abd pain, N/V/D. Her symptoms started w/ nausea while eating
dinner at ~ 8 p.m, associated w/ diaphoresis. She vomited
several times(non-bilious, non-bloody) then developed severe,
constant diffuse abdominal pain, radiating to back. She then
developed diarrhea, ~ 5 episodes loose, no BRBPR or melena. She
presented to [**Hospital3 **] where an Abd CT c/w acute
pancreatitis w/ lipase >80K and amylase 789. No recent travel,
no recent viral illnesses/URI symptoms. No h/o prior similar
symptoms; no h/o GB disease
*
In ED T 98.2, HR 99, bp 160/96. resp 20, 94% 2L.
Past Medical History:
PMHx
1) HTN
2) Type II DM: controlled w/ diet and exercise
3) Rosacea
4) s/p tonsillectomy
5) TAH: for cervical cancer
Social History:
SHx: Lives alone, no tobacco use, (+) EtOH (2 glasses of wine
several times a week), no other drug use. Works/volunteers w/
homeless. Has two sons [**Name (NI) 449**] and [**Name (NI) **] who are both very
involved in her care.
Family History:
FHx: uterine/cervical cancer on Father's side, breast cancer on
mother's side. F MI [**84**] yrs
Physical Exam:
T 98.2, HR 99, bp 160/96. resp 20, 94% 2L.
Gen: Pleasant obese female laying in bed. NAD
HEENT: no icterus
JVP: not elevated
CV: tachycardic, nml S1,S2 no m/r/g
Lungs: Bibasilar crackles
Abdomen: decreased bowel sounds. equisite diffuse tenderness
with rebound present.
Extremities: 2+ DPP with no edema
Neuro: A&O x 3. pleasant conversant, able to obey commands,
appropriate.
Pertinent Results:
*
Brief Hospital Course:
As above, Ms [**Known lastname 60613**] presented to [**Hospital1 18**] on [**4-6**] from OSH for
evaluation/treatment of severe acute pancreatitis of unknown
etiology. It was evident that she was quite sick, and she was
admitted to the ICU for close monitoring. Aggressive fluid
resuscitation was intiated as central and arterial lines were
placed. She began to experience respiratory distress and
required intubation with ventilatory support. A post-pyloric
feeding tube was placed and she was started on tubefeeds. TPN
was initiated, as well. CT demonstrated severe necrotizing
pancreatitis, in addition to multiple pulmonary nodules
worrrisome for metastatic disease. She was started on imipenem
for prolphylaxis to prevent infected necrotizing pancreatitis.
Ms. [**Known lastname 60613**] remained in the ICU for several weeks requiring
ventilatory support, and fluid resuscitation to prevent
worsening of her pancreatitic necrosis. She experienced
frequent loosse stools and C. Diff cultures returned positive
and she was started on flagyl. Repeat CT scans revealed the
development of a giant pseudocyst. She eventually was weaned
from ventilatory support and extubated, which she tolerated
well. She developed a biliary stricture and on [**5-4**], she
[**Month/Year (2) 1834**] a PTC with internal/external biliary catheter
placement, which seemed to relieve her obstruction well. She
was eventually transferred to the floor in stable condition. On
[**2134-5-18**], Ms. [**Known lastname 60613**] [**Last Name (Titles) 1834**] open drainage of her giant
pancreatic pseudocyst with gostostomy tube placement and
jejunosotmy tube placement (see Op Note), which she tolerated
reasonably well. After recovery in the PACU, she was
transferred to the floor in stable condition. She would remain
stable post-operatively. Physical began to help her out of bed
and ambulate. It should be noted that her ability to ambulate
has progressed slowly, and she will continue to need extensive
physical therapy in rehab. Her bowel function was slow to
return and she again was started on TPN. Eventually tubefeeds
were started and advanced to goal. She began to experience fever
with a rising WBC and repeat CT revealed an abscess in the left
paracolic gutter; on [**5-27**], the abscess was subsequently drained
by IR and pigtail catheter was placed for further drainage. Ms
[**Known lastname 60613**] would continue to remain stable, and progress slowly from
this serious illness that she has suffered. She was advanced to
a regular diet, which she has tolerated well. Her tubefeed were
cycled, then stopped. She has continued to have loose stools,
but repeat C. diff cultures are negative x 3. On [**6-4**], she was
discharged to rehab in stable condition for extended care.
Medications on Admission:
Meds: no herbal medications.
1) Accupril 20 mg PO daily
2) Folic acid
3) MV1
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Elixir Sig: Six [**Age over 90 1230**]y (650)
mg PO Q4-6H (every 4 to 6 hours) as needed for fever or pain.
2. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
3. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) UNITS
Subcutaneous HS (at bedtime).
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl
Ophthalmic PRN (as needed).
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1)
ML Intravenous DAILY (Daily) as needed.
9. Dolasetron Mesylate 12.5 mg/0.625 mL Solution Sig: One (1)
Intravenous Q8H (every 8 hours) as needed.
10. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash on buttocks.
12. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
13. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every
4 to 6 hours) as needed.
14. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
15. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
16. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO
QIDACHS (4 times a day (before meals and at bedtime)).
17. Insulin Regular Human Injection
18. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
19. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
20. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
21. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Acute necrotizing pancreatitis
Giant Pancreatic pseudocyst
C. diff colitis
Biliary stricture
Discharge Condition:
Stable
Discharge Instructions:
Please return to the emergency room if you experience severe
abdominal pain, nausea vomiting, severe fever or chills, chest
pain or shortness of breath.
Followup Instructions:
Please follow up CT lung nodules with repeat scan
Follow up with Dr. [**Last Name (STitle) **] in [**2-11**] weeks after your discharge
from the hospital
ICD9 Codes: 5990, 5119, 5180, 2760, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1193
} | Medical Text: Admission Date: [**2169-4-19**] Discharge Date: [**2169-4-24**]
Date of Birth: [**2108-9-15**] Sex: M
Service: MEDICINE
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Transfer from rehab for hematocrit drop
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy [**2169-4-21**]
History of Present Illness:
Mr. [**Known lastname **] is a 60 year-old male with ERD s/p DCD transplant
in [**10/2167**] on Prograf/MMF, DM type 2, HTN, PVD s/p TMA with skin
graft from left thigh, and CAD s/p PCI, who was initially
admitted from [**Hospital3 **] following a hematocrit drop. Of
note, he was recently discharged from [**Hospital1 18**] on [**2169-4-13**]
following an admission for wound debridement after a recent
right TMA, further complicated by ARF treated with pulse
steroids. A transplant biopsy returned negative for rejection.
At [**Hospital1 **], his hematocrit dropped from 30 to 27 to 24.8 and
his stools were reportedly guaiac positive. A ROS was largely
negative. He was transferred to [**Hospital1 18**] for further evaluation. In
ED, Hct 27, stools guaiac negative, NGL negative. However, his
blood pressure repeatedly dropped to the 80s. He responded to
IVF (NS) and was transfused 1 unit of PRBCs. He was also found
to be mildly hypoglycemic with a FS 74, and given 1 amp of D50.
He was subsequently admitted to the ICU for further care.
In the ICU, his usual medications were continued. He remained
hemodynamically stable, infectious work-up negative. Repeated
stool guaiacs are documented as negative. A hemolysis work-up
was negative. An EGD was performed today, remarkable for
esophagitis and gastritis without bleeding. He is being
transferred to the floor for further care.
Past Medical History:
1. ESRD status post DCD transplant [**10/2167**], followed by Dr.
[**Last Name (STitle) **]
2. Hypertension
3. DM type 2, last HbA1c 7.2% on [**2169-4-13**]
4. History of retinal hemorrhage status post vitrectomy
5. CAD status post PTCA (cath [**3-/2167**] 70% stenosis in small RCA,
LAD 50% lesion, 90% PM3, PDA 80%, EF LV gram 50%, 2 cypher
stents in LCx)
6. Mixed systolic and diastolic dysfunction, EF 40%
7. Peripheral vascular disease s/p right TMA with skin graft
from left thigh
8. Polyneuropathy
9. Statust post appendectomy
Social History:
Lives with wife, former [**Name2 (NI) 1818**] 1.5 ppd stopped in [**2145**]. Denies
alochol use.
Family History:
Not reviewed with patient.
Physical Exam:
Physical examination on day of transfer from ICU:
VITALS: T 97.4, BP 125/70, HR 78, RR 16, Sat 100% on RA.
GEN: In NAD. Lying in bed.
HEENT: Anicteric.
NECK: JVP not elevated.
RESP: Mostly CTAB, few basilar crackles that clear with cough.
CVS: RRR. Normal S1, S2. No S3, S4. No murmur appreciated.
GI: BS NA. Abdomen soft, non-tender. Transplant kidney in RLQ.
EXT: Without edema. Left thigh site with clean base, no
dressing. Right foot wound clean, no odor, no purulent drainage.
Pertinent Results:
Relevant laboratory data on admission:
CBC:
WBC-4.7 RBC-3.16* HGB-9.1* HCT-27.2* MCV-86 MCH-28.8 MCHC-33.5
RDW-16.0*
NEUTS-54.4 BANDS-0 LYMPHS-35.3 MONOS-7.6 EOS-2.0 BASOS-0.8
PLT COUNT-188
Chemistry:
GLUCOSE-84 UREA N-7 CREAT-0.8 SODIUM-137 POTASSIUM-3.6
CHLORIDE-107 TOTAL CO2-22 ANION GAP-12
CK(CPK)-37*, CK-MB-NotDone cTropnT-0.03*
LACTATE-1.1
Tacrolimus level on day of discharge: 3.2 on Tacrolimus 2.5 mg
PO BID
Relevant imaging data:
[**2169-4-19**] CXR: No failure, no infiltrate.
[**2169-4-21**] EGD: Grade 1 esophagitis in the lower third of the
esophagus.
Erosion and erythema in the antrum compatible with gastritis.
Otherwise normal EGD to second part of the duodenum.
[**2169-4-24**] ECHO: Report pending.
Brief Hospital Course:
60 year-old male status post DCD kidney transplant in [**10/2167**] on
tacrolimus and MMF, also with DM2, CAD and PVD statust post
recent TMA with skin graft from left thigh, initially admitted
with episodes of hypotension responsive to IVF, and anemia. His
hospital course will be briefly reviewed by problems.
1. Hypotensive episodes, resolved: He initially responded to IVF
and transfusion of one unit of PRBCs in the Emergency
Department. He was admitted to the ICU for close hemodynamic
monitoring, and remained hemodynamically stable. Cardiac enzymes
were not cycled given low suspicion. His stools were guaiac
negative, without evidence of bleeding. An infectious work-up
was performed with negative U/A, urine culture, CXR and blood
cultures. A cosyntropin stimulation test showed an appropriate
cortisol response. A repeat echocardiogram was obtained, report
pending at the time of discharge. A recent study in [**12/2168**]
showed EF 30-35%. His Metoprolol was resumed on [**2169-4-20**], and
continued throughout his hospital stay.
2. Anemia: His hematocrit was at baseline at 27 when he arrived
to the ED. Repeated stool guaiacs were negative. However, he was
reportedly guaiac positive at the rehab facility. An EGD was
performed on [**2169-4-21**], notable for mild esophagitis and
gastritis without bleeding. He was placed on PPI [**Hospital1 **] for 1 week,
then return to daily dose. Other work-up included iron studies
not suggestive of iron deficiency, hemolysis work-up negative,
folate and B12 normal, reticulocyte inappropriate. As noted
above, he was given 1 unit of PRBCs in the ED, with subsequently
stable hematocrit. Hematocrit at D/C 27.5. We recommend a repeat
colonoscopy as an out-patient.
Given his concomitant leukopenia, consideration was given to
Bactrim-induced myelosuppression. Consideration could be given
to changing to a different prophylactic medication as an
out-patient. Other possibilities include a primary bone marrow
process. Follow-up with hematology was arranged on [**2169-5-29**] with
Dr. [**Last Name (STitle) 6160**].
3. Status post DCD kidney transplant: His creatinine remained at
baseline. His tacrolimus level was at goal, and he was continued
on his usual dose 2.5 mg PO BID. He was also continued on MMF
1gm PO BID. A CMV viral load is pending at the time of
discharge.
4. Status post recent TMA with graft from left thigh: His wound
was clean on exam at [**Hospital1 18**]. However, he was reportedly placed on
Levofloxacin at [**Hospital3 **] on [**2169-4-18**] with plan to
complete a 14-day course (last dose on [**2169-5-1**]). This was
continued in the hospital. Given non-compliance with touch
weight-bearing, he is to remain non weight-bearing on his RLE
until vascular follow-up.
5. CAD: No acute issues in hospital. He was continued on
Ezetimibe 10 mg daily, ASA. Metoprolol was transiently held on
admission, resumed on day #2.
6. DM type 2: His oral regimen was held on admission, resumed on
[**4-21**]/0/7. Fair glycemic control in hospital.
Medications on Admission:
Protonix 40mg qday
Calcium carbonate 500mg tid:prn
Tacrolimus 2.5mg [**Hospital1 **]
Glipizide 10mg qday
Rosiglitazone 4mg qday
Regular insulin sliding scale
Ambien 5mg qhs
Mycophenolate mofetil 1gm [**Hospital1 **]
Tamsulosin 0.4mg qhs
Metoprolol 12.5mg [**Hospital1 **]
Cholecalciferol 400 units qday
Ca carbonate 500mg qday
Bactrim SS 1 tab qday
Zetia 10mg qday
Oxycodone 10mg prn
MVI
Senna, bisacodyl, colace, MgOH
Levofloxacin 500mg qday
Simvastatin 20mg qhs
ASA 81mg qday
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for
5 days: To complete on [**2169-4-28**]
.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day: To begin on
[**2169-4-29**].
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
5. Glipizide 10 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO DAILY (Daily).
6. Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale
Injection ASDIR (AS DIRECTED).
8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
9. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO at bedtime.
11. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
12. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
13. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed.
15. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
18. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO DAILY (Daily) as
needed for constipation.
19. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 doses: To be completed on [**2169-5-1**].
20. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
21. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
22. Tacrolimus 5 mg Capsule Sig: 0.5 Capsule PO BID (2 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
Hypotension
Anemia
Secondary:
1. ESRD status post DCD transplant [**10/2167**], followed by Dr.
[**Last Name (STitle) **]
2. Hypertension
3. DM type 2, last HbA1c 7.2% on [**2169-4-13**]
4. History of retinal hemorrhage status post vitrectomy
5. CAD status post PTCA (cath [**3-/2167**] 70% stenosis in small RCA,
LAD 50% lesion, 90% PM3, PDA 80%, EF LV gram 50%, 2 cypher
stents in LCx)
6. Mixed systolic and diastolic dysfunction, EF 40%
7. Peripheral vascular disease s/p right TMA with skin graft
from left thigh
8. Polyneuropathy
Discharge Condition:
Stable, normotensive
Discharge Instructions:
You were admitted with a low blood pressure and a low blood
count. There was no evidence of bleeding, and the reason for
your low blood pressure is unknown.
Please take all of your medications as prescribed.
Please keep all of your follow-up appoinments.
Please call your doctor or return to the hospital if you
experience bleeding, chest pain, shortness of breath, fevers or
anything else of concern.
Followup Instructions:
Please follow up with Hematology ([**Telephone/Fax (1) 14703**] (Dr. [**Last Name (STitle) 6160**]
on [**5-29**] at 9am. Hematology is located on the [**Hospital Ward Name **]
of [**Hospital1 18**] on the [**Location (un) **] of the [**Hospital Ward Name 23**] building.
Please follow up with Dr. [**Last Name (STitle) **] (primary care doctor's office)
on Thursday, [**4-27**] at 2pm.
Please follow with Dr. [**Last Name (STitle) 1391**] of vascular surgery on [**5-10**] at 10:15am located in the [**Hospital Unit Name **], suite 5C.
Appointments scheduled prior to this hospitalization:
1. Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2169-5-30**] 10:00am
2. Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2169-6-7**] 8:40am
Completed by:[**2169-4-24**]
ICD9 Codes: 3572, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1194
} | Medical Text: Admission Date: [**2168-6-3**] Discharge Date: [**2168-6-6**]
Date of Birth: [**2097-3-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
angina
Major Surgical or Invasive Procedure:
[**2168-6-3**] coronary artery bypass x 4 (LIMA-LAD, SVG-Dx, SVG-OM,
SVG-PDA)
History of Present Illness:
The patient is a 71 year old white male who has been
experiencing an increase in anginal symptoms for 2 weeks prior
to admission. Exercise treadmill test was positive and on
cardiac catheterization the patient was found to have left main
and right coronary artery disease. He was referred for surgical
revascularization at this time.
Past Medical History:
peripheral vascular disease
hypertension
hyperlipidemia
Social History:
lives with wife
works as courier/driver
tobacco: 60+ pack years, quit 2 months ago
EtOH: 1 drink/day
Family History:
2 brothers and mother with MI
Physical Exam:
VS: 98.8, 121/79, 50SB, 12, 98%2L
ht: 5'[**68**]" wt: 82.5kg
Gen: NAD
Skin: unremarkable
HEENT: PERRL, EOMI
Neck: supple, full ROM
Chest: lungs CTAB
Heart: RRR, no murmur, rub or gallop
Abd: soft, NT, ND, +BS
Ext: warm, well-perfused, no edema
varicosities: mild
Neuro: grossly intact, MAE, follows commands, non-focal
Pulses:
femoral: right- sheath, L 2+
DP: 1+ b/l
PT: 1+ b/l
radial: 2+ b/l
Pertinent Results:
[**2168-6-5**] 07:30AM BLOOD WBC-12.2* RBC-3.43* Hgb-11.3* Hct-33.8*
MCV-98 MCH-32.8* MCHC-33.4 RDW-14.7 Plt Ct-249
[**2168-6-5**] 07:30AM BLOOD Glucose-114* UreaN-16 Creat-0.8 Na-136
K-4.5 Cl-104 HCO3-25 AnGap-12
[**2168-6-5**] 07:30AM BLOOD Mg-2.0
Pre Bypass: The left atrium is mildly dilated. No spontaneous
echo contrast is seen in the body of the left atrium. A patent
foramen ovale is present. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. There are complex
(>4mm) atheroma in the descending thoracic aorta. There are
three aortic valve leaflets. The aortic valve leaflets are
moderately thickened. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. There is
no pericardial effusion.
Post Bypass: Preserved biventricular function, LVEF >55%. Aortic
contours intact. MR remains trace, Aortic valve function
unchanged. Remaining exam unchanged. All findings discussed with
surgeons at the time of the exam.
Brief Hospital Course:
The patient was transferred from an outside hospital for urgent
surgical revascularization. He was admitted and brought to the
operating room for urgent coronary artery bypass x 4. Overall
the patient tolerated the procedure well and post-operatively
was transferred to the CVICU in good condition for observation
and recovery on neosynephrine. By POD 1 the patient was
extubated, alert and oriented and breathing comfortably. He was
neurologically intact and hemodynamically stable on no inotropic
or vasopressor support. He was found suitable for transfer to
telemetry at this time. The patient continued to make excellent
progress. Chest tubes and pacing wires were discontinued
without complication. Post-operative course was uneventful.
Physical therapy was consulted for assistance with
post-operative strength and mobility. By POD 3 the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. He was discharged to home with VNA
services in good condition on POD 3. Appropriate follow-up was
advised.
Medications on Admission:
nitroglycerin prn
pravachol 20'
lisinopril 10'
metoprolol 25''
MVI
asa 81'
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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
3. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Home Health
Discharge Diagnosis:
coronary artery disease
status post coronary artery bypass x 4
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
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 2 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) 39975**] in 4 weeks [**Telephone/Fax (1) 109004**]
Dr. [**Last Name (STitle) **] in [**1-26**] weeks [**Telephone/Fax (1) 88720**]
Please call for appointments
Completed by:[**2168-6-6**]
ICD9 Codes: 4111, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1195
} | Medical Text: Admission Date: [**2110-11-17**] Discharge Date: [**2110-11-24**]
Date of Birth: [**2062-3-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 1406**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting x4 with left
internal mammary artery to the left anterior descending
artery and reverse saphenous vein graft to the right coronary
artery, obtuse marginal artery, and diagonal artery.
History of Present Illness:
48 year old male with 2-3 week history of exertional chest
pressure, now increasing in frequency - underwent ETT which he
had chest pain and ST depressions. Underwent cardiac
catheterization at NEBH which revealed coronary
artery disease and is being transferred in for surgical
evaluation.
Past Medical History:
Hypertension
Diabetes mellitus
GERD
Asthma
Social History:
Lives with: spouse
Occupation: owns janitorial company
Tobacco: 3 pack year history quit 15 years ago
ETOH: denies
Family History:
Father CABG at age 62
Physical Exam:
Pulse: 80 Resp: 20 O2 sat: 100% 2 l nc
B/P Right: 130/80 Left: 129/79
Height: 5'9" Weight: 203pouunds stated
General: No acute distress
Skin: Dry [x] [**Known firstname 5235**] [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x] no lymphadenopathy
Chest: Lungs clear bilaterally [x] anterior
Heart: RRR [x] Irregular [] Murmur no
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] no palpable masses
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: None [x]
Neuro: Grossly [**Known firstname 5235**]
Pulses:
Femoral Right: femoral sheath Left: +2
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +1 Left: +1
Carotid Bruit Right: no bruit Left: no bruit
Pertinent Results:
[**2110-11-24**] 06:50AM BLOOD WBC-10.2 RBC-3.13* Hgb-9.4* Hct-27.5*
MCV-88 MCH-29.9 MCHC-34.0 RDW-13.2 Plt Ct-287#
[**2110-11-23**] 05:00AM BLOOD WBC-9.2 RBC-2.70* Hgb-8.4* Hct-23.9*
MCV-89 MCH-31.1 MCHC-35.1* RDW-13.1 Plt Ct-175
[**2110-11-23**] 05:00AM BLOOD Glucose-126* UreaN-20 Creat-0.9 Na-137
K-3.8 Cl-102 HCO3-26 AnGap-13
[**2110-11-24**] 06:50AM BLOOD K-4.4
[**2110-11-24**] 06:50AM BLOOD Mg-2.2
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The ascending, transverse and descending thoracic [**Year/Month/Day 5236**] are
normal in diameter and free of atherosclerotic plaque.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
Preserved biventricular systolic fxn.
No AI, no MR. [**First Name (Titles) **] [**Last Name (Titles) 5235**].
Brief Hospital Course:
Transferred in from outside hospital after cardiac
catheterization on nitroglycerin drip and femoral sheath to
intensive care unit. He underwent preoperative workup and was
transferred to the floor on hospital day two on heparin, sheath
removed, for completion of preoperative workup.
The patient was brought to the operating room on [**2110-11-19**] where he
underwent CABGx4 with Dr. [**Last Name (STitle) **]. Please see op report for
details. Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for invasive monitoring. The patient does have a
history of diabetes and blood glucose was difficult to manage
following surgery. [**Last Name (un) **] was consulted, and we appreciate
their recommendations. Blood glucose came under good control,
and he was transferred to the telemetry floor. Beta blockade
and diuresis were initiated. Chest tubes and pacing wires were
discontinued without complication. PT worked with the patient
on strength and mobility. By POD 5 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. He was found suitable for discharge to home with
VNA at this time. He will be on insulin at home and he did
undergo insulin teaching prior to discharge.
Medications on Admission:
Metformin 1000 mg daily stopped [**11-13**]
Aspirin 81 mg daily
Effient 10 mg daily
Coreg ER 10 mg daily
Lipitor 20 mg daily
Prilosec 40 mg [**Hospital1 **] stopped [**11-13**]
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO Q12H (every 12 hours).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO twice
a day.
Disp:*120 Tablet(s)* Refills:*2*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
1 weeks.
Disp:*7 Tablet(s)* Refills:*0*
9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1
weeks.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
10. Insulin Glargine 100 unit/mL Solution Sig: One (1)
Subcutaneous once a day: 40 units in am.
Disp:*qs * Refills:*2*
11. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous with
meals: see sliding scale instructions.
Disp:*qs * Refills:*2*
12. Insulin Needles (Disposable) Needle Sig: One (1)
Miscellaneous four times a day.
Disp:*qs * Refills:*2*
13. Insulin Syringes (Disposable) 1 mL Syringe Sig: One (1)
Miscellaneous four times a day.
Disp:*qs * Refills:*2*
14. DME
glucometer
15. DME
lancets for glucometer
disp: qs 1 month
16. DME
glucose test strips
disp: qs 1 month
Discharge Disposition:
Home With Service
Facility:
vna care of [**Location (un) **]
Discharge Diagnosis:
Coronary artery disease s/p CABG
Angina
Diabetes Mellitus
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Primary Care Dr [**Last Name (STitle) **] in [**11-15**] weeks
Cardiologist Dr [**Last Name (STitle) 7389**] in [**11-15**] weeks
[**Last Name (un) **] Diabetes Center ([**Telephone/Fax (1) 4847**] in 1 week
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2110-11-24**]
ICD9 Codes: 4111, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1196
} | Medical Text: Admission Date: [**2196-1-15**] Discharge Date: [**2196-1-20**]
Service: Neurology
HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old
right-handed man with a history of coronary artery disease,
insulin dependent diabetes mellitus, hypertension, peripheral
vascular disease, atrial fibrillation status post stroke with
left leg weakness. He had recurrent episodes of confusion
shaking for the past four years. He was evaluated
extensively at [**Hospital3 417**] Hospital for these spelss of
transient ischemic attack versus seizure. He had several
EEGs said to have been not suggestive of epileptic activity.
He has been tried on AEDs without improvement. He was last seen
at [**Hospital3 417**] Hospital on [**12-31**] for evaluation of a 20-
minute episode of garbled speech and "confusion" and was
transferred to [**Hospital1 69**] Neurosurgery
service for further evaluation and management.
As part of the work-up, the Neurosurgery Service performed a
conventional angiogram which reportedly showed bilateral
vertebral artery stenosis, right side 70%, left
side 75%. Therefore, the Neurosurgery Service decided to proceed
with stent angioplasty of the left vertebral artery.
He was then discharged to rehabilitation on [**1-12**]. He did
well until this morning when he was found again to have a spell
of "being confused". His wife indicates that he was not answering
questions appropriately. He was brought to the emergency room
where he was noted by emergency room staff to have a 15-minute
episode of moaning and garbled speech. The patient
then returned to baseline. Dr. [**Last Name (STitle) 1132**] asked us to evaluate
the patient for question of transient ischemic attack versus
further management options.
REVIEW OF SYSTEMS: His wife indicates that he had gradual
cognitive decline which became more pronounced during the
past year. He also has urinary incontinence at baseline, no
headache, he has recurrent falls. The patient denies
vertigo, diplopia, tinnitus. He has left leg weakness since
[**2195-10-16**] status post stroke.
MEDICATIONS ON ADMISSION: Tylenol; vitamin D; atenolol;
paroxetine; calcium carbonate; quinidine; lisinopril and
allopurinol. He is not on aspirin.
ALLERGIES: Dilantin and Aricept.
SOCIAL HISTORY: He is a retired iron worker. He is married
and lives with his wife. [**Name (NI) **] quit smoking 30 years ago. He
has three children. His wife indicates a history of alcohol
abuse in the past. She always handled the finances at home.
FAMILY HISTORY: Coronary artery disease. A brother has
[**Name (NI) 5895**] disease.
PHYSICAL EXAMINATION: The patient was afebrile, pulse 64
with occasional irregularities, blood pressure 140/75. In
general he was a well-nourished, mildly overweight older man
lying in the Emergency Department bed. He did not appear to
be in any distress. HEENT was normocephalic, atraumatic.
Mucous membranes were moist. On lung examination he was
clear to auscultation bilaterally. Cardiac was irregular
with no murmurs. Abdomen was soft, nontender, nondistended,
positive bowel sounds x 4. Extremities had 2+ pulses, no
edema. Neurologically he was awake, alert, oriented to
place, month and year, oriented to personal information, date
of birth, address and phone number. He stated that he was
here because he didn't feel well but could not elaborate,
unable to provide driving directions from his home to the
[**Location (un) **] Building where he worked for years. He was unable to
name all grandchildren and had difficulty with son's age.
Speech and language were intact. There was no neglect, no
apraxia. Right pupil was status post surgery at 2 mm. On
the left it was 3 mm. He had decreased adduction of the left
eye and nystagmus of the right eye on right gaze. There was
no field cut, no Horner's, no ptosis. He had flattened right
nasolabial fold. His palate went up symmetrically. He had
normal tone and strength in both upper extremities, no drift.
He had drift of the left lower extremity. He had tremulous
finger-nose-finger bilaterally. Rapid alternating movements
were intact. Deep tendon reflexes were 2+ in the upper
extremities, 1+ at the knees. Right toe was down, left toe
was up. He had normal cortical sensation, no bruits and
positive glabellar and snout.
LABORATORY STUDIES: White count was 8.2, hematocrit 38.6,
platelet count 213, INR 1.1, PTT 32.8, sodium 140, potassium
4.6, chloride 104, bicarbonate 27, BUN 21, creatinine 1.4,
glucose 125, CK 59, troponin negative, calcium, magnesium and
phosphate were normal. B12, TSH, folate from [**1-3**] were
within normal limits. RPR was negative. EKG showed normal
sinus rhythm. Magnetic resonance angiography from [**2196-1-3**] did not demonstrate any diffusion abnormalities.
There was a T2 and flail segment abnormality in the
periventricular white matter. He had increased ventricular
size and cerebral atrophy. Magnetic resonance angiography of
his head was normal. There was no evidence of vertebral
stenosis. Left vertebra was dominant. Magnetic resonance
angiography of the neck showed mild right internal carotid
artery stenosis, normal flow in both vertebral arteries. CT
angiography on the day of admission showed normal results.
HOSPITAL COURSE: The patient was admitted to the neurology
service initially to the intensive care unit. He was
transferred out of the intensive care unit on hospital day
two, placed on telemetry and no cardiac events were noted.
He was placed on EEG monitoring and no seizures were noted.
The patient did not have his usual spells. In addition
there were no interictal spikes suggestive of a seizure
disorder.
The patient was taken off video EEG monitoring on [**1-19**].
He was empirically started on Keppra at 250 mg p.o. b.i.d.
which will be titrated up as an outpatient to a goal of 1,500
mg p.o. b.i.d. The patient will be discharged on [**2196-1-20**] to
rehabilitation.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSES:
1. Seizure disorder, although transient ischemic attacks
cannot be ruled out.
2. Dementia.
3. Diabetes mellitus.
4. Degenerative joint disease.
5. Atrial fibrillation.
6. Peripheral vascular disease.
7. Depression.
8. Hypertension.
FOLLOW UP: The patient will follow up as an outpatient with
Dr. [**Last Name (STitle) 1132**] and an appointment will be made for him to see a
behavioral neurologist.
DISPOSITION: The patient is being discharged to
rehabilitation.
[**Name6 (MD) 725**] [**Name8 (MD) 726**], M.D. [**MD Number(1) 727**]
Dictated By:[**Last Name (NamePattern1) 5476**]
MEDQUIST36
D: [**2196-1-20**] 10:48
T: [**2196-1-20**] 10:58
JOB#: [**Job Number 24435**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1197
} | Medical Text: Admission Date: [**2180-1-12**] Discharge Date: [**2180-1-28**]
Date of Birth: [**2131-3-13**] Sex: F
Service: SURGERY
Allergies:
Iodine Containing Agents Classifier / Iron Derivatives
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
Gangrene of the right fourth toe.
Major Surgical or Invasive Procedure:
A jump graft from femoral anterior tibial vein graft to dorsalis
pedis artery with non reversed lesser saphenous vein and right
fourth toe open amputation.
History of Present Illness:
This 48-year-old lady with juvenile diabetes
and long history of peripheral vascular disease has
previously undergone a right femoral anterior tibial bypass
to the proximal anterior tibial artery. She subsequently
developed 2 episodes of recurrent ischemia in her right foot
with a patent graft, and was found to have disease in her
anterior tibial artery [**First Name3 (LF) 22594**] to the vein graft, but proximal
to the dorsalis pedis artery. This area has been
angioplastied twice due to severe ischemia of her foot. The
second time we did it we decided to revise this with a
bypass, since the recurrence rate of stenosis between the 2
episodes was quite short. She has gangrene of her toe and
requires toe amputation at the same time
Past Medical History:
(1) CAD s/p CABG ([**2164**]) s/p PTCA/PCI (Stenting of LAD in [**1-21**]),
(2) TIA; occluded L ICA ([**2174**]); Min plaque R ICA.
(3) DMI (since age 6) with Triopathy/Gastroparesis.
(4) HTN
(5) Hypercholesterolemia
(6) H/O Pneumonia.
(7) Iron deficiency anemia
(8) H/O Kidney stones
(9) H/O DVT
(10)PVD s/p L 4th toe amp, s/p SFA Bypass Graft and LFA
(11)Thrombectomy([**2166**])
(12)hx pericarditis
(13)I&D lt. buttocks abcess [**11/2171**]
Cath [**8-23**]: Report Unavailable.
Cath [**11-24**]:
(1) 3VD.
(2) Patent SVG-Diagonal
(3) Patent SVG-PDA
(4) Patent LIMA-LAD
(5) Occluded SVG-OM. COMMENTS: LMCA patent. LAD had a mid total
occlusion. LCX mild diffuse disease. Occluded OM. RCA proximal
100% stenosis. SVG-PDA 40% mid stenosis. [**Month/Year (2) **] LAD beyond the
touchdown patent w/ mild 30-40% in-stent restenosis.
ECHO: Not available.
pMIBI ([**4-/2173**]): EF51%. Apical akinesis. Mod min rev [**First Name (Titles) 22594**] [**Last Name (Titles) **]
and apical perf defect.
Social History:
Lived with husband and two children. Worked as a nurse??????s aid for
two women with MS. [**First Name (Titles) **] [**Last Name (Titles) 1818**]: 20+ p-y. [**12-25**] drinks
ETOH/week. No drugs/IVDU.
Family History:
No CAD/MI/DM. Mother and father healthy. [**Name2 (NI) **] son (age 21) has
high chol.
Physical Exam:
VITAL SIGNS: Her blood pressure is 130/80, pulse was 78 and
regular, and her weight was stable at 135 pounds.
SKIN: Without rash, lesions, or nodules. She did have erythema
of her right foot / open wound on fore foot is C/D/I.
HEENT: Pupils are equal, round, and reactive. Conjunctivae,
nose, and throat were clear. Hearing intact to finger rubbing.
NECK: Without mass or thyromegaly without cervical or
supraclavicular lymphadenopathy.
CHEST: Clear to percussion and auscultation.
HEART: Showed normal PMI without S3, S4, or murmurs.
ABDOMEN: Soft, without masses, tenderness, or organomegaly.
She
had tenderness in the right inguinal area. There was tender
lymphadenopathy.
EXTREMITIES: Exam of the leg and foot was as above. Her ulcers
appear dry and her skin is erythematous. There is no edema.
Pulses: R DP/PT dopp / palp graft, L DP/PT dopp / palp graft
Pertinent Results:
[**2180-1-25**] 06:20AM BLOOD
WBC-9.3 RBC-3.21* Hgb-9.0* Hct-28.4* MCV-88 MCH-28.2 MCHC-31.9
RDW-14.8 Plt Ct-513*
[**2180-1-25**] 06:20AM BLOOD
PT-13.1 PTT-30.4 INR(PT)-1.1
[**2180-1-25**] 06:20AM BLOOD
Glucose-89 UreaN-16 Creat-1.4* Na-141 K-4.6 Cl-104 HCO3-29
AnGap-13
[**2180-1-24**] 04:50AM BLOOD
Calcium-9.1 Phos-4.2 Mg-2.0
[**2180-1-12**] 08:54PM
URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.012
URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-TR
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
URINE RBC-[**4-30**]* WBC-[**1-24**] Bacteri-FEW Yeast-NONE Epi-0-2
[**2180-1-21**] 10:10 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2180-1-22**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
[**2180-1-19**] 1:30 pm SWAB Site: TOE RIGHT 4TH TOE.
GRAM STAIN (Final [**2180-1-19**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2180-1-21**]):
BETA STREPTOCOCCUS NOT GROUP A OR B. SPARSE GROWTH.
ANAEROBIC CULTURE (Final [**2180-1-23**]): NO ANAEROBES ISOLATED.
Brief Hospital Course:
Pt admitted on [**1-12**]
pre-op'd / foot xrays show osteo of 4th digit / AB started /
cx's taken
[**1-12**]
Underwent a A jump graft from femoral anterior tibial vein graft
to dorsalis pedis artery with non reversed lesser saphenous vein
and right fourth toe open amputation.
Tolerated the procedure well. No complications
Recovered in the PACU. Once recovered from the PACU sent to the
VICU in stable condition.
Bedrest
[**1-14**]
HLIV / regualr diet
[**1-15**] - [**1-18**]
low u/o and decrease o2 sats / responeded to lasix / PRBC given
[**1-17**]
c/o chest pressure / diagnosis of CHF and NSTEMI / tx to CCU
Cardiology is consulted - pt has been complaining of recurrent
CP. There was no ECG changes but cardiac enzymes returned
positive (TnT 0.16 with CPK 94), and cardiology was consulted on
[**1-17**], and pt was taken to cath lab for intervention. Cath showed
diffuse severe disease of LMCA, LAD, LCx, RCA. SVG to RCA was
patent with [**Month/Year (2) 22594**] RCA which had 90% lesions in the PLB
unchanged from previous angiography. LIMA to LAD was patent.
Origin Left subclavian had 70% and left subclavian was stented
with a Genesis stent and the final residual was 0% with normal
flow. LVEDP was elevated at 32 with PCW mean 29. Pt is getting
admitted to CCU overnight for observation and diuresis.
[**1-18**]
Transfer back to VICU
[**1-19**]
Pt undergoes a incision and debridement of r fourth toe
amputation site under local
[**Date range (1) 23163**]
wound watched with VAC dressing changes
AB tailored to treat strep b
[**1-27**]
VAC DC / changed to wet to dry dressing changes
PT / case management
Pt stable for DC
Home on PO AB
Creat stabalized from ARF
Medications on Admission:
Plavix 75', ASA 325', diltiazem 120', isosorbide 120',
lisinopril 10', toprol 100', pravastatin 80', percocet
Discharge Medications:
1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: Two (2) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
Disp:*30 Suppository(s)* Refills:*0*
4. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*15 Tablet(s)* Refills:*0*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*0*
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
7. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Insulin
Insulin SC (per Insulin Flowsheet)
Sliding Scale & Fixed Dose
Bedtime
Glargine 15 Units
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Humalog
Glucose Insulin Dose
0-70 mg/dL [**11-23**] amp D50
71-100 mg/dL 0 Units 0 Units 0 Units 0 Units
101-120 mg/dL 2 Units 2 Units 2 Units 0 Units
121-140 mg/dL 3 Units 3 Units 3 Units 0 Units
141-160 mg/dL 3 Units 3 Units 3 Units 0 Units
161-180 mg/dL 4 Units 4 Units 4 Units 0 Units
181-200 mg/dL 5 Units 5 Units 5 Units 0 Units
201-220 mg/dL 6 Units 6 Units 6 Units 2 Units
221-240 mg/dL 7 Units 7 Units 7 Units 4 Units
241-260 mg/dL 9 Units 9 Units 9 Units 5 Units
261-280 mg/dL 10 Units 10 Units 10 Units 6 Units
281-300 mg/dL 13 Units 13 Units 13 Units 7 Units
> 300 mg/dL Notify M.D. .
12. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Ischemic toe
PAD
ARF - creat 0.8 on admission / 1.5 on DC / High
Discharge Condition:
Stable
Discharge Instructions:
WOUND CARE:
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your wound(s).
New pain, numbness or discoloration of your lower or upper
extremities (notably on the side of the incision).
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
OTHER INFORMATION:
You may shower immediately upon coming home. No bathing. keep
your open wound dry. Dressing changes twice a day
Avoid taking a tub bath, swimming, or soaking in a hot tub
untill your wound is completely healed
Limit strenuous activity and or heavy lifting until the wound
is well healed. Activity may prevent the wound from healing.
Do not drive a car unless cleared by your Surgeon.
Try to keep your affected limb elevated when not in use, This
decreases swelling to the affected wound and helps in the
healing process.
You may have an ace wrap around the affected limb with the
wound. This helps prevent swelling to the area. You may take
this off at night. But when you are doing activity the ace wrap
should be worn.
ANTIBIOTICS:
You may have a prescription for antibiotics. Take as directed.
Be sure you take the full course even if the wound looks well
healed. Failure to do so may lead to infection.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2180-4-25**] 11:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7323**], M.D. Date/Time:[**2180-6-20**] 11:10
Call Dr [**Last Name (STitle) **] office and schedule am appointment for one
week. He can be reached at [**Telephone/Fax (1) 3121**]
Completed by:[**2180-1-28**]
ICD9 Codes: 4280, 9971, 5849, 3572, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1198
} | Medical Text: Admission Date: [**2187-5-30**] Discharge Date: [**2187-6-3**]
Date of Birth: [**2129-7-12**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
hyponatremia
spontaneous bacterial peritonitis
Major Surgical or Invasive Procedure:
Paracentesis [**6-2**]
History of Present Illness:
57 yo F with Etoh/HCV cirrhosis, who was seen in routine liver
follow up care and noted to have a sodium of 115 and sent to the
ED. PAtient reports feeling weak and tired since Sunday but
denies fever, chills, nausea, vomiting, diarrhea. She denies
headache, confusion, vision change, slurred speech or gait
ataxia. She reports no change in her diet and she has been
strictly following a 1.5g fluid restriction and remained on her
diuretics. She notes she feels very thirsty and he mouth
always feels dry. Reported no change in abdominal girth.
Clinic note indicates that she has had a 10lb weight loss in the
last month but had no bleeding or encephalopathy.
.
Of note, she lost almost 20lbs after her last admission and was
briefly (1 week) on a lower dose of diuretics, has been back at
full dose for the last month or so. Her last recorded sodium
was 128 on [**2187-4-6**].
.
In the ED initial vital signs were 98.6 101 99/60 16 100% RA.
Exam notable for: no asterixis, mildly distended abdomen.
Labs were notable for: Sodium of 113 and chloride of 81. WBC
20.9, U/A negative. T. Bili 12.2. Paracentesis done and showed
2550 WBC with polys pending. Patient was given one dose of
ceftriaxone and 1L NS with 50g albumin and admitted to the ICU
for hyponatremia. CXR PA and Lat was unremarkable. Vs on
transfer: 99.6 86 108/68 16 100% RA.
.
Review of Systems:
(+) Per HPI
(-) Review of Systems: GEN: No fever, chills, night sweats,
HEENT: No headache, sinus tenderness, rhinorrhea or congestion.
CV: No chest pain or tightness, palpitations. PULM: No cough,
shortness of breath, or wheezing. GI: No nausea, vomiting,
diarrhea, constipation. No recent change in bowel habits, no
hematochezia or melena. GUI: No dysuria or change in bladder
habits. DERM: No bruising. NEURO: No numbness/tingling in
extremities.
Past Medical History:
-Alcoholic and hepatitis C cirrhosis. She has decompensation
with jaundice and ascites. She has no esophageal varices and no
history of encephalopathy.
- Hepatitis C virus, genotype 1, viral load 70,000.
- Alcohol abuse.
- Severe esophagitis.
- Portal hypertensive gastropathy.
- Klebsiella Bacteremia in the setting of acute hepatic
decompensation
Social History:
Previously lived in VT, recently moved to St. [**Doctor Last Name **]. Family in
[**State 350**]. Patient reports cocaine use >20 years ago. She
denies tobacco. Per report she was drinking 1-2 drinks 4 times
a week up until 3 months ago and has been sober since then
Family History:
Renal failure [**3-7**] NSAIDS in mother, HTN in multiple family
members; no liver disease
Physical Exam:
VS: T:afebrile P: 90 BP:112/63 R: 18 100% on RA on room air
GEN: cachetic, jaundiced woman, AOx3, NAD
HEENT: MM dry, no JVD, no cervical, supraclavicular, or
axillary LAD
Cards: RR no murmurs/gallops/rubs
Pulm: CTAB except decreased BS at base.
Abd: Distended but soft, NT, no rebound/guarding,
Limbs: No LE edema, no tremors or asterixis
Skin: No rashes, mild bruising on arms appear old
Neuro: CNs II-XII intact. 5/5 strength in U/L extremities.
sensation intact to LT, cerebellar fxn intact (FTN, HTS).
Pertinent Results:
[**2187-5-30**] 12:00PM BLOOD WBC-20.9*# RBC-2.38* Hgb-9.4* Hct-25.8*
MCV-109* MCH-39.4* MCHC-36.3* RDW-14.9 Plt Ct-101*#
[**2187-6-2**] 05:10AM BLOOD WBC-6.8 RBC-2.16* Hgb-8.2* Hct-22.0*
MCV-102* MCH-37.9* MCHC-37.2* RDW-16.9* Plt Ct-72*
[**2187-5-30**] 12:00PM BLOOD Neuts-85* Bands-1 Lymphs-9* Monos-5 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2187-5-30**] 05:43PM BLOOD Neuts-85.7* Lymphs-8.9* Monos-4.7 Eos-0.6
Baso-0.2
[**2187-5-30**] 12:00PM BLOOD PT-19.7* PTT-32.7 INR(PT)-1.8*
[**2187-6-2**] 05:10AM BLOOD PT-21.9* PTT-107.3* INR(PT)-2.0*
[**2187-5-29**] 03:35PM BLOOD UreaN-15 Creat-0.8 Na-115* K-4.4 Cl-78*
HCO3-22 AnGap-19
[**2187-6-2**] 05:10AM BLOOD Glucose-83 UreaN-9 Creat-0.5 Na-120*
K-4.2 Cl-90* HCO3-25 AnGap-9
[**2187-5-30**] 12:00PM BLOOD ALT-45* AST-116* LD(LDH)-691*
AlkPhos-116* TotBili-12.4*
[**2187-6-2**] 05:10AM BLOOD ALT-27 AST-42* LD(LDH)-179 AlkPhos-94
TotBili-7.1*
[**2187-5-30**] 12:00PM BLOOD Albumin-3.1* Calcium-8.8 Phos-3.8 Mg-1.9
[**2187-6-2**] 05:10AM BLOOD Albumin-3.6 Calcium-8.5 Phos-2.2* Mg-1.9
[**2187-5-29**] 03:35PM BLOOD AFP-8.5
[**2187-5-30**] 12:00PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
[**2187-5-30**] 05:43PM BLOOD Ethanol-NEG
[**2187-5-30**] 12:02PM BLOOD Glucose-149* Na-115* K-4.7 Cl-81*
calHCO3-39*
.
[**2187-5-30**] 02:09PM ASCITES WBC-2550* RBC-250* Polys-82* Lymphs-2*
Monos-13* Mesothe-1* Other-2*
[**2187-6-2**] 02:28PM ASCITES WBC-80* RBC-365* Polys-9* Lymphs-11*
Monos-0 Mesothe-2* Macroph-78*
[**2187-5-30**] 02:09PM ASCITES TotPro-1.8 Glucose-148 LD(LDH)-99
Albumin-0.8
[**2187-6-2**] 02:28PM ASCITES TotPro-2.6 Glucose-156 Creat-0.3
LD(LDH)-119 Amylase-34 TotBili-3.8 Albumin-1.6
Brief Hospital Course:
Ms. [**Known lastname **] was a 57 year-old woman with HCV and alcoholic
cirrhosis who was admitted from home after being found to have
profound hyponatremia. On admission she was found to have
spontaneous bacterial peritonitis and received appropriate
therapy with resolution.
Hyponatremia: It is likely that her SBP and dietary
indiscretions contributed to her worsened hyponatremia. She
initially received fluid resuscitation and suspension of her
diuretics with some improvement from 113 to 118. Subsequently
she was placed on a 1L fluid restriction with continued
resolution of her serum sodium to 123. It is also likely that
treatment of her SBP further contributed to improved serum
sodium. She was discharged on a 1L fluid restriction and a
reduced dose of her diuretic regimen. She will have her sodium
level checked on [**2187-6-5**].
.
# SBP: She presented with no abdominal pain, but met criteria
for SBP by paracentesis with >250 PMNs. She was treated for 5
days with IV Ceftriaxone with appropriate albumin given on day 1
and 3 ([**5-30**] and [**6-1**]). She also received a therapeutic
paracentesis of 4.5 on [**6-2**] and received appropriate albumin
protection following paracentesis. Analysis of peritoneal fluid
revealed resolution of SBP with 8 PMNs. She was discharged on
cipro daily for SBP prophylaxis
.
# Anemia: She has a known baseline Hct of 22-24 and presented
with a Hct of 20. She received 1 unit of PRBC and subsequently
remained with a stable Hct of 22 throughout her hospitalization.
.
# Alcoholic/Hep Cirrhosis: It was likely that her SBP causing
decompensation of her LFTs which were subsequently observed to
improve following SBP treatment.
Medications on Admission:
MVI daily
Vitamin D on Sundays
Lasix 80
Spironolactone 200
Discharge Medications:
1. Vitamin D Oral
2. multivitamin Oral
3. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Cipro 250 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Hyponatremia
Spontaneous Bacterial Peritonitis
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 for low sodium. You were
evaluated and treated by the medicine service. You were found to
have an infection in your belly fluid and your received
antibiotics. You also received removal of this fluid from your
belly, which showed that the infection had been treated. By
limiting your liquid intake your sodium level improved. Please
continue to observe a 1 liter liquid intake restriction. Please
take your medications as prescribed and keep your outpatient
appointments.
.
The following changes have been made to your home medication:
1. Your Lasix has been DECREASED to 20 mg daily
2. Your Spronolactone has been DECREASED to 100 mg daily
3. You were STARTED on Cipro 250 mg daily
.
No other changes have been made to your home medications.
Followup Instructions:
Please come to the [**Hospital1 18**] lab on Tuesday for a blood draw.
Please call [**Telephone/Fax (1) 2422**] to set up an appointment with Dr. [**Last Name (STitle) **]
for within the next 2 weeks. Your current appointment is as
follows:
Department: LIVER CENTER
When: FRIDAY [**2187-8-31**] at 11:40 AM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Please follow up with your primary care doctor, Dr. [**Last Name (STitle) 92938**], as
previously scheduled. Phone: [**Telephone/Fax (1) 92939**].
ICD9 Codes: 2761, 2859, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1199
} | Medical Text: Admission Date: [**2107-6-3**] Discharge Date: [**2107-6-9**]
Date of Birth: [**2028-1-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine / Iodine-Iodine Containing
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2107-6-3**] Coronary artery bypass graft x 2 (Left internal mammary
artery to left anterior descending, Saphenous vein graft to
diagonal)
History of Present Illness:
79 year old male with known coronary artery disease s/p cypher
stent to RCA in [**2098**] who has been complaining of chronic angina
with minimal exertion. In addition, notes difficulty breathing,
severe fatigue and chest pressure with light ADLs, such as
showering and picking up leaves. Despite maximal medical therapy
he is still complaining of recurrent angina and was referred for
elective catheterization. Catheterization revealed diffuse left
anterior descending narrowing with new narrowing at branching of
ostium which is not amenable to stenting without stenting over
circumflex. He presents today for surgical evaluation.
Past Medical History:
Coronary artery disease s/p cypher stent to RCA [**2098**]
Diabetes
Dyslipidemia
Hypertension
Chronic Renal Insufficiency (b/l cre 1.5- 1.9)
GERD/PUD
Hiatal hernia
Spinal Stenosis
Benign prostatic hypertrophy
"Infection" of RLE foot-knee from a cut on his toe as a child
Past Surgical History:
s/p Posterior cervical laminectomy, [**2076**] (by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **])
Lumbar laminectomy [**2104**]
Left hip- removal of fat tumor
Herniorrhaphy [**2075**]
Left Cataract
Social History:
Race: Immigrant from [**Country 1684**]
Lives with: Wife
Occupation: Retired mechanic
Tobacco: remote history as a teenager
ETOH: Denies
Family History:
Brother died of MI at age 47
Physical Exam:
Pulse: 80 Resp: 18 O2 sat: 98%
B/P Right: 109/66 Left: 105/61
Height: 5'8" Weight: 84 kg
General: NAD
Skin: Dry [X] intact [X]
HEENT: PERRLA [] EOMI [x] pupils fixed (cataracts)
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x]
Edema none
Varicosities: moderate varicosities
well-healed scar medial right leg- ~3inches below knee (s/p
surgery for "infection")
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Carotid Bruit no bruits appreciated
Pertinent Results:
[**2107-6-3**] Echo: PREBYPASS: No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses and cavity size
are 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.
The ascending aorta is mildly dilated. There are complex (>4mm)
atheroma in the descending thoracic aorta. The aortic valve
leaflets (3) are mildly thickened. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits).
POSTBYPASS: There is preserved biventricular systolic function.
The study is otherwise unchanged from the prebypass period.
[**6-8**] CXR: The lungs are low in volume but clear. The cardiac
silhouette is enlarged. The mediastinal silhouette and hilar
contours are normal. No pleural effusion or pneumothorax is
present. Sternal wires are intact.
[**2107-6-9**] 10:47AM BLOOD WBC-5.6 RBC-3.73* Hgb-11.8* Hct-34.5*
MCV-93 MCH-31.5 MCHC-34.1 RDW-15.0 Plt Ct-137*
[**2107-6-8**] 05:00AM BLOOD WBC-4.4 RBC-3.66* Hgb-11.2* Hct-31.8*
MCV-87 MCH-30.6 MCHC-35.2* RDW-15.0 Plt Ct-95*
[**2107-6-6**] 04:35AM BLOOD WBC-2.6*# RBC-2.65* Hgb-8.2* Hct-23.4*
MCV-88 MCH-31.0 MCHC-35.0 RDW-15.0 Plt Ct-73*
[**2107-6-3**] 04:32PM BLOOD WBC-5.6 RBC-2.60*# Hgb-8.2*# Hct-23.0*#
MCV-88 MCH-31.6 MCHC-35.7* RDW-14.8 Plt Ct-67*
[**2107-6-9**] 10:47AM BLOOD Plt Ct-137*
[**2107-6-7**] 09:30AM BLOOD PT-12.0 PTT-23.0 INR(PT)-1.0
[**2107-6-3**] 04:32PM BLOOD Plt Smr-VERY LOW Plt Ct-67*
[**2107-6-3**] 04:32PM BLOOD PT-13.9* PTT-26.7 INR(PT)-1.2*
[**2107-6-3**] 04:32PM BLOOD Fibrino-198
[**2107-6-9**] 10:47AM BLOOD Glucose-166* UreaN-34* Creat-1.7* Na-136
K-3.9 Cl-98 HCO3-27 AnGap-15
[**2107-6-6**] 04:35AM BLOOD Glucose-173* UreaN-43* Creat-2.3* Na-133
K-5.0 Cl-98 HCO3-27 AnGap-13
[**2107-6-3**] 05:41PM BLOOD UreaN-31* Creat-1.4* Na-136 K-4.8 Cl-107
HCO3-22 AnGap-12
[**2107-6-6**] 04:35AM BLOOD TotBili-1.6*
[**2107-6-7**] 1:31 pm SPUTUM Site: EXPECTORATED
Source: Expectorated.
**FINAL REPORT [**2107-6-9**]**
GRAM STAIN (Final [**2107-6-7**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
2+ (1-5 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Final [**2107-6-9**]):
SPARSE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S).
Brief Hospital Course:
Admitted same day surgery and was brought to the operating room
for coronary artery bypass graft surgery. Please see operative
report for surgical details. He received cefazolin for
perioperative antibiotics and was transferred to the intensive
care unit for post operative management. That evening he was
weaned from sedation, awoke neurologically intact, and was
extubated without complications. On post-op day one he was
started on beta-blockers, diuretics and metformin. Later that
day he was transferred to the floor. Physical therapy worked
with him on strength and mobility. On post operative day two he
had episodes of nausea treated with antiemtics and then short
episode of confusion so his narcotics were stopped and he was
placed on ultram for pain management with good effect. Due to
increased creatinine to 2.1 his lasix and metformin were
stopped, and lantus was increased for blood glucose management.
Over the next few days his creatinine peaked at 2.3 on [**6-6**] and
trended down to 1.7 at discharge. He was resumed on lasix for
diuresiss with lower extremity edema. Additionally he had
decreased hematocrit requiring transfusions, and restarted on
home iron. Hematocrits were trended daily and they remained
stable. Also his white blood cell count dropped but no fever
and differential was normal, he was pan cultured and to date
only grew on gram negative rods from sputum and was placed on
levaquin. He continued to improve and was ready for discharge
to rehab on post operative day six to Newbridge on the [**Doctor Last Name **]
with plan for follow up wound check next week for evaluation of
right leg.
Medications on Admission:
Doxazosin 4 mg daily
Finasteride 5 mg daily
Isosorbide mononitrate 10 mg daily
Pantoprazole 40 mg daily
Simvastatin 80 mg daily
Tramadol 50 mg Tablet, 1-2 Tablets PO every eight hours PRN
Metoprolol succinate 50 mg [**Hospital1 **]
Betamethasone valerate 0.1 % Cream, apply to affected area twice
daily
Lorazepam 0.5 mg [**Hospital1 **] prn for anxiety
Metformin 1,000 mg [**Hospital1 **]
Nitrostat 0.4 mg Sublingual PRN for chest pain
Travatan Z 0.004 % Drops Ophthalmic
Brimonidine 0.15 % Drops Ophthalmic
Aspirin 81 mg daily
Amlodipine 2.5 mg daily
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
4. Ultram 50 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
5. doxazosin 4 mg Tablet Sig: One (1) Tablet PO once a day.
6. finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
9. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1)
Tablet PO once a day.
10. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
11. levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days.
12. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
13. Mucinex 1,200 mg Tablet, ER Multiphase 12 hr Sig: One (1)
Tablet, ER Multiphase 12 hr PO twice a day.
14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) ml Inhalation Q2H (every 2 hours) as
needed for wheezing.
15. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
16. lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO twice a day: 0.25
mg twice a day .
17. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: Six (6)
Tablet PO DAILY (Daily): 6000 mcg .
18. sliding scale insulin
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
0-70 mg/dL Proceed with hypoglycemia protocol Proceed with
hypoglycemia protocol Proceed with hypoglycemia protocol Proceed
with hypoglycemia protocol
71-90 mg/dL 0 Units 0 Units 0 Units 0 Units
91-140 mg/dL 3 Units 3 Units 3 Units 0 Units
141-180 mg/dL 6 Units 6 Units 6 Units 2 Units
181-220 mg/dL 9 Units 9 Units 9 Units 4 Units
221-280 mg/dL 12 Units 12 Units 12 Units 6 Units
19. insulin glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime.
20. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
21. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Coronary artery disease s/p CABG
Anemia
Diabetes Mellitus
Dyslipidemia
Hypertension
Chronic Renal Insufficiency (creatinine 1.5- 1.9)
Gastroesophageal reflux disease
Hiatal hernia
Spinal Stenosis
Benign prostatic hypertrophy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram as needed
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right - healing well, no erythema or drainage, significant
ecchymosis knee up through thigh no warmth
Edema +1 pitting bilateral lower extremities
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
Wound check Cardiac surgery office [**Telephone/Fax (1) 170**] on [**6-15**] at 11 am
Surgeon: Dr. [**First Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 170**] on [**6-30**] at 1:00pm
Cardiologist: Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] [**Telephone/Fax (1) 62**] on [**7-6**] at 3:00pm
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 172**] in [**3-1**] 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:[**2107-6-9**]
ICD9 Codes: 2875, 2859, 2724, 5859 |
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