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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1200
} | Medical Text: Admission Date: [**2192-10-23**] Discharge Date: [**2192-11-30**]
Service: MEDICINE
Allergies:
Penicillins / Ciprofloxacin / Atenolol / Amiodarone /
Diphenhydramine / Neosporin / Tetanus Toxoid,Adsorbed /
Vancomycin / Bactrim Ds / Heparin Agents
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
hypotension, altered mental status.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
89F with multiple medical problems who presented to [**Hospital1 18**] on
[**2192-10-23**] d/t hypotension from E. coli urosepsis in setting of
poor PO intake, hypovolemia, and poor IV access/fluid
administration. Briefly, the patient is s/p recent 1 month
admission to [**Hospital3 **] for COPD exacerbation, complicated by
AIN [**12-28**] Cipro, and hypernatremia, discharged to [**Hospital 100**] rehab.
She was admitted to the MICU on [**10-23**] w/ urosepsis and
hypotension, and required dopamine and dobutamine for septic
shock with cardiogenic shock component and was given stress dose
steroids for adrenal insufficiency. She was initially treated
with Linezolid, meropenem, and gentamycin which was narrowed to
ceftriaxone once E.coli identified (completed 10 day course).
She was called out to floor on [**10-28**] and remained HD stable with
tapering of steroids (finished [**11-14**]). On [**11-6**] the patient was
hypothermic and blood cultures were drawn and demonstrated
Stenotrophomonas bacteremia; she was started on Bactrim which
was changed to ceftaz on [**11-13**] due to worsening renal failure
with plan for 14 day course. 2 days after finishing Ceftaz she
became hypothermic on the floor (temps to 91) and hypotensive.
She was transferred to the MICU on [**11-22**] - where she responded
to IVF/warming blanket. She was started on stress dose
steroids. Stat Abd CT only showed left pleural fluid collection
(although study inadequate due to lack of contrast). Blood
cultures have remained negative since [**11-8**]. Urine has grown
yeast, she is s/p one dose of fluconazole for yeast in her urine
with continued yeast despite this dose. She had a renal US today
to evaluate for possible abscess and received a second dose of
fluconazole.
.
In regards to ARF, patient developed AIN at OSH d/t cipro and
was prerenal d/t septicemia. Her renal function improved daily
as HD's improved, with renal following. Developed exacerbation
while on bactrim, which was stopped. Cr drifted down to a low of
1.0, but she has been intermittently diuresed d/t whole body
anasarca, leading to worsening renal function again - lasix was
stopped on [**11-21**]. Additionally, there was concern for HIT as PF4
was positive but SRA negative so no longer on treatment with
argatroban for HIT. Also, patient has had significant whole body
edema d/t RV failure and hypoalbuminemia and she was
intermittently diuresed as above.
.
On review of systems, the patient denies any chest pain,
shortness of breath, night sweats, fevers, chills, weight loss,
night sweats, fatigue, headaches, dizziness, blurred vision,
sore throat, nausea, vomiting, abdominal pain, any new rashes,
denies dysuria, hematuria, increased urgency, diarrhea,
constipation, hematochezia, melena, epistaxis. All other
systems reviewed in detail and negative except for what has been
mentioned above.
Past Medical History:
CAD s/p left circumflex stent in [**2182**]
COPD
CHF
HTN
Hyperlipidemia
Sick sinus syndrome s/p pacemaker placement [**2188**]
Syncope
PAF
GERD
Diverticulosis of the sigmoid colon
s/p colon resection [**12-28**] colonc cancer
History of VRE in urine and stool
Spinal stenosis
Iron deficiency anemia
Social History:
From [**Hospital **] rehab. h/o smoking. Good family supports.
Family History:
Noncontributory.
Physical Exam:
ADMISSION EXAM
VS: t: 96.1; BP: 104/36; HR: 75; RR: 16; O2: 99 5L
Gen: Lethargic, though easily arousable. Words are slightly
mumbled but in NAD
HEENT: Left surgical pupil. R pupil ERRL; EOMI; sclera
anicteric; conjunctiva slightly pale
Neck: JVD to mandible. No LAD
CV: RRR S1S2. No M/R?
Lungs: Scattered crackles at bases, course sounds. Pt unable to
take in deep breaths of me.
Ext: 2+ pitting edema b/l. DP 1+
Neuro: Difficult to do exam. CN II-XII tested, intact. Can grip
hands and moves all four limbs. Biceps, brachio, pattella [**11-27**].
Skin: Scattered diffuse erythematous, nonwarm rash throughout.
On back blachable with few echhymotic areas. Scattered erythema
on abdomen, extremities and face. No pustules or macules.
Confluencing in areas.
Pertinent Results:
Hematology:
[**2192-10-23**] 01:05PM PT-15.0* PTT-33.8 INR(PT)-1.3
[**2192-10-23**] 09:18AM WBC-4.9 RBC-3.31* HGB-10.1* HCT-30.5* MCV-92
MCH-30.5 MCHC-33.1 RDW-21.4*
[**2192-10-23**] 09:18AM NEUTS-74* BANDS-14* LYMPHS-6* MONOS-1* EOS-4
BASOS-0 ATYPS-0 METAS-0 MYELOS-1*
.
Chemistry:
[**2192-10-23**] 09:18AM GLUCOSE-135* UREA N-62* CREAT-2.3* SODIUM-141
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-24 ANION GAP-17
[**2192-10-23**] 09:18AM proBNP-6508*
[**2192-10-23**] 09:18AM CALCIUM-8.4 PHOSPHATE-4.4 MAGNESIUM-2.3
[**2192-10-23**] 01:05PM FIBRINOGE-341
[**2192-10-23**] 09:18AM CORTISOL-11.2
[**2192-10-23**] 01:58PM TSH-1.6
[**2192-10-23**] 01:58PM CORTISOL-23.8*
[**2192-10-23**] 01:05PM CORTISOL-21.2*
[**2192-10-23**] 06:51AM LACTATE-1.0
[**2192-10-23**] 06:45AM CK(CPK)-21*
[**2192-10-23**] 06:45AM CK-MB-NotDone cTropnT-0.06*
[**2192-10-23**] 05:20AM PO2-36* PCO2-51* PH-7.35 TOTAL CO2-29 BASE
XS-0
[**2192-10-23**] 12:50AM ALT(SGPT)-31 AST(SGOT)-34 CK(CPK)-25* ALK
PHOS-255* AMYLASE-42 TOT BILI-0.7
[**2192-10-23**] 12:50AM LIPASE-63*
.
Other Data:
[**2192-11-26**]: C.diff negative
[**2192-11-25**]: Urine culture: YEAST. >100,000 ORGANISMS/ML.
2ND ISOLATE. <10,000 organisms/ml.
[**2192-11-23**]: Blood culture x 2 pending
[**2192-11-8**]: Blood culture STENOTROPHOMONAS (XANTHOMONAS)
MALTOPHILIA.
ANAEROBIC BOTTLE (Final [**2192-11-15**]):
PORPHYROMONAS SPECIES. BETA LACTAMASE NEGATIVE.
.
[**10-23**] CXR IMPRESSION: Interval increase in size in the cardiac
silhouette that may represent increasing heart size, or perhaps
a pericardial effusion. There is no evidence of failure.
.
[**10-23**] Head CT: A hypodense focus in the right lentiform nucleus,
which could represent subacute infarction. Please note
sensitivity of MR is much higher than the present CT in
detecting acute brain ischemia.
.
[**10-24**] Echo: Conclusions: 1. The left atrium is moderately
dilated. The left atrium is elongated. 2. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). 3.The right ventricular cavity is mildly dilated.
[Intrinsic right ventricular systolic function is likely more
depressed given the severity of tricuspid regurgitation.]
4.The ascending aorta is mildly dilated. 5.The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. No aortic regurgitation is seen. 6.The mitral valve
leaflets are mildly thickened. Mild to moderate ([**11-27**]+) mitral
regurgitation is seen. 7.Severe [4+] tricuspid regurgitation is
seen. 8.There is moderate pulmonary artery systolic
hypertension. 9.There is no pericardial effusion. Compared
with the findings of the prior study (images reviewed) of
[**2189-6-11**], the RV is now mild to moderately dilated with severe
TR.
.
[**10-25**] Renal US: Evidence of some bilateral renal cortical
atrophy. No signs of obstruction. Small left effusion noted
.
[**10-29**] KUB: Moderate amount of air and stool throughout the colon.
No
dilated bowel.
.
[**10-23**] CXR IMPRESSION: Interval increase in size in the cardiac
silhouette that may represent increasing heart size, or perhaps
a pericardial effusion. There is no evidence of failure.
.
[**10-23**] Head CT: A hypodense focus in the right lentiform nucleus,
which could represent subacute infarction. Please note
sensitivity of MR is much higher than the present CT in
detecting acute brain ischemia.
.
[**10-24**] Echo: Conclusions: 1. The left atrium is moderately
dilated. The left atrium is elongated. 2. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). 3.The right ventricular cavity is mildly dilated.
[Intrinsic right ventricular systolic function is likely more
depressed given the severity of tricuspid regurgitation.]
4.The ascending aorta is mildly dilated. 5.The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. No aortic regurgitation is seen. 6.The mitral valve
leaflets are mildly thickened. Mild to moderate ([**11-27**]+) mitral
regurgitation is seen. 7.Severe [4+] tricuspid regurgitation is
seen. 8.There is moderate pulmonary artery systolic
hypertension. 9.There is no pericardial effusion. Compared with
the findings of the prior study (images reviewed) of [**2189-6-11**],
the RV is now mild to moderately dilated with severe TR.
.
[**10-25**] Renal US: Evidence of some bilateral renal cortical
atrophy. No signs of obstruction. Small left effusion noted
.
[**10-29**] KUB: Moderate amount of air and stool throughout the colon.
No
dilated bowel.
.
[**11-22**]: CT Abdomen/Pelvis
1. Limited examination due to lack of intravenous contrast and
large amount of streak artifact within the pelvis due to patient
body habitus. Given these limitations, no definite evidence of
colitis or diverticulitis identified.
2. Moderate-sized left side pleural fusion and asymettric soft
tissue swelling of left chest wall.
3. Extensive degenerative changes of the thoracic and lumbar
spine with compression fractures of T8 and T9 vertebral bodies
of uncertain chronicity.
4. Midline omental containing hernia. No evidence of infarction
or bowel obstruction. Large amount of stool in rectal vault.
.
[**11-23**]: CT Chest
1. Limited study due to the lack of intravenous contrast [**Doctor Last Name 360**]
and motion artifact.
2. Cardiomegaly, pericardial effusion, and moderate pleural
effusion on the left and small pleural effusion on the right
with associated atelectasis. The evaluation of the underlying
cause of effusion is limited due to the lack of intravenous
contrast [**Doctor Last Name 360**].
3. Enlarged left thyroid gland with 2-cm nodule.
4. Findings suggestive of tracheobronchomalacia with mucous
secretion in the right main bronchus and bronchus intermedius
and lower lobe bronchi.
5. Small amount of ascites and gallstone. Evaluation of the
upper abdomen is limited.
6. Left upper lobe opacity. Follow-up to comfirm resolution.
.
[**11-27**]: Renal US:
The right kidney measures 10.1 cm. The left kidney measures
10.4
cm. There are no stones, hydronephrosis, or perinephric fluid
collection bilaterally. Again seen is evidence of cortical
atrophy.
There is mild-to-moderate amount of ascites.
.
[**11-29**]: Thyroid US:
Study is limited by patient respiratory motion. Right
thyroid gland measures 2.5 x 2.1 x 3.7 cm, and the left thyroid
gland measures 2.8 x 2.8 x 3.3 cm. Both lobes are heterogeneous
with multiple masses. The largest nodule is within the left
mid/lower pole of the thyroid gland and measures 2.4 x 1.3 x 2.2
cm. This nodule corresponds to the nodule noted on recent CT,
and is likely stable dating back to [**2189-5-26**] when a chest
radiograph demonstrated fullness of the left superior
mediastinum. IMPRESSION: Multinodular goiter
Brief Hospital Course:
89F w/ multiple medical problems admitted initially to MICU with
E. coli urosepsis, now resolved, complicarted by ARF,
stenotrophomonas bactermia, hypotension, adrenal insufficiency,
GI bleeding, HIT type 2, hospital-acquired pneumonia.
.
# Adrenal insufficiency: She has had cortisol levels in the
past, both in the setting of sepsis and while completing a
steroid taper, which have been consistent with both relative and
absolute adrenal insufficiency, respectively. She had a normal
cosynotropin stim test on [**11-23**], however cortisol level was <19
in setting of hypotension so started on stress-dose steroids.
After receiving two days of stress dose steroids, she was
transitioned to prednisone 10mg and tapered to 5mg at discharge
which she should continue for 2 days. She will followup with
endocrine as an outpatient.
.
# Hypotension: Initially likely [**12-28**] hypovolemia and ?adrenal
insufficiency and responded well to IVFs and steroids. The
patient is chronically low temperatures, raising concern for
infectious source but blood cx neg since [**11-8**] and no
leukocytosis. Urine culture since E.coli with only yeast (see
below).
.
# Altered mental status: Delirium on transfer to MICU, which
improved with treatment of hypotension and hypothermia. All
sedating meds were briefly held until mental status improved.
A&Ox3 at discharge.
.
#. ID: The patient was admitted with a E coli UTI and likely
urosepsis (hypotensive and hypothermic, though no positive blood
cultures). She was admitted to the ICU and initially required 2
pressors to maintain her blood pressure. She improved with
Ceftriaxone and stress dose steroids, and was sent to the
medical floor on day 4, where she remained hemodynamically
stable, afebrile and with negative cultures. She completed a 10
day course of Ceftriaxone. Her steroids were slowly tapered.
.
However, on [**11-6**] the patient became lethargic and hypothermic;
blood cultures grew Stenotrophomonas. She was initally started
on Cefepime, which was changed to Bactrim when the speciation
was performed. She was then changed to ceftaz on [**11-13**] due to
rising creatinine from the bactrim; she completed a full course
of ceftaz on [**2192-11-22**].
On [**11-23**], the patient again became hypotensive, workup
significant only for urine culture with yeast likely [**12-28**]
foley/antibiotics, which was treated with a two doses of
fluconazole. Renal U/S revealed no evidence of abscess or fluid
collection. Repeat urine culture [**11-28**] with 10-100K yeast but
patient asymptomatic. Last positive blood culture was [**11-8**].
.
A worsening retrocardiac opacity was noted on her CXR, she was
started on empiric meropenem and linezolid for hospital acquired
pneumonia. Without a confirmed organism, linezolid was stopped
after 4 days and she will complete a 10 day course of meropenem
(started [**11-23**]; will complete [**12-2**]). Aspiration precautions. Good
SaO2, afebrile, and comfortable at discharge.
.
# HIT Type 2: 1. The patient's platelets fell from 132 on
admission to 71 on [**10-29**]. HIT antibody was positive; therefore
the patient was started on argatroban and all heparin products
were discontinued. Her platelets trended up, and coumadin was
added when her platelets were >100. However, as the pretest
probability of HIT was low, a serotonin releasing antibody was
sent as well; this result returned negative. Hematology was
[**Month/Day (4) 4221**] and recommended heparin be still listed as allergy as
possible HIT. She will be discharged on coumadin for both
possible HIT and afib.
.
#. GI bleed/ANEMIA: The patient has a chronic anemia with a
baseline Hct of 29-30, and is on epo as an outpatient. Her
stool was persistantly heme + throughout her admission, though
without frank blood. The patient has a history of colon CA s/p
resection. GI was [**Month/Day (4) 4221**]; however the patient has had
numerous EGD's and colonoscopies in the past 2 years for this
chronic problem, therefore GI recommended continuing
anticoagulation for HIT type 2 as above and pursuing a capsule
endoscopy as an outpatient (scheduled to followup with Dr.
[**First Name (STitle) 572**]. Epo was discontinued prior to discharge as her Hct was
33 and stable. She was given Iron supplements given her ongoing
GI blood loss and started on a PPI [**Hospital1 **]. She did require PRBC
transfusion while her INR was supertherapeutic; presumably the
anticoagulation accelerated her chronic slow GI blood losses.
Hct remained stable at discharge (~30). She will need repeat Hct
checks with her INR's to ensure no increasing blood loss and
outpatient GI workup as above.
.
# RENAL/ELECTROLYTES:
1. ARF: The patient had an episode of AIN at the OSH during her
recent admission [**12-28**] Cipro. She was admitted with an elevated
Cr likely due to prerenal ARF secondary to septicemia coupled
with resolving AIN. Renal was [**Month/Day (2) 4221**]. The patient's renal
function improved daily as the patient became hemodynamically
stable, and returned to her baseline (1.0) while on the floor.
Nephrotoxic meds were avoided. The patient again developed ARF
when started on Bactrim; her creatinine peaked at 2.0; renal was
reconsulted. Her creatinine improved with discontinuation of
bactrim. Her lasix was held as her renal function recovered, and
now that her creatinine has trended down to 1.3, she is being
gently diuresed for total body volume overload on her home lasix
dose of 40mg [**Hospital1 **].
.
2. HYPERNATREMIA- The patient developed hypernatremia with a
free water deficit as high as 4.5 L despite being 8L positive
for length of stay. The hypernatremia resolved with gentle
fluids (D5w), encouragement of PO free water intake, and
tapering of her stress dose steroids.
.
3. Hypokalemia- The patient had hypokalemia on admission which
resolved with repletion over the first few days of her stay.
.
# CV: Ischemia: CAD s/p left circumflex stent in [**2182**],
hyperlipidemia, HTN. Restarted statin, BB when hypotension
resolved and aspirin when no significant GI bleed. Will defer
starting imdur, ACEi to PCP as outpatient given patients
multiple medication allergies, poor tolerance of new agents, and
GI bleeding. Rhythm: PAF, sick sinus s/p pacer. On Coumadin as
outpatient for afib, d/c'd at OSH during previous admission for
heme positive stool. She was anticoagulated with argatroban
upon diagnosis of HIT, and then bridged to coumadin during her
admission. Continued on BB for rate control. Pump- preserved
EF, however, h/o R sided /diastolic failure and presented with
severe anasarca. Lasix 40 PO BID was started after the patient
became hemodynamically stable and her kidney function had
returned to baseline. She should continue to be diuresed slowly
with goal I/O -0.5 to 1 liter per day. She was continued on her
home dose beta blocker. ACE-I was held given recent ARF; will
defer adding ACE to PCP as outpatient.
.
# COPD / trachebronchomalacia: Continued on scheduled/prn nebs.
?tracheobronchomalacia on [**11-23**] chest CT. IP [**Month/Year (2) 4221**] who
reviewed films and recommended outpatient pulm followup with
possible treatment after maximizing COPD regimen. She is
scheduled to be evaluated in Pulmonary clinic.
.
# Thyroid nodule: A 2cm left lobe nodule was noted incidentally
on CT chest. Thyroid US revealed multinodular goiter. TSH was
3.9 on [**11-24**]; free T4 was sent and is pending. Outpatient
endocrine followup as above.
.
# SKIN- 1. The patient recently developed a severe drug reaction
to Cipro at OSH; and presented with a dermatitis with open
sores. The wound care nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**]. She was initially
treated with fexodenadine and pepcid; these were discontinued as
her rash improved. Her skin was treated with silvadene
cream-->open areas; hydrocortisone cream; sarna PRN per the
wound care nurse. 2. The patient developed perirectal skin
irritation and breakdown due to diarrhea (c diff negative,
likely medication induced). A rectal tube was inserted and
meticulous skin care re: the wound care RN was performed with
improvement.
.
# Nutrition: A Dobhoff feeding tube was placed for nutrition
while her mental status was decreased, but now that MS has
improved, she was able to resume a regular po diet (low Na,
cardiac, [**Doctor First Name **]). The Dobhoff tube was discontinued. A recent
swallow study did not show any aspiration risk.
.
A flu shot was administered.
Medications on Admission:
Tylenol 650 mg q6 prn
Bisacodyl 10 mg qday
MOM
Atarax 10 mg po q6 prn
Ferrous sulfate 325 mg [**Hospital1 **]
Pepcid 20 mg [**Hospital1 **]
Lasix 40 mg po q8am, q2 pm
Combivent inhalers- three times a day
Darbepoetin alpha 60 mcg qc qweek
Colace 100 mg [**Hospital1 **]
Fexodenadine 60 mg qday
Fluticasone/salmeterol 500/50 1 puff [**Hospital1 **]
Guafenisin 1200 mg [**Hospital1 **]
Isosorbide mononitrate 60 mg qday
Toprol XL 25 mg qday
Pantoprazole 40 mg [**Hospital1 **]
Potassium chloride 20 mEq qday
Silvadene cream to rash/eroded areas of neck, chest, arms, legs
and back
Hydrocortisone cream to body rash [**Hospital1 **]
Discharge Medications:
1. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
5. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed.
6. Cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a
day) as needed for itching.
7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-27**]
Drops Ophthalmic PRN (as needed).
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
9. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
sliding scale Subcutaneous ASDIR (AS DIRECTED).
10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to
6 hours) as needed.
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
15. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl
Topical PRN (as needed).
17. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane QID
(4 times a day) as needed.
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
19. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours) as needed for shortness of breath or
wheezing.
20. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 days.
21. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
22. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
23. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours) for 2 days.
24. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
25. Hydroxyzine HCl 10 mg Tablet Sig: One (1) Tablet PO every
six (6) hours as needed for anxiety.
26. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
twice a day.
27. Combivent 103-18 mcg/Actuation Aerosol Sig: [**11-27**] Inhalation
three times a day.
28. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO once a day.
29. Advair Diskus 500-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
30. Guaifenesin 1,200 mg Tablet Sustained Release 12HR Sig: One
(1) Tablet Sustained Release 12HR PO twice a day as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
E coli UTI with urosepsis
Stenotrophomonas bacteremia
HIT type 2
Acute blood loss anemia
[**Hospital **]
Hospital-acquired pneumonia
CHF
.
Secondary:
CAD s/p left circumflex stent in [**2182**]
COPD
HTN
Hyperlipidemia
Sick sinus syndrome s/p pacemaker placement [**2188**]
Syncope
PAF
GERD
Diverticulosis of the sigmoid colon
s/p colon resection [**12-28**] colon cancer
Spinal stenosis
Iron deficiency anemia
Discharge Condition:
Good.
Discharge Instructions:
During this admission you have been treated for a severe urinary
tract infection, bacteremia (a blood infection), acute renal
failure as well as a platelet disorder called Heparin-Induced
Thrombocytopenia type 2.
.
Please continue to take all medications as prescribed.
2gm sodium diet; fluid restriction 1.2L
Measure weights daily, call your doctor if increase > 3 pounds
.
New medications: coumadin, meropenem, metoprolol, prednisone,
atorvastatin, aspirin
Discontinued medications: toprol XL, erythropoeitin, imdur,
potassium
.
Please call your doctor or come to the emergency room
immediately if you develop fevers, chills, confusion, chest
pain, shortness of breath, incontinence, black or bloody stools,
or any other concerning symptoms.
Followup Instructions:
Follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in 2 weeks, call [**Telephone/Fax (1) 14943**].
.
Gastroenterology: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4465**], MD Date/Time:[**2192-12-6**] 2:15.
Please discuss your guaiac positive stools and possibly
obtaining a capsule endoscopy.
.
Pulmonary: DR. [**First Name8 (NamePattern2) 5445**] [**Last Name (NamePattern1) 1843**]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2192-12-17**] 2:30. [**Hospital1 18**], [**Hospital Ward Name 23**] building [**Location (un) 436**].
Please discuss management of your COPD and possible further
evaluation for tracheobronchomalacia.
.
Endocrinology: [**Name6 (MD) 21503**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2193-1-8**] 2:00. [**Hospital1 18**], [**Hospital Ward Name 23**] building [**Location (un) 436**].
Please discuss further evaluation of your multinodule goiter and
prior diagnosis of adrenal insufficiency.
ICD9 Codes: 486, 5119, 2760, 2851, 5859, 2930, 2768, 5845, 4280, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1201
} | Medical Text: Admission Date: [**2116-4-9**] Discharge Date: [**2116-4-14**]
Date of Birth: [**2036-4-9**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Lipitor
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
coronary artery disease
Major Surgical or Invasive Procedure:
coronary artery bypass grafts x 3 (LIMA-LAD,SVG-OM,SVG-diag)
[**4-10**]
History of Present Illness:
This 80 year old female with chronic, stable exertional angina,
developed chest and back pain on [**4-7**]. This resolved after
three nitroglycerins. She had recurrent pain the next day while
seeing her primary care physician. [**Name10 (NameIs) **] was admitted elsewhere
and ruled out for infarction with troponins of 0.14.
Cathterization was done which demonstrated double vessel and was
transferred fro surgery.
Past Medical History:
Hypertension
Hyperlipidemia
varicose veins-for surgery w/[**Last Name (un) 3407**] [**4-30**]
s/p bilat cataract surgery
hematuria followed by Dr. [**Last Name (STitle) 17696**]
Ovarian cyst removal
Umbilical hernia
s/p cataract surgery
Social History:
Race:Russian
Last Dental Exam:does not like to visit dentist, per pt. has
many
broken teeth that need to be extracted
Lives with: alone
Occupation:
Tobacco: denies
ETOH:occasional small amount
Family History:
noncontributory
Physical Exam:
admission:
Pulse:67 Resp:18 O2 sat: 98%
B/P Right: 135/74 Left:
Height: Weight:
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 3/6 SEM, loudest at R
sternal border
Abdomen: Soft [x] non-distended [x] pain over suprapubic area,
worse w/palp[] bowel sounds + [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
bilat
Neuro: Grossly intact[x]
Pulses:
Femoral Right: 2+ Left:2+
DP Right:1+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right: none Left:none
Pertinent Results:
[**2116-4-14**] 04:30AM BLOOD WBC-8.0 RBC-2.74* Hgb-8.2* Hct-24.2*
MCV-88 MCH-29.9 MCHC-33.9 RDW-12.8 Plt Ct-267
[**2116-4-13**] 04:25AM BLOOD WBC-10.5 RBC-2.80* Hgb-8.7* Hct-24.7*
MCV-88 MCH-31.0 MCHC-35.1* RDW-12.8 Plt Ct-201
[**2116-4-9**] 11:24PM BLOOD WBC-8.9 RBC-4.35 Hgb-13.8 Hct-37.7 MCV-87
MCH-31.8 MCHC-36.7* RDW-13.2 Plt Ct-297
[**2116-4-14**] 04:30AM BLOOD UreaN-43* Creat-1.3* K-4.4
[**2116-4-9**] 11:24PM BLOOD ALT-16 AST-17 LD(LDH)-175 AlkPhos-125*
Amylase-58 TotBili-2.4*
[**2116-4-9**] 11:24PM BLOOD Glucose-123* UreaN-23* Creat-0.8 Na-140
K-4.0 Cl-103 HCO3-28 AnGap-13
Brief Hospital Course:
Following admission she was taken the next day to the Operating
Room where revascularization was performed. See operative note
for details. She weaned from bypass on Propofol alone. She was
extubated easily and CTs and wires were removed uneventfully.
Following transfer to the floor she was seen by Physical Therapy
for mobility and strength. Wounds were clean and healing well.
She had brief atrial fibrillation which converted to sinus
rhythm with IV and then oral Amiodarone. Sinus rhythm persisted
after that brief episode.
She was transferred to a rehabilitation facility for further
recovery prior to return home. Medications, restrictions and
follow up are as outlined elsewhere.
Medications on Admission:
Atenolol 25 mg daily
Aspirin 81 mg daily
Nitroglycerin patch prn
Nitroglycerin 0.4 mg sublingual q5 minutes prn chest pain
Ambien 5 mg daily
Zocor 10 mg daily
Procardia 10mg daily
Senokot unknown dose
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Amiodarone 200 mg Tablet Sig: as written Tablet PO BID (2
times a day) for 4 weeks: two tablets twice a day for two weeks,
then one tablet twice daily for two weeks, then discontinue.
4. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Risperidone 1 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/temp. Tablet(s)
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
10. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] rehab center of the [**Location (un) **]
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts
hypertension
hyperlipidemia
s/p bilateral cataract extractions
Discharge Condition:
Alert and oriented x3, nonfocal.
Ambulating with steady gait.
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Discharge Instructions:
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.
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**]).
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge of sternal wound.
**Please call cardiac surgery office with any questions or
concerns ([**Telephone/Fax (1) 170**]). Answering service will contact on call
person during off hours.**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] on [**Last Name (LF) 766**], [**5-18**] at 1:30pm
Please call to schedule appointments with:
Primary Care: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17697**] ([**Telephone/Fax (1) 4606**]) in [**11-23**] weeks
Cardiologist:. Dr. [**Last Name (STitle) 17698**] in [**11-23**] 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.**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2116-4-14**]
ICD9 Codes: 4111, 5180, 4019, 2724, 4241 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1202
} | Medical Text: Admission Date: [**2135-2-1**] Discharge Date: [**2135-2-4**]
Date of Birth: [**2048-10-7**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1185**]
Chief Complaint:
hemoptysis
Major Surgical or Invasive Procedure:
Rigid bronchoscopy.
History of Present Illness:
Mr. [**Known lastname 1968**] is an 86yo M with PMH of metastatic renal cell
carcinoma with metastasis to the right lung, with endobronchial
disease, s/p broncheal stenting in [**2133**], with multiple episodes
of non-massive hemoptysis, and recent rigid bronchoscopy with
balloon dilatation of Bronchus intermedius, who is admitted to
the MICU with hemoptysis. .
.
Two days prior to admission he had worsening of his chronic
cough with associated retching and nausea. He felt feverish and
noted maximum temperature 98.2 at home. He was seen in [**Location (un) **]
[**Last Name (un) 19700**] treated with nebulizer treatments and discharged home.
Around midnight following day, he began coughing up blood in
teaspoon quantities which he estimates adds up to approximately
3/4-1 cup. He developed dyspnea and returned presented to
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**] hospital. Where vitals were 148/80 79 18 97%
RA. HGB/HCT was 13.6/41, INR 1.1. He was given 500cc IVNS and
albuterol/atrovent nebs. Non-Con CT chest showed known pulmonary
mets apparently unchanged from [**2135-1-4**] thought the final read
was not available. He was transferred to [**Hospital1 18**] ED for further
management.
.
In the ED inital vitals were, 97.8 62 138/72 20 97% 2L NC. Labs
were notable for Na 130, WBC 3.3, Hgb/Hct 12.5/37, Plts 129,
normal coags. CXR showed elevated right hemidiaphragm with
minimal mediastinal shift to the right. He was not given any
blood transfusions or intervenous fluids. He was seen by IP who
recommended bronch with rigid scope and admission to the ICU for
close monitoring. Vitals on transfer were P:71 BP:151/65 20 100%
3LNC.
.
Of note, patient underwent bronchoscopy [**2135-1-17**] with where
stenosis of the bronchus intermedius stent was noted and treted
with balloon dilation of the right middle segment/bronchus
intermedius and tumor ablation with electrocautery of
granulation tissue within the stent and in the distal end of the
stent.
Past Medical History:
Oncologic History:
- in [**4-/2122**] Mr. [**Known lastname 1968**] had a right-sided kidney lesion found
incidentally. He underwent a right nephrectomy at [**Hospital1 84018**]. Pathology noted a 3-cm clear cell lesion,
grade I - II, confined to the cortex. Ureteral & vascular
margins were free of tumor, no vascular invasion was seen.
Right adrenal gland was (-). He was followed serially with CT
scans.
- in late [**2132**], developed recurrent hemoptysis which prompted
ENT evaluation & chest imaging, which showed a compressive mass
in the right bronchus. He had a flexible bronchoscopy at
[**Hospital1 1562**] complicated by significant bleeding & was transferred
to [**Hospital1 18**] [**2133-1-14**]. Chest CT showed a mass encasing the right
pulmonary artery & invading the bronchus intermedius. He
underwent a rigid bronchoscopy w/ tumor biopsy, debridement, &
stent placement [**2133-1-15**]. underwent argon plasma coagulation.
- He had brachytherapy at [**Hospital3 2358**].
- on [**2133-5-27**] he had a metal stent placed by IP.
- on [**2133-6-8**] started on sunitinib.
- on [**2133-6-18**] developed hemoptysis requiring Sutent hold through
[**2133-6-23**] & again [**Date range (1) 36573**].
- [**Date range (1) 14706**] Sutent was restarted, completed 1 cycle; but [**2133-7-21**]
bloodwork showed low WBC/Plts, drug was again held through
[**2133-8-8**]. He returned [**2133-8-25**] & reported scant hemoptysis x 2
days & his Sutent was stopped. He was then on 25mg x14 days of
28 day cycle.
- on [**2133-11-25**], saw Dr. [**Last Name (STitle) **] for bronchoscopy which showed stent
in good position, no endobronchial lesions were seen.
- [**2133-12-29**] with ongoing cough, sputum production. trial of
albuterol INH & Pulmonology recommended use of PPI/fluticasone.
He was seen again 2 weeks later, w/o improvement in his
symptoms.
- [**1-9**] Platelets>150 and CT chest showed interval growth of
right hilar mass, w/ worse occlusion of the R mainstem bronchus.
We then increased Sutent dosing to 37.5mg/day on 2 week on, 2
week off basis.
- in follow-up [**2134-2-2**], his cough had improved but plts were low,
necessitating hold
- on [**2134-2-17**], restarted once plts 98
- follow-up [**2134-3-2**], He was doing well apart from ongoing
respiratory symptoms of cough, sputum production & scant
hemoptysis/mild epistaxis. His platelets were 109. At that time
we discussed possibly resuming Sutent earlier than 2 weeks off
therapy if respiratory symptoms persisted. He resumed drug 1
week later & returned [**2134-3-30**]. He did well w/ only scant
hemoptysis. He had stopped Flonase due to epistaxis.
- on [**2134-4-1**] bronchoscopy w/ Dr. [**Last Name (STitle) **] which showed a large
endobronchial lesion in the [**Hospital1 **], friable w/ stent [**03**]% occluded.
- on [**2134-5-18**] was doing well apart from scant hemoptysis.
platelets were stable at 95.
- on [**2134-6-8**], for follow up, doing well apart from 2-3 days of
pruritic rash on left sided torso consistent with herpes zoster.
We initiated valacyclovir TID for 14 days. He developed pain at
the site which continued despite use of Tylenol and was
prescribed a lidocaine patch.
- On [**2134-7-13**] CT appeared to show overall minimal decrease
to affected area and decreased compression of the right main
stem bronchus. Stable appearance of the stent within the
bronchus intermedius. Notable is interval development of a left
adrenal nodule with rim of enhancement given characteristics and
rapid growth concerning for metastasis. Interval resolution of
the right pleural effusion.
- On [**2134-9-30**] pulm rigid bronch revealed his metal stent
well-covered with granulation tissue was visualized in the
bronchus intermedius. An 80% stenosis to the right lower lobe
was seen distal to the stent, and the bronchoscope could not
pass. Electrocautery was used in strips along the [**Hospital1 **], then
forceps were used to gently open the RLL to 60-70% remaining
stenosis.
PMH/PSH:
Renal cell Carcinoma
Hypothyroidism,
Lyperlipidemia,
Hypertension.
Status post partial right adrenalectomy, and right nephrectomy
Social History:
He is married and he and his wife live on [**Hospital3 4298**]. His
wife was recently diagnosed with early stage breast cancer and
is being seen by Dr. [**First Name (STitle) **] here at [**Hospital1 18**] from Breast Oncology. Pt
worked for an investment firm in [**Location 8398**]and retired 20
years ago. He smoked a pipe one to two times a day for >20 years
and smoked cigars for two years. He drinks one scotch every
three weeks
Family History:
Father mastoid infection and died in his 50s.
Mother CHF died in her 70s.
Older sister alive and well.
Three adult children alive and well.
Physical Exam:
Admission exam
Vitals: T:97.2 BP:143/72 P:67 R:20 O2:93% 2LNC
General: Elderly male wearing glasses appearing comfortable,
occasionally coughing, alert, oriented, no acute distress
HEENT: Pink conjunctiva, no crusted blood in nasopharynx or oral
pharynx
Neck: supple, JVP not elevated, no LAD
Lungs: Broncheal breath sounds on the rigt, left CTA. No wheezes
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, trace ankle edema.
Labs: see below
Discharge exam:
Vitals: T:97.0 128/75 p65 r20 98%
General: Elderly male wearing glasses appearing comfortable,
occasionally coughing, alert, oriented, no acute distress
HEENT: Pink conjunctiva, no crusted blood in nasopharynx or oral
pharynx
Neck: supple, JVP not elevated, no LAD
Lungs: Broncheal breath sounds on the right, left CTA. Faint
expiratory wheezes and rhonchi, R>L.
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, trace ankle edema.
Labs: see below
Pertinent Results:
Admission labs
[**2135-2-1**] 03:23PM BLOOD WBC-3.5* RBC-3.81* Hgb-12.4* Hct-35.9*
MCV-94 MCH-32.7* MCHC-34.7 RDW-14.2 Plt Ct-118*
[**2135-2-1**] 09:50AM BLOOD Neuts-75.9* Lymphs-15.4* Monos-5.9
Eos-2.4 Baso-0.3
[**2135-2-1**] 09:50AM BLOOD PT-12.2 PTT-32.3 INR(PT)-1.1
[**2135-2-1**] 09:50AM BLOOD Glucose-112* UreaN-14 Creat-1.1 Na-130*
K-7.2* Cl-97 HCO3-27 AnGap-13
[**2135-2-1**] 09:50AM BLOOD Phos-3.5 Mg-1.6
Discharge labs
Studies
[**2134-2-1**] CXR: The cardiac and mediastinal contours appear
unchanged including moderate tortuosity of the aorta. The heart
is probably normal in size. Elevation of the right hemidiaphragm
with substantial opacity involving the right hilum and nearby
cardiophrenic sulcus appear similar compared to the recent prior
examination. Regarding the lung parenchyma, no definite nodules
are demonstrated radiographically. IMPRESSION: Similar medial
right basilar opacity which is nonspecific but shows air
bronchograms, perhaps associated with radiation fibrosis in the
appropriate setting, although coinciding malignant mass in the
area is not
excluded.
.
[**2135-2-2**] Bronchoscopy in brief: The procedure, indications,
preparation and potential complications were explained to the
patient, who indicated his understanding and signed the
corresponding consent forms. A standard time out was performed
as per protocol. The procedure was performed for diagnostic and
therapeutic purposes at the operating room. A physical exam was
performed. The bronchoscope was introduced orally and advanced
under direct visualization until the tracheobronchial tree was
reached.The procedure was not difficult. The quality of the
preparation was good. The patient tolerated the procedure well.
There were no complications.
.
Other findings: Intubated with 11-12 Dumon-[**Doctor Last Name 25373**] bronchoscope.
The main trachea was normal in appearance. Clear oozing blood
was noted in the RMSB. The flexible bronchoscope was used to
clean the airways. There were no abnormalities of the left sided
airways. The RBI stent was noted to be fractured at multiple
areas. There was a stent post jutting into the RMSB but was not
damaging airway. The stent was clearly fractured at the distal
end. There was a mild increase in bleeding from the proximal
aspect upon entering the stent. The RMSB was intubated with the
rigid scope. Tissue ablation with electrocautery was used to
achieve hemostasis with good effect. Upon further inspection the
RML bronchus was jailed. The RUL was extrisically compressed.
There were no complications.
[**2135-2-3**] Bilateral U/s Lower Extremities:
IMPRESSION: No evidence of DVT within right or left lower
extremities.
[**2135-2-3**] CXR: IMPRESSION: No new areas of consolidation to suggest
an acute pneumonia. Similar post treatment appearance of right
lung as described.
Dishcarge Labs:
[**2135-2-4**] 06:45AM BLOOD WBC-3.3* RBC-3.76* Hgb-12.4* Hct-36.2*
MCV-96 MCH-33.1* MCHC-34.4 RDW-13.9 Plt Ct-110*
[**2135-2-1**] 09:50AM BLOOD Neuts-75.9* Lymphs-15.4* Monos-5.9
Eos-2.4 Baso-0.3
[**2135-2-4**] 06:45AM BLOOD Glucose-122* UreaN-21* Creat-1.1 Na-131*
K-4.1 Cl-94* HCO3-32 AnGap-9
[**2135-2-3**] 09:30PM BLOOD CK(CPK)-147
[**2135-2-3**] 09:30PM BLOOD CK-MB-4 cTropnT-<0.01
[**2135-2-3**] 03:00PM BLOOD CK-MB-5 cTropnT-<0.01
[**2135-2-4**] 06:45AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.6
Brief Hospital Course:
Mr. [**Known lastname 1968**] is an 86yo M with PMH of metastatic renal cell
carcinoma to the lungs, who presents with hemoptysis.
.
# Hemoptysis: While we initially entertained other reasons for
the hemoptysis, the obvious source seemed to be his lung
metasteses. On the night of his admission he underwent rigid
broncoscopy by IP who saw that he had a fractured bronchus
intermedius stent with friable tissue around it, causing right
main stem bleeding. The tissue was cauterized, otherwise
without incident, and then the patient was taken back to the
MICU. He had an uneventful night, and the was transferred to
the floor for additional monitoring. In the MICU that morning
he had a fever to 100.4, which was believed to be from the
procedure, and no cultures were taken, no antibiotics were
given. His O2 saturation and Hct remained stable on the floor
during his stay. Subjectively his cough decreased to him, and
reports that the productive of his cough decreased, was less
bloody. He was initially mainatined on 2L NC O2 coming out of
the MICU, but was weaned do room air. At discharge, he was
walking around the floor relatively quickly, without shortness
of breath or coughing.
.
# Chest Pain: The patient had an episode of chest pain on the
night of his floor stay, and then again during the day on [**2-3**].
The pain he said was typical of a chronic CP that he has
intermittently. They seemed to be related to excercise, after
his finishes walking, non-descript per him, but [**7-10**], right
anterior chest wall, worse with breathing, and lasting for
hours, then spontaneosly resolving. Because of this we cycled
two troponins, which were negative, got a CXR which didn't show
new focal consolidation, and got lower extremity U/S, which was
also negative for DVT. We were initially concerned about PE,
but the history of it wasn't great, was not tachycardic
(although beta blocked), maintaining his O2 saturation on his
own. On the other hand, he has little pulmonary reserve, and PE
could be devastating. Ultimately the CP didn't recur, and no
further work up was done.
.
# Renal Cell Carcinoma: The patient is currently off the Sutent
per his oncologist, who agreed that it was good to stop it for
now. We emailed his oncology team to inform them of everything
that was happening, and they were happy to hear from us.
Otherwise, the decision to resume his Sutent will be made at a
later date by his oncologist.
.
# HTN: Pt is currently currently normotensive, given hemoptysis
will hold antihypertensives until hemostasis has been achieved.
.
# Hypothyroidism: Wasn't an active issue. Continued
Levothyroxine 100mg Daily.
.
# Post herpatic neuralgia: affecting left abdomen. Unchanged
from past, not active during this hospitalization, using
lidocaine patch.
.
.
.
.
Transition Issues:
1) He will require additional instrumentation by IP. The IP
office is going to call him, but the patient was instructed to
call them if he hadn't heard from them in 1 to 2 days.
2) At some time the question of whether to restart his Sutent
will have to be made. that will be decided upon by his oncology
team in conjunction with the interventional pulmonologists.
3) His amlodopine and atenolol were stopped during this
admission due to concern of hypotension and blood loss. He was
normotensive here the entire time, and was discharged without
him starting them again. His blood pressure will need to be
re-checked to resume his medication.
.
.
.
.
.
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA 2 puffs INH q4
AMLODIPINE - 5 mg Daily
ATENOLOL - 50 mg Daily
BENZONATATE - 200 mg TID PRN
CODEINE-GUAIFENESIN - 100 mg-10 mg/5 mL Liquid - 5 ml QHS PRN
LEVOTHYROXINE - 100 mcg Daily
LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch,
OMEPRAZOLE - 20 mg Daily
SIMVASTATIN - 20 mg Daily
SUNITINIB [SUTENT] - 37.5 mg daily two weeks on, one weeks off.
GUAIFENESIN [MUCINEX] - 1,200 mg [**Hospital1 **]
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
2. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. benzonatate 100 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day) as needed for Cough.
4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Topical once a day as needed for pain.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. sunitinib 12.5 mg Capsule Sig: Three (3) Capsule PO once a
day: Daily, two weeks on, one weeks off.
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*50 Capsule(s)* Refills:*1*
10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*50 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
11. codeine sulfate 15 mg Tablet Sig: One (1) Tablet PO every
4-6 hours as needed for cough.
Disp:*50 Tablet(s)* Refills:*1*
12. guaifenesin 1,200 mg Tablet, ER Multiphase 12 hr Sig: One
(1) Tablet, ER Multiphase 12 hr PO twice a day.
Disp:*60 Tablet, ER Multiphase 12 hr(s)* Refills:*2*
13. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Inhalation five times a day as needed for shortness of
breath or wheezing.
Disp:*2 * Refills:*1*
14. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing/dyspnea.
Disp:*20 mL* Refills:*3*
Discharge Disposition:
Home
Discharge Diagnosis:
1) Sub-massive hemoptysis.
2) Fractured endobronchial stent with friable tissue.
3) Shortness of breath.
4) Intermittent chest pain.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 1968**],
It was a pleasure to meet you during your stay here. To
summarize, you came to the hosptial because you were becoming
increasingly short of breath and you were coughing up more blood
than usual. The interventional pulmonologists performed a
bronchoscopy which showed that one of the your stents was
broken, and that you had some bleeding tissue around the stent.
They cleaned the tissue up with cautery, dilated the stent with
a balloon, and this seemed to resolve your symptoms. On the day
after your procedure you had a slight temperature, but that
quickly went down and nothing came of it. You were monitored in
the hospital first in the ICU, and then on the general medical
floor, and then later we determined it was safe for you to go
home. You have a follow up appointment already scheduled with
the pulmonologists for next week.
It was a pleasure to see you, thank you for coming to [**Hospital1 18**].
Followup Instructions:
The Interventional Pulmonologists will call you to schedule an
appointment to be seen in a week or two. If you do not hear
from them in a day, call them at [**Telephone/Fax (1) 7769**].
Their address is :
[**Last Name (LF) **],[**First Name3 (LF) **] MULTI-SPECIALTY
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
MULTI-SPECIALTY THORACIC UNIT-CC9
These are other appointments that you currently have scheduled.
Keep these appointments.
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2135-2-22**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2135-2-22**] at 2:00 PM
With: DRS. [**Name5 (PTitle) **]/[**Doctor Last Name **] [**Telephone/Fax (1) 13016**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2135-2-22**] at 2:00 PM
With: DR. [**First Name8 (NamePattern2) 2801**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]
Completed by:[**2135-2-4**]
ICD9 Codes: 4019, 2875, 2449, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1203
} | Medical Text: Admission Date: [**2129-7-24**] Discharge Date: [**2129-7-28**]
Date of Birth: [**2091-11-30**] Sex: F
Service: .
DISCHARGE DIAGNOSES:
1. Resolved status epilepticus.
2. Eating disorder.
3. Active suicidal ideation.
4. Electrolyte abnormalities.
5. Therapeutic levels of anti-epileptic drugs to be
monitored.
HISTORY OF PRESENT ILLNESS: This is a 37 year old right
handed woman with a complicated past cardiac history and
history of seizure who was transferred to the Neurology
Service following hospitalization in the Intensive Care Unit
for status epilepticus. History was obtained initially from
notes and her MRI. The patient was initially unable to
provide detailed information.
Six weeks prior to presentation at [**Hospital1 190**], she attempted suicide by hanging herself with
duct tape and since has been hospitalized at [**Hospital 1680**]
[**Hospital 7637**] Hospital. Two days ago, on the [**8-23**], she
was witnessed to have what was described as a generalized
tonic-clonic seizure activity, with one episode lasting 30
seconds, and then within 20 minutes, a second episode lasting
one minute. She has more activity on the right side compared
to the left. She was given intramuscular Valium and a bit
later had another seizure and became "unresponsive and
apneic". Paramedics were called and on the way to the
hospital she became pulseless without heart sounds. CPR was
initiated. On the way to [**Hospital1 188**] Emergency Department she was intubated. Tegretol
level was 4.4 that day at [**Hospital1 1680**].
She was extubated one hour later upon arrival to [**Hospital1 346**] and was admitted to the Intensive
Care Unit for overnight observation. However, she had eight
seizures in 45 minutes and was given a total of 12 mg of
Ativan. This resulted in 30 seconds of apnea and she was
re-intubated. She was loaded on Dilantin and apparently had
continued "seizure-like activity" and further loaded on
phenobarbital. Since then, she has been seizure free and was
extubated on the 17th.
PAST MEDICAL HISTORY: (Obtained from patient)
1. The patient reports seizures only a few times a year
since age of 14 when she had her first seizure following
anesthesia for an appendectomy. In recent months, she says
they have been increasing in frequency. She denies history
of head injury and recalls normal birth and development. She
states that she is trained as an R.N. but did have to repeat
first grade. She had an episode by report of status
epilepticus 15 to 20 years ago and, more recently, in [**2129-5-9**], when she was intubated at [**Hospital6 33**]. At
present, she states she has not had any complaint with her
medications and denies any change in medication. She denies
headache but complains of feeling nauseated and dizzy with a
sensation of movement.
Her primary neurologist, Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) 42023**], at [**Hospital3 **],
has obtained multiple EEGs and ambulatory EEG recordings
which were all normal. He reports that she has a history of
a eating disorder and has suspected that she has used
pharmacologic mydriatic [**Doctor Last Name 360**] to "fake" a blown pupil, and
that she has "faked" a Babinski response previously. He has
wondered if she may have non-electrographic seizures and she
apparently was to be evaluated at [**Hospital6 1130**] recently, but this was cancelled because of her
hospitalization at [**Hospital1 1680**].
2. History of depression with suicide attempts in the past.
3. Post-traumatic stress disorder.
4. History of physical and sexual abuse.
5. Her neurologist mentioned also that she has headaches for
which she was taking excessive amounts of Excedrin but which
did not improve with Amitriptyline or Topamax.
6. She has had frequent jaw dislocations.
MEDICATIONS ON ADMISSION:
1. Tegretol.
2. Klonopin.
3. Dilantin.
4. Phenobarbital.
5. Clonidine.
6. Ambien.
7. Seroquel.
8. Zoloft.
9. Nortriptyline.
ALLERGIES: She is allergic to bees.
SOCIAL HISTORY: She is a nurse, currently not working.
Smokes one half a pack a day.
PHYSICAL EXAMINATION: On admission, sleepy woman in no acute
distress although she is sitting on bed with her head down
and holding an emesis basin. She is afebrile; blood pressure
is 92/60; heart rate is 68; respiratory rate 16. Head is
normocephalic, atraumatic. Mucous membranes were moist and
oropharynx clear. Cardiac examination is regular rate and
rhythm with no murmurs, rubs or gallops. Lungs are clear to
auscultation. Extremities are without edema.
NEUROLOGIC EXAMINATION: The patient is sleepy but arouses
briefly to voice. She is slow to respond. She makes two
omissions in reciting the months of the year forward and can
only go backwards up to [**Month (only) **] (question effort). She can
name her parts of the watch and able to repeat. Cranial
nerve examination reveals pupils which are equal, 7 mm, round
and reactive to light to 5 mm. Funduscopic examination is
normal. Visual fields are grossly full to confrontation.
She is uncooperative with formal examination but extraocular
muscles are grossly intact, although it seems like she has
nystagmus on up gaze and lateral gaze. Her face is symmetric
and intact to light touch and pinprick. Hearing is intact to
light finger rub. Tongue and palate are midline. Motor
examination reveals normal bulk and tone. She moves all
extremities but is uncooperative to formal testing. There is
pronator drift to the right which appears functional as hand
drops down due to what seems to be lack of effort. Deep
tendon reflexes are symmetric. Plantar responses flexor
bilaterally. Sensory examination is grossly intact to light
touch, temperature and vibration. Gait testing is deferred
at this time.
IMAGING: Head CT scan did not show any hemorrhage or
ischemia. An EEG that was done while the patient was in the
Intensive Care Unit showed diffuse beta activity with burst
of slowing. There were no epileptiform features.
HOSPITAL COURSE: The patient was admitted to the Neurology
Service for close monitoring of reported seizure-like
activity. While she was on our service, she did not have any
further seizures. Management was as follows:
1. Another EEG was done on the 20th, that showed
disorganized background with beta activity likely due to
benzodiazepines and phenobarbital. She also had very
infrequent bursts of generalized left slowing, but there was
importantly, no focal slowing. Also, importantly, there were
no epileptiform activity.
2. We had a difficult time in trying to give her proper
nutrition because she would refuse. For this reason, she
also had some electrolyte abnormalities, including potassium
that went down to 3.0, and magnesium that went down to 1.5.
She was given magnesium oxide supplement and potassium
chloride supplement and her electrolyte values on the day of
discharge are within normal limits.
3. She was continued on Dilantin that was started in the
Intensive Care Unit. It is currently at 350 mg q. day. She
was continued on Tegretol which was 200 mg three times a day
but we have increased it to 300/200/200. This morning, her
Dilantin level is 15.6 and Tegretol level is 4.7. Potassium
is 3.6 and magnesium is 1.6, all within normal limits.
4. Psychiatry consultation was involved and they gave
recommendations to start all of her psychiatric medicines
that she was on at [**Hospital1 1680**] which was done. They also favored
transfer to [**Hospital 1680**] Hospital after she had been cleared from a
neurology standpoint.
5. Given the significant element of overlay, it is
impossible to determine whether she has had any clinically
electrographic seizures, short of having her prolonged
Telemetry and monitoring this way. Because her primary
neurologist wishes to have her be followed at [**Hospital6 2121**], we will defer these studies at the
discretion of her primary neurologist. Should there be a
re-evaluation in this direction, the Epilepsy Center at [**Hospital1 1444**] would be happy to follow this
patient.
MEDICATIONS ON TRANSFER:
1. Tylenol 325 to 650 mg q. four to six p.r.n. pain.
2. Phenytoin 350 mg p.o. q. day.
3. Potassium carbonate 500 mg p.o. twice a day.
4. Neutra-Phos one packet p.o. twice a day.
5. Haloperidol 200 mg intramuscularly q. four p.r.n.
agitation.
6. Carbamazepine 300 mg in the morning, 200 mg at noon and
200 mg in the evening.
7. Clonazepam 2 mg p.o. three times a day 45 minutes before
meals.
8. Clonazepam 2 mg p.o. q. h.s.
9. Nortriptyline 50 mg p.o. q. h.s.
10. Seroquel 200 mg p.o. q. h.s.
11. Seroquel 25 mg p.o. q. h.s. p.r.n., extra dose for night
terror as needed.
12. Zoloft 50 mg p.o. q. day.
13. Folic acid/ multivitamin / thiamine, one tablet p.o. q.
day.
Please note that she may need to have intravenous "banana
bag" if her nutritional status does not improve. This
management decision will have to be made by her psychiatrist
at [**Hospital1 1680**].
CONDITION AT DISCHARGE: Stable.
DISCHARGE INSTRUCTIONS:
All follow-up will be determined through her primary
neurologist from a neurological standpoint and any further
follow-up would be determined by [**Hospital 1680**] Hospital.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37274**], M.D. [**MD Number(1) 37275**]
Dictated By:[**Name8 (MD) 11440**]
MEDQUIST36
D: [**2129-7-28**] 14:38
T: [**2129-7-28**] 15:12
JOB#: [**Job Number 38209**]
ICD9 Codes: 4275 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1204
} | Medical Text: Admission Date: [**2126-9-10**] Discharge Date: [**2126-9-17**]
Date of Birth: [**2054-8-31**] Sex: F
Service: CARDIAC SURGERY
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 45065**] is a 71-year-old
female with a history of cerebrovascular accident in [**2106**] and
[**2122**], and a history of bradycardia and syncope. She also has
a history of hypertension and hypercholesterolemia, without
previously-documented coronary artery disease. In [**2126-3-27**], she had an echocardiogram performed for the evaluation
of her bradycardia and syncope. The echocardiogram at the
time showed a left ventricular ejection fraction of 60 to
65%, with normal wall thickness and normal regional wall
motion.
Approximately one to two months prior to admission, the
patient developed new-onset substernal chest pain that
radiated to her back and often awakened her from sleep. The
chest pain was often accompanied by diaphoresis and shortness
of breath. It would resolve spontaneously after
approximately one hour.
In [**2126-7-28**], the patient had a MIBI performed. She
developed her typical chest pain with ST segment changes as
well as dyspnea. The imaging further showed significant
anterior, septal and inferior ischemia. The patient also had
a Holter monitor placed at that time. Her chest pain
recurred at the end of [**2126-7-28**] at rest, lasting
approximately an hour. She was referred to a cardiologist
for evaluation and cardiac catheterization. The cardiac
catheterization was performed on [**2126-8-27**]. It revealed left
main coronary artery 60% stenosis, 50% proximal left anterior
descending stenosis, 95% left circumflex artery stenosis, as
well as 80% stenosis of the first obtuse marginal artery.
The left ventricular ejection fraction was estimated at 60%.
PAST MEDICAL HISTORY:
1. Three vessel coronary artery disease
2. History of cerebrovascular accidents in [**2106**] and [**2122**]
3. History of bradycardia and syncope
4. Hypertension
5. Hypercholesterolemia
6. Obesity
7. Peripheral vascular disease
MEDICATIONS ON ADMISSION:
1. Norvasc 2.5 mg once a day
2. Uniretic 7.5 mg once a day
3. Lipitor 20 mg once a day
4. Meclizine 12.5 mg once a day
5. Aspirin 325 mg once a day
6. Sublingual nitroglycerin as needed
7. Lorazepam one pill daily at bedtime as needed
ALLERGIES: No known drug allergies.
FAMILY HISTORY: Mother died from myocardial infarction and
also family history of cerebrovascular accidents.
SOCIAL HISTORY: Denies use of alcohol or tobacco.
PHYSICAL EXAMINATION: Afebrile, heart rate 71, blood
pressure 144/75, weight 68 kg. General: Well-nourished,
elderly female, in no apparent distress. Skin: Within
normal limits. Head, eyes, ears, nose and throat: Within
normal limits, no jugular venous distention, no bruits.
Respiratory: Clear to auscultation bilaterally. Cardiac:
Regular rate and rhythm, normal S1 and S2, no murmurs, rubs.
Abdomen: Very mild tenderness in the left lower quadrant,
otherwise soft, nontender, nondistended, with hypoactive
bowel sounds, no hepatosplenomegaly. Extremities: Warm and
well perfused. Pulses present bilaterally, upper and lower
extremities. Varicosities: None. Neurologic examination:
Grossly nonfocal. There is weakness of the right upper
extremity and also right lower extremity noted.
LABORATORY DATA: Hematocrit 39.5, white blood cell count
8.8, platelets 488. Glucose 83, BUN 11, creatinine 1.0,
sodium 139, potassium 3.4. ALT 16, AST 19, alkaline
phosphatase 93, total bilirubin 0.5. Electrocardiogram
performed on [**2126-9-5**] showed sinus rhythm with heart rate of
66. The ST segment abnormalities were recorded in Leads I,
AVL and V4 through V6.
HOSPITAL COURSE: The patient had a cardiac catheterization
performed in [**2126-8-27**] at the outside facility, which
showed three vessel coronary artery disease with acceptable
left anterior descending, diagonal and an occluded obtuse
marginal target. She was referred and accepted for coronary
artery bypass grafting. She was consequently admitted to
Cardiac Surgery service.
On [**2126-9-10**], the patient underwent coronary artery bypass
grafting x 3, with left internal mammary artery to left
anterior descending, saphenous vein graft to diagonal,
saphenous vein graft to obtuse marginal. The patient
tolerated the procedure well. There were no complications.
The total cardiopulmonary bypass time was 69 minutes, and
aortic cross-clamp time was 46 minutes.
The patient was transferred to the Intensive Care Unit in
fair condition. She remained intubated. The patient
remained in sinus rhythm with stable blood pressure. She was
adequately diuresed. The patient was extubated on the same
day without any complications. The patient was briefly on
the insulin pump for elevated blood glucose levels. She was
maintained on Lopressor. Perioperative antibiotics were
administered.
On postoperative day two, the patient was transferred to the
regular floor in stable condition. Soon thereafter, she
experienced atrial fibrillation with heart rate in the 130s
to 140s. She was treated with intravenous Lopressor and also
amiodarone. She was started on oral amiodarone as well as a
standing dose. Her chest tube was removed. Her central line
was removed. Her urine catheter was removed.
The patient reverted to sinus rhythm several hours later on
postoperative day two. She otherwise remained stable.
Physical Therapy was consulted, which followed the patient
during her hospitalization, and eventually cleared the
patient to go home. The patient was ambulating with
assistance. She remained largely asymptomatic. Supplemental
oxygen was weaned off. Her incision was clean, dry and
intact. Her lungs were clear to auscultation bilaterally.
The patient experienced another episode of atrial
fibrillation on postoperative day five, which was treated
with intravenous Lopressor. She converted to sinus rhythm
again within 24 hours. The patient was discharged to home on
postoperative day seven, on [**2126-9-17**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DESTINATION: Home.
DISCHARGE DIAGNOSIS:
1. Three vessel coronary artery disease status post coronary
artery bypass grafting
2. Hypertension
3. Atrial fibrillation
4. Peripheral vascular disease
5. Hypercholesterolemia
6. Obesity
DISCHARGE MEDICATIONS:
1. Lipitor 20 mg by mouth once daily
2. Lasix 20 mg by mouth twice a day for seven days
3. Potassium chloride 20 mEq by mouth twice a day for seven
day
4. Amiodarone 400 mg by mouth once daily for 30 days
5. Colace 100 mg by mouth twice a day as needed for
constipation
6. Percocet one to two tablets by mouth every four to six
hours as needed for pain
7. Aspirin 325 mg by mouth once daily
8. Lopressor 50 mg by mouth twice a day
DI[**Last Name (STitle) 408**]E INSTRUCTIONS:
1. The patient is to have VNA services for wound check,
blood pressure and heart rate checks, as well as medication
checks.
2. The patient is to see Dr. [**Last Name (Prefixes) **], her surgeon, in
approximately four weeks.
3. The patient is to see Dr. [**Last Name (STitle) 41364**], her cardiologist, in
approximately two to three weeks.
4. The patient is to see her primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) **], in approximately one to two weeks.
5. The patient is to receive outpatient occupational therapy
as instructed.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 10097**]
MEDQUIST36
D: [**2126-9-18**] 20:32
T: [**2126-9-19**] 00:00
JOB#: [**Job Number 45066**]
ICD9 Codes: 9971, 4019, 2720, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1205
} | Medical Text: Admission Date: [**2129-5-26**] Discharge Date: [**2129-6-3**]
Date of Birth: [**2050-7-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2129-5-27**] Aortic Valve Replacement utilizing a 25mm St. [**Male First Name (un) 923**]
Porcine Valve
History of Present Illness:
This is a 78 year old male with severe aortic stenosis and a
history significant for atrial fibrillation on coumadin,
hypertension, dyslipidemia, history of DVT/Phlebitis s/p filter
placement & removal, COPD and a history of respiratory failure.
An echo by Dr [**First Name (STitle) 7756**] on [**2129-4-22**] demonstrated progressive aortic
stenosis with [**Location (un) 109**] 0.9, peak gradient 80/mean 45, mild MR/ TR.
LVEF 65%. He reports shortness of breath on exertion only, such
as climbing one flight of stairs, carrying a bag from car, or
walking up an incline. This has been getting worse over the past
6 months. He also reports bilateral ankle edema. He was
referred for right and left heart catheterization. He is now
being referred to cardiac surgery for an aortic valve
replacement.
Past Medical History:
Severe aortic stenosis
Atrial fibrillation, on Coumadin
Hypertension
Dyslipidemia
History of DVT/Phlebitis in post -op state, s/p filter placement
& removal
COPD
History of respiratory failure
OSA, uses CPAP
History of pneumonia, remote
Obesity
Hypothyroidism
History of prostate cancer, s/p TURP
Radiation proctitis
ED
Diverticular disease
Osteoarthritis with bilateral knee pain
GERD
Renal insufficiency, per patient
Hernia
Rhematoid arthritis
s/p Cataract surgery, bilateral
s/p TURP
s/p Arthroscopic knee surgery
s/p 3 hernia repairs
Social History:
Lives with: wife
Occupation:retired
Cigarettes: quit 40 years ago, smoked for 15 years 2 packs/day
ETOH: < 1 drink/week [x] [**3-15**] drinks/week [] >8 drinks/week []
Illicit drug use: denies
Family History:
No premature coronary artery disease
Physical Exam:
PREOP EXAM
Pulse:50 Resp:16 O2 sat:100/RA
BP Right:119/57 Left:132/59
Height: 6' Weight: 238 lbs
General: WDWN elderly male in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x] Cataract surgery x 2
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x] distant lung sounds
Heart: RRR [] Irregular [x] Murmur [x] grade _2/6 Systolic _
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel
sounds+ [x], obese, diastasis
Extremities: Warm [x], well-perfused [x] Edema [x] ___1+__
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2 Left: 2
DP Right: 1 Left: 1
PT [**Name (NI) 167**]: 1 Left: 1
Radial Right: 2 Left: 2
Carotid Bruit Right: no Left: no
Discharge:
Gen NAD
Neuro A&O x3, MAE, nonfocal exam
Pulm CTA diminished bases bilat
CV irreg-irreg, sternum stable, incision-CDI
Abdm soft, NT/ND/NABS
Ext warm, well perfused. 2+ edema bilat
Pertinent Results:
[**2129-5-27**] ECHO
Pre Bypass: The left atrium is mildly dilated. Mild spontaneous
echo contrast is present in the left atrial appendage. A
probable thrombus is seen in the left atrial appendage. No
atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). The right ventricular cavity is
mildly dilated with normal free wall contractility. The right
atrium is markedly enlarged. There are complex (>4mm) atheroma
in the aortic arch. There are complex (>4mm) atheroma in the
descending thoracic aorta. There are three aortic valve
leaflets. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area 0.8-1.0cm2). Trace aortic regurgitation is seen. The mitral
valve leaflets are moderately thickened. There is severe mitral
annular calcification. Trivial mitral regurgitation is seen.
There is no pericardial effusion.
Post Bypass: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylepherine. A
well-seated bioprosthetic valve is seen in the aortic position
with normal leaflet motion and gradients (mean gradient = 14
mmHg). No aortic regurgitation is seen. Regional and global left
ventricular systolic function are normal. Mitral valve anterior
leflet with increased mobility mva 3.24 cm2 by pressure half
time. MR remains trace. Remaining exam is unchanged. All
findings discussed with surgeons at the time of the exam.
Admission Labs:
[**2129-5-26**] 05:25PM PT-12.4 PTT-29.5 INR(PT)-1.1
[**2129-5-26**] 05:25PM PLT COUNT-153
[**2129-5-26**] 05:25PM WBC-5.7 RBC-3.90* HGB-10.7* HCT-35.6* MCV-91
MCH-27.4 MCHC-30.1* RDW-18.6*
[**2129-5-26**] 05:25PM %HbA1c-5.9 eAG-123
[**2129-5-26**] 05:25PM ALBUMIN-4.1 MAGNESIUM-2.3
[**2129-5-26**] 05:25PM LIPASE-32
[**2129-5-26**] 05:25PM ALT(SGPT)-18 AST(SGOT)-19 ALK PHOS-63
AMYLASE-72 TOT BILI-0.5
[**2129-5-26**] 05:25PM GLUCOSE-139* UREA N-27* CREAT-1.5* SODIUM-142
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-30 ANION GAP-13
Discharge Labs:
[**2129-5-31**] 04:32AM BLOOD WBC-6.9 RBC-3.06* Hgb-8.4* Hct-27.8*
MCV-91 MCH-27.3 MCHC-30.0* RDW-18.5* Plt Ct-118*
[**2129-5-31**] 04:32AM BLOOD Plt Ct-118*
[**2129-5-31**] 04:32AM BLOOD Glucose-107* UreaN-26* Creat-1.1 Na-141
K-3.9 Cl-104 HCO3-27 AnGap-14
[**2129-5-31**] 04:32AM BLOOD Calcium-8.3* Phos-2.1* Mg-2.6
[**2129-6-2**] 04:43AM BLOOD PT-14.0* PTT-54.5* INR(PT)-1.3*
[**2129-6-1**] 04:49AM BLOOD PT-12.7* PTT-42.4* INR(PT)-1.2*
Radiology Report CHEST (PA & LAT) Study Date of [**2129-5-30**] 8:30 AM
Final Report : There is mild improvement of bilateral
interstitial markings and hilar prominence compared with prior
exam. No focal opacities are seen in the right, while the left
lung demonstrates improved aeration although with persistent
lower lobe atelectasis with concurrent small pleural effusion.
The mediastinum is widened secondary to mediastinotomy, but
unchanged compared with prior exam. There is no evidence of
pneumothorax. Old right-sided sixth rib fracture is again noted.
A right IJ line is seen ending in the mid SVC. Sternotomy wires
are intact.
IMPRESSION: Interval improvement of pulmonary vascular
congestion, left lower lobe atelectasis and left sided pleural
effusion.
Brief Hospital Course:
Mr. [**Known lastname 67619**] was admitted for intravenous Heparin and routine
preoperative evaluation prior to aortic valve replacement.
Workup was unremarkable and he was cleared to proceed with
surgery. On [**5-27**] Dr. [**Last Name (STitle) **] performed a bioprosthetic aortic
valve replacement - for surgical details, please see operative
note.
In summary he had: Aortic valve replacement with [**Street Address(2) 17009**]. [**Hospital 923**]
Medical Biocor Epic tissue valve. His bypass time was 77 minutes
with a crossclamp time of 58 minutes. He tolerated the operation
well and post-operatively was brought to the CVICU for invasive
monitoring. On the day of surgery he woke neurologically intact,
was weaned from the ventilator and extubated.
On postoperative day one, he was transferred to the stepdown
floor for continued post-operative care. Coumadin was resumed
for atrial fibrillation. Gentle diuresis was initiated. He
worked with nursing and physical therapy to increase his
postoperative strength and mobility. All tubes lines and
epicardial pacing wires were discontinued without complication.
On postoperative day three, he did have a temperature of 101.0.
Blood cultures were drawn and negative at the time of discharge,
urine culture was negative and the the triple lumen catheter was
discontinued. Heparin intravenous was started for [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**]
on intra-op echo and preoperative atrial fibrillation. He failed
a voiding trial and the foley catherter was replaced. Flomax
therapy was initiated. The foley catheter was discontinued on
the evening of postoperative day number 3 without further
complication. He did have some serous midsternal drainage and
was started on Kefzol on POD3. This was resolved at the time of
discharge. He was afebrile, WBC normal and was sent home on no
antibiotics. He is to come to the wound clinic on [**2129-6-7**] for
follow up.
The remainder of his hospital course was uneventful and he was
discharged home on POD 7. He is to follow-up with Dr [**Last Name (STitle) **] in
1 month-appointment already scheduled.
Medications on Admission:
AMITRIPTYLINE 10 mg HS
ATENOLOL 50 mg Daily
CLOBETASOL 0.05 % Cream - as needed
DESONIDE 0.05 % Cream - as needed
ADVAIR DISKUS 250 mcg-50 mcg/Dose Disk with Device - one puff
inhaled twice a day
FOLIC ACID 1 mg daily
FUROSEMIDE 20 mg daily
LEVOTHYROXINE 150 mcg Daily
METHOTREXATE SODIUM 2.5 mg Tablets, Dose Pack - three Tablets
once a week on Friday
OMEPRAZOLE 20 mg Daily
PREDNISONE 5 mg Daily
VIAGRA 100 mg PRN
SIMVASTATIN 20 mg Daily
SPIRIVA WITH HANDIHALER 18 mcg Capsule, w/Inhalation Device -
two
puffs inhaled once a day
WARFARIN 2 mg Daily
CALCIUM CARBONATE-VITAMIN D3 Dosage uncertain
VITAMIN D3 400 unit Daily
VITAMIN B-12 500 mcg Daily
METHYLCELLULOSE 500 mg PRN
MULTIVITAMIN Dosage uncertain
OMEGA 3 FISH OIL Dosage uncertain
Discharge Medications:
1. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing,
sob.
Disp:*1 * Refills:*1*
3. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation QID (4 times a day).
Disp:*1 * Refills:*2*
4. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 Cap(s)* Refills:*1*
5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*1*
6. levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*1*
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*1*
10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
11. 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*
12. 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:*1*
13. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
14. methotrexate sodium 2.5 mg Tablet Sig: Three (3) Tablet PO
QFRI (every Friday).
Disp:*12 Tablet(s)* Refills:*1*
15. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*1*
16. amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for sleep.
Disp:*30 Tablet(s)* Refills:*0*
17. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
18. potassium chloride 20 mEq Packet Sig: One (1) Packet PO once
a day.
Disp:*30 Packet(s)* Refills:*1*
19. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
20. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
21. warfarin 5 mg Tablet Sig: Seven (7) mg PO once a day: Please
check INR on [**2129-6-4**].
Disp:*30 mg* Refills:*1*
22. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Aortic Stenosis - s/p AVR
Atrial Fibrillation with left atrial appendage thrombus
Hypertension
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with percocet
Incisions:
Sternal - healing well, no erythema or drainage
Edema 1+
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 CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2129-6-7**] 10:30am
in the [**Hospital **] medical office building, [**Doctor First Name **], [**Hospital Unit Name **]
Surgeon: Dr. [**First Name (STitle) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2129-6-29**] 1:30pm in the [**Hospital **] medical office building,
[**Doctor First Name **], [**Hospital Unit Name **]
Cardiologist: Dr. [**Last Name (STitle) 7526**] [**2129-6-13**] at 11:30a
Please call to schedule appointments with your
Primary Care Dr.[**Last Name (STitle) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 71053**] in [**5-12**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication atrial fibrillation and
thrombus in the left atrial appendage
Goal INR 2-2.5
First draw [**2129-6-3**] and then [**Last Name (un) **] other day until stable
Results to phone fax Atrius coumadin clinic
Completed by:[**2129-6-3**]
ICD9 Codes: 496, 2749, 2724, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1206
} | Medical Text: Admission Date: [**2131-3-8**] Discharge Date: [**2131-3-14**]
Date of Birth: [**2074-6-16**] Sex: M
Service: CARD [**Doctor First Name 147**]
CHIEF COMPLAINT: Positive exercise stress test.
HISTORY OF PRESENT ILLNESS: The patient is a 57 year old
male who had an exercise stress test on [**2131-2-26**]. The
patient had no chest pain but did show ST segment depressions
with peak exercise. The patient reported exertional chest
discomfort over the previous year with the pain resolving
with rest. The patient underwent a cardiac catheterization
on [**2131-3-5**], which revealed three vessel coronary artery
disease. The patient was scheduled for bypass.
PAST MEDICAL HISTORY:
1. Diabetes mellitus.
2. Recent pneumonia.
PAST SURGICAL HISTORY:
1. Foot surgery to remove ulcers.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Lasix 40 mg p.o. q. day.
2. Potassium 20 mEq p.o. q. day.
3. Aspirin 325 mg p.o. q. day.
4. Diovan 80 mg p.o. q. day.
5. Coreg.
6. Insulin 70/30, 25 units twice a day.
HOSPITAL COURSE: The patient was admitted to the [**Hospital1 346**] on [**2131-3-8**] and taken to the
Operating Room where he underwent a two vessel bypass with a
left internal mammary being grafted to the left anterior
descending artery and a saphenous vein graft being grafted to
the obtuse marginal. During the procedure, the patient was
noted to have what appeared to be adhesions over his right
atrium. It was difficult to dissect off the right coronary
artery which was an intended target. Part of the patient's
epicardium was biopsied and sent to pathology to rule out
malignancy and an intraoperative Cardiology consultation was
requested.
The Cardiologist contact believed that the patient's right
coronary artery lesion could be stented by cardiac
catheterization. The patient tolerated the procedure well
and was transferred to the Cardiac Intensive Care Unit while
intubated as is customary.
The patient had an uneventful recovery and was extubated late
on the day of surgery. The patient's diet was advanced. The
patient had some brief period of nausea on postoperative day
number two; this resolved.
The patient's blood sugar was closely monitored and because
of some elevated numbers, the patient was restarted on his
usual home dose of 70/30 insulin on postoperative day number
two.
The patient was subsequently adequately covered with a
sliding scale. The patient's chest tubes were removed on
postoperative day number three and the patient was
transferred out to the floor on that date.
The patient underwent successful cardiac catheterization on
postoperative day number four with two stents placed. Please
refer to the Cardiac catheterization report for further
details. By postoperative day number six and post cardiac
catheterization day number two, the patient was deemed ready
for discharge. At the time of discharge, the patient was
tolerating a diabetic diet. The patient had ambulated with
Physical Therapy and was deemed ready for discharge home with
continued home Physical Therapy.
The patient was on percocet for pain control.
The patient's sternal incision was healing well with clean
and dry appearance and well approximated with Steri-Strips.
CONDITION AT DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Metoprolol 25 mg p.o. twice a day.
2. Colace 100 mg p.o. twice a day.
3. Aspirin 325 mg p.o. q. day.
4. Percocet p.r.n.
5. Plavix 75 mg p.o. q. day.
6. Lasix 40 mg p.o. q. day.
7. Potassium 20 mEq p.o. q. day.
DISCHARGE INSTRUCTIONS:
1. The patient was to follow-up with Dr. [**Last Name (STitle) 70**] in one to
two weeks following discharge.
2. The patient was also to follow-up with his Cardiologist
within one to two weeks following discharge for further
management of his cardiac medications.
3. The patient was also asked to schedule a follow-up
appointment with his primary care physician within one to two
weeks following discharge.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Diabetes mellitus.
[**Known firstname **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 997**]
MEDQUIST36
D: [**2131-3-14**] 12:30
T: [**2131-3-14**] 18:54
JOB#: [**Job Number 107665**]
ICD9 Codes: 3572, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1207
} | Medical Text: Admission Date: [**2168-11-17**] Discharge Date: [**2168-11-20**]
Date of Birth: [**2117-8-31**] Sex: M
Service: MEDICINE
Allergies:
Fish derived
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
upper gastrointestinal bleed
Major Surgical or Invasive Procedure:
Esophogastroduodenoscopy
History of Present Illness:
Mr. [**Known lastname 26438**] is a 51 year old man with h/o PSC cirrhosis (c/b
ascites, encephalopathy, esophageal varices) on the transplant
list, HCV, prior UGIB from known varices, who was transferred
from an OSH with melanotic stools and hematemesis.
.
The patient started having melanotic stools at 3am. He waited to
call his liver transplant coordinator this AM, who advised him
to go to his local hospital, get stabilized, and then request
transfer to [**Hospital1 18**]. He has had a total of 6 bowel movements
today, formed black stools, and most recently some bright red
blood per rectum. He also had 2 episodes of hematemesis this AM
prior to going to the OSH. He's had shortness of breath at rest
since yesterday, lightheadedness since today. Also notes several
episodes of palpitations. No fevers, chills, chest pain.
+chronic diffuse abdominal pain.
.
At the OSH, the patient was given Morphine 14mg IV, started on
Protonix and Octreotide gtt's, 1L NS. He was being transfused
1unit pRBCs on transfer to our ED. He was hemodynamically stable
with HCT 31 (baseline mid30s).
.
In the ED, initial vs were: 97.7 72 113/73 18 98%. Repeat HCT
drawn during the transfusion of pRBCs from the OSH was 33. Exam
was notable for grossly bloody rectal exam. Patient remained
hemodynamically stable, but had a grossly bloody bowel movement
(~250cc) and was admitted to the ICU. Patient was continued on
PPI and octreotide gtt's. He was given Ceftriaxone 1g IV,
Morphine 4mg IV x1 for abdominal pain. Vitals prior to transfer:
T 98 P 87 BP 117/79 RR 18 O2sat 97%2LNC.
.
On the floor, the patient is currently itchy and c/o abdominal
pain. No current nausea or vomiting. He had another 300cc bowel
movement of maroon colored stool. Mild SOB at rest currently. He
had otherwise been doing well at home and has stayed out of the
hospital for >2 weeks.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough. Denied chest pain or tightness. No
recent change in bladder habits. No dysuria. Denied arthralgias
or myalgias.
Past Medical History:
# cirrhosis c/b ascites, encephalopathy and bleeding esophageal
varices, on transplant list
# Primary sclerosing cholangitis
# History of UGIB in [**10-12**], [**5-28**]
# HCV: by history, had positive HCV with HCV VL in [**2157**], but on
follow up cleared HCV spontaneously
# Horseshoe kidney
# Heart murmur
# Distant history of polysubstance abuse
# History of dysphagia with normal barium swallow on [**2167-11-24**]
# Typical Angina
Social History:
Lives with one of his 2 sons. [**Name (NI) **] lots of family support
(mother, sisters, [**Name2 (NI) 12232**]) - requires 24 hour care at home. Not
currently employed, on SSI.
- EtOH: history of abuse, last drink > 22 yrs ago
- Drugs: history of polysubstance abuse including cocaine,
crack, barbiturates, amphetamines, and marijuana. none for 20
years.
- Smoking: quit > 16 yrs ago, 25 pack year history
Family History:
No pertinent family history, including PSC, liver disease, or
other gastrointestinal disease. Grandfather with diabetes.
Physical Exam:
Admission Physical Exam:
Vitals: T: 96.4 BP: 119/82 P: 79 R: 22 O2: 96% 2LNC
General: Alert, oriented, no acute distress
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, distended, mild diffuse ttp, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, 1+ pitting edema b/l R>L
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
intact in all extremities, no asterixis
.
Discharge Physical Exam:
Vitals: 98.6, 75, 124/74, 20, 100% RA
General: Alert, oriented x 3, no acute distress
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mildly distended, non-tender, bowel sounds
present, no rebound tenderness or guarding, no organomegaly;
paracentesis site clean, dry, non-tender
GU: no foley
Ext: warm, well perfused, 2+ pulses, 1+ pitting edema b/l R>L
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
intact in all extremities, mild tremor; no asterixis
Pertinent Results:
On admission:
[**2168-11-17**] 07:45PM BLOOD WBC-12.5*# RBC-3.64* Hgb-11.3* Hct-33.4*
MCV-92 MCH-31.0 MCHC-33.8 RDW-17.9* Plt Ct-145*#
[**2168-11-17**] 07:45PM BLOOD PT-16.7* PTT-34.4 INR(PT)-1.5*
[**2168-11-17**] 07:45PM BLOOD Glucose-96 UreaN-18 Creat-1.0 Na-134
K-6.5* Cl-104 HCO3-18* AnGap-19
[**2168-11-17**] 07:45PM BLOOD ALT-46* AST-99* LD(LDH)-307* AlkPhos-217*
TotBili-5.3*
.
Crit trend 33.4->31.0->28.2->27.0->29->24->26
.
On discharge:
[**2168-11-20**] 08:44AM BLOOD WBC-5.1 RBC-2.85* Hgb-8.7* Hct-26.4*
MCV-93 MCH-30.7 MCHC-33.1 RDW-18.2* Plt Ct-111*
[**2168-11-20**] 04:50AM BLOOD Glucose-104* UreaN-17 Creat-1.0 Na-134
K-4.8 Cl-104 HCO3-24 AnGap-11
[**2168-11-20**] 04:50AM BLOOD ALT-39 AST-83* LD(LDH)-170 AlkPhos-178*
TotBili-4.5*
.
EGD [**2168-11-18**]: A sliding medium size hiatal hernia was seen.
Protruding Lesions 3 cords of grade II to III varices were seen
in the lower esophagus. Two cords had stigmata of recent
bleeding with a protruding vessel noted. Banding was applied to
three cords. Red blood was seen in the whole stomach. Normal
mucosa was noted.
Brief Hospital Course:
Mr. [**Known lastname 26438**] is a 51 year old man with history of PSC
cirrhosis, complicated by esophageal varices, ascites, and
encephalopathy, who was transferred from an OSH with
gastrointestinal bleed.
.
#. Gastrointestinal bleed: The patient was transferred from an
OSH to the [**Hospital1 18**] ICU with melanotic stools and hematemesis. He
was started on PPI and octreotide drips. He remained
hemodynamically stable, but received one unit of PRBCs as he was
actively bleeding. In the ICU, the patient underwent endoscopy
that showed 3 cords of grade [**2-4**] varices with a stomach full of
blood. Varices were banded. The patient was continued on
octreotide for 48 hrs. He was transitioned to his home PPI
regimen. The patient's hematocrit remained stable after the
banding procedure, and he was transferred to the floor. On the
medical floor, the patient's diet was advanced, and he tolerated
a low salt regular diet without difficulty. He experienced one
episode of epigastric pain s/p banding that resolved with one
dose of morphine (pain atypical for ACS, EKG unchanged). His
hematocrit remained stable. He was started on nadolol for
esophageal varices in addition to his home protonix 40 mg PO BID
and sucralfate.
.
#. Leukocytosis: Patient admitted with leukocytosis to 12.5,
likely related to acute stress of bleed. Diagnostic
paracentesis negative for SBP. Blood cultures remained negative
throughout admission, and the patient remained without
localizing infectious symptoms. Leukocytosis resolved without
intervention.
.
#. Hepatic Encephalopathy: On admission, patient had mild
hepatic encephalopathy in the setting of GI bleed. Lactulose
was held on admission, as patient was having many melanotic
bowel movements. The patient continued his home rifaximin.
Once his hematocrit stabilized, lactulose was resumed, and the
patient's mental status normalized.
.
#. ESLD: [**2-3**] to PSC, complicated by ascites, encephalopathy, and
esophageal varices. The patient is on the liver transplant
list. On admission, the patient was started on ceftriaxone 1g
q24 for spontaneous bacterial peritonitis prophylaxis in the
setting of GI bleed. He underwent diagnostic paracentesis that
showed no evidence of spontaneous bacterial peritonitis. Lasix,
Spironolactone, and lactulose were held given acute bleed in the
ICU. He resumed home therapy with lasix, spironolactone,
lactulose, and rifaximin once hematocrit remained stable on the
medical floor. For his ascites, the patient underwent routine
paracentesis the day of discharge (as he was due for his weekly
paracentesis) without complication. The patient was repleted
with 25% albumin following his paracentesis. He was discharged
to home with follow up with his outpatient hepatologist. He
should undergo re-banding 3 weeks following discharge.
.
#. Abdominal pain: The patient has a history of chronic
abdominal pain, for which he is on sucralfate, simethicone,
Maalox, and gabapentin. These medications were held on
admission in the setting of acute GI bleed. He resumed home
medications on transition to the medical floor.
.
#. Depression: Chronic. The patient remained in good spirits
throughout admission. He denied suicidal or homicidal ideation.
Citalopram was first held while the patient was in the ICU.
Home citalopram was then resumed upon transfer to the medical
floor.
.
#. Code: Full code
Medications on Admission:
Cholestyramine-sucrose 4 gram PO TID
Cictalopram 40mg PO daily
Lactulose 15mL PO TID
Midodrine 10mg PO TID
Pantoprazole 40mg PO BID
Rifaximin 550mg PO BID
Ursodiol 250mg PO TID
MVI 1tab PO daily
Spironolactone 50mg PO daily
Furosemide 40mg PO daily
Trazodone 50mg PO qhs prn
Ciprofloxacin 500mg PO daily
Simethicone 80mg PO TID
Magnesium oxide 400mg PO TID
Gabapentin 200mg PO TID
Maalox 15-30mL PO TID prn
Sucralfate 1g PO QID
Acetaminophen 500mg PO q6h prn
Zofran 4mg PO TID prn
Discharge Medications:
1. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO
TID (3 times a day).
2. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. lactulose 10 gram/15 mL Solution Sig: One (1) PO three times
a day.
4. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. ursodiol 250 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
12. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a
day.
13. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day) as needed for gas/abd pain.
14. magnesium oxide 400 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
15. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
16. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO TID (3 times a day) as needed for abdominal pain.
17. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
18. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
19. nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
20. Zofran 4 mg Tablet Sig: One (1) Tablet PO TID PRN as needed
for nausea.
Discharge Disposition:
Home With Service
Facility:
VNA Care [**Location (un) 511**]
Discharge Diagnosis:
Primary Diagnosis: Esophageal variceal bleed
Secondary diagnosis: PSC cirrhosis complicated by esophageal
varices, ascites, and encephalopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the ICU with bleeding per rectum. You
received one unit of packed red blood cells for your bleeding.
You underwent an upper endoscopy where you were found to have 3
cords of esophageal varices with evidence of active bleeding.
The varices were banded and your blood counts remained stable.
You were transferred to the medical floor. On the medical
floor, we continued to monitor the stability of your blood
counts. You were able to tolerate solid foods. You underwent
routine paracentesis, as it had been over a week since your last
paracentesis. You were then discharged to home. You should
follow up for repeat upper endoscopy in 3 weeks to monitor the
status of your esophageal bands.
.
Medication changes this admission:
START nadolol 10 mg daily
Followup Instructions:
Department: TRANSPLANT
When: WEDNESDAY [**2168-11-23**] at 11:00 AM
With: TRANSPLANT [**Hospital 1389**] [**Hospital **] [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
You will be called with a follow-up appointment for a repeat
upper endoscopy.
ICD9 Codes: 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1208
} | Medical Text: Unit No: [**Numeric Identifier 68286**]
Admission Date: [**2135-4-19**]
Discharge Date: [**2135-4-30**]
Date of Birth: [**2087-3-21**]
Sex: M
Service: MED
HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old
male who was well known to the surgery service having had a
malignant pheochromocytoma resected in [**2134-8-20**]. At the
time he had multiple small liver metastases and a very large
malignant pheochromocytoma. The decision at that time was to
observe his liver metastases. Hence, the endocrinologist
thought that this would not create a problem.
The patient represented to [**Location (un) **] in late [**Month (only) 547**] with
distention and difficulty having bowel movements. He was also
found to have hypoxia based on shunting. No pulmonary
embolism was found. The patient had massive hepatomegaly
which may have been the cause of some of his pain. The
patient was transferred to [**Hospital6 2018**] and underwent a CT scan which confirmed the finding at
[**Hospital3 **]. We made multiple efforts to decompress the
colon with enemas and cathartics but this did not work. There
was some question as to whether he had a small bowel
obstruction. The patient did not progress and the decision
was made to take him to the operating room on [**2135-4-21**].
At this point, the patient had been transferred to the ICU
because of difficulty breathing. We were hoping to do
colonoscopy with the patient intubated but the GI service
felt that was probably not an option given his tenuous state.
Lysis of adhesions showed a transition point in the mid
jejunum with some lysis of adhesions but this did not appear
to be the cause for his bowel obstruction. The patient
developed acute renal failure requiring dialysis. By [**4-23**]
the hope was that he can be weaned from the ventilator. He
continued to require labetalol and nicardipine to control his
blood pressure. By [**4-24**], the patient had worsening chest x-
ray consistent with pneumonia. He was extubated on [**4-25**] but
no real progress was made on his ileus. He was started TPN.
At this point consideration for colonoscopy was reopened with
the GI team. The endocrine team recommended starting
doxazosin. The GI service continued to be reluctant to
perform colonoscopy. By [**4-26**] the patient was felt to be
stable but no progress was made in terms of GI function. The
decision was made to try to a Gastrografin enema both for
diagnosis and treatment as recommended by the GI service.
The patient continued to be somewhat unstable but was unable
to maintain his ventilatory status without intubation. By [**4-27**] he had a couple of small bowel movements after the
Gastrografin enema and the NG tube was removed because of
lack of output and discomfort. Unfortunately by [**4-28**] the
patient continued to do poorly and we felt that we had to do
a decompressive laparotomy for his pseudoobstruction with
high bladder pressures. On the beginning of the operation he
desaturated and the feeling was that he probably had an
endobronchial on the right and a left chest tube was placed
and the endotracheal tube was pulled back. Decompressive
laparotomy showed massive dilated loops of bowel without
specific obstruction. The cecum was very distended and
cecostomy tube was placed with a 26 Foley. The abdomen was
left open.
After this operation, the patient continued to deteriorate
with worsening respiratory status. On [**4-29**] the opened
abdomen was removed and bowel was visualized and appeared to
be pink and viable. There was some question as to whether it
was not viable, but this did not seem to be the case. The
patient continued to require high-dose pressors without much
response. A family meeting was held with the patient's wife
and they decided that given his current status and his
underlying condition, that they would proceed with comfort
measures only. On [**2135-4-30**], the patient expired at 5:20
p.m.
DIAGNOSIS:
1. Metastatic pheochromocytoma.
2. Colonic pseudo-obstruction.
3. Sepsis.
4. Renal failure.
5. Acute respiratory distress syndrome.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**MD Number(2) 16263**]
Dictated By:[**Last Name (NamePattern1) 16475**]
MEDQUIST36
D: [**2135-11-8**] 12:39:35
T: [**2135-11-10**] 09:49:37
Job#: [**Job Number **]
cc:[**Last Name (NamePattern1) 68287**]
ICD9 Codes: 486, 5180, 2767, 5849, 4271, 5070, 2749, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1209
} | Medical Text: Admission Date: [**2179-10-19**] Discharge Date:
Date of Birth: [**2104-7-19**] Sex: M
Service:
PREOPERATIVE DIAGNOSIS: Protein malnutrition.
POSTOPERATIVE DIAGNOSIS: Protein malnutrition.
PROCEDURE: Placement of endoscopic gastrostomy tube.
ASSISTANT: [**Doctor First Name 69826**] [**Doctor Last Name **].
ANESTHESIA: MAC and local.
ESTIMATED BLOOD LOSS: Minimal.
PROCEDURE: The patient was brought to the operating room and
properly identified. Anesthesia was provided per the nurses'
notes. The flexible endoscope was passed through the
patient's mouth under direct vision into the stomach which
was insufflated with air. The abdomen was prepped and draped
and after infusion of local anesthesia, a suitable site was
identified and a needle was passed through the abdominal wall
under direct vision into the stomach. The wire was passed and
grasped with the flexible endoscope and pulled through the
patient's mouth. The percutaneous endoscopic tube was then
attached to the wire and then pulled through and secured to
the abdominal wall. This was attached through the clamp
device. The patient tolerated this well and was brought to
recovery in satisfactory addition. Sponge, needle and
instrument count were correct at the end of the case.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 853**], MD [**MD Number(2) 69827**]
Dictated By:[**Last Name (NamePattern1) 69828**]
MEDQUIST36
D: [**2179-10-19**] 15:04:37
T: [**2179-10-19**] 15:19:53
Job#: [**Job Number 69829**]
ICD9 Codes: 5070, 2760, 2761, 4280, 4019, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1210
} | Medical Text: Admission Date: [**2114-2-13**] Discharge Date: [**2114-2-16**]
Date of Birth: [**2063-5-9**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
Hypertensive Urgency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 50 y/o F with h/o HTN not on Bp medications who
presents with acute chest pain and elevated BP.
.
She reports that at 11:30 am, developed acute chest pain, [**4-16**],
while sitting in front of the computer. Squizzing sensation,
lasted minutes, + diaphoresis. + palpitations, + lightheaded.
Intermittent. Later on felt to be radiated to her jaw and left
arm. Denied speech problems, headache, nausea, vomit, blurry
vision. No prior episodes in the past.
.
Normally, she is able to walk more thatn 1 flight of stairs or
more than 1 block without significant problems.
.
In the Ed, VS T 98.8, Hr 97, Bp 199/119, BP L 213/106, R 208/104
RR 18, sats 99% on RA. she received, 10 mg IV lopressor, 25
loppressor [**Last Name (LF) **], [**First Name3 (LF) **] 325 mg x1, nitro drip and tylenol 650 x1.
.
On review of symptoms, 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.
.
*** Cardiac review of systems is notable for absence of dyspnea
on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle
edema
She does report feeling lighheaded about 3 weeks ago and was
told that she had a vasovagal episode.
Past Medical History:
Heroin abuse clan for 10 years.
HTN on hctz up until 6 months ago.
.
Cardiac Risk Factors: Diabetes (-), Dyslipidemia(-),
Hypertension (+)
Social History:
Lives with husband. [**Name (NI) **] 1 [**Name2 (NI) **].
Smokes 1 packs every 4 days for 30 years. Yes alcohol 3 glases
of wine per week. [**Doctor Last Name 14039**] at Symphony [**Doctor Last Name **].
Family History:
Grand father with heart problems
Physical Exam:
VS: BP 188/104, HR 67, RR 16 ,100 O2 RA
Gen: WDWN middle aged female in NAD, pleaseant
HEENT: PEERLA, EOM preserved. moist oral mucose
Neck: Supple. no JVP appreciated. No carotid bruits
CV: RRR s1-s2 normal. no murmurs,
Lung: clear to auscultation bilateraly
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No edema.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
EKG : HR 90, NSR, normal axis, <1mm st depression in II, AVf,
v4, v5.
short PR interval.
.
[**2114-2-13**] 01:40PM WBC-8.0 RBC-4.21 HGB-12.3 HCT-36.9 MCV-88#
MCH-29.3# MCHC-33.4 RDW-13.7
[**2114-2-13**] 01:40PM NEUTS-70 BANDS-0 LYMPHS-22 MONOS-7 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2114-2-13**] 01:40PM HYPOCHROM-1+ ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL TARGET-1+
[**2114-2-13**] 01:40PM PLT SMR-NORMAL PLT COUNT-195 LPLT-1+
[**2114-2-13**] 01:40PM CK-MB-4 cTropnT-<0.01
[**2114-2-13**] 01:40PM CK(CPK)-1046*
[**2114-2-13**] 01:40PM GLUCOSE-92 UREA N-11 CREAT-0.6 SODIUM-138
POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-27 ANION GAP-17
[**2114-2-13**] 10:57PM CK-MB-3 cTropnT-<0.01
[**2114-2-13**] 10:57PM CK(CPK)-606*
[**2114-2-14**] 05:10AM BLOOD ALT-17 AST-34 CK(CPK)-460* AlkPhos-107
TotBili-0.7
[**2114-2-14**] 05:10AM BLOOD CK-MB-3 cTropnT-<0.01
[**2114-2-15**] 11:13AM BLOOD ALDOSTERONE-PND
[**2114-2-15**] 11:13AM BLOOD RENIN-PND
[**2114-2-14**] 04:29PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008
[**2114-2-14**] 04:29PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2114-2-14**] 04:29PM URINE RBC-1 WBC-1 Bacteri-FEW Yeast-NONE Epi-2
[**2114-2-14**] 04:29PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-POS
.
CXR [**2114-2-13**]: PORTABLE UPRIGHT CHEST, ONE VIEW: Heart size is
normal. Hilar and mediastinal contours are normal. Lungs are
clear, without consolidation or interstitial edema. Pleural
surfaces are normal. Osseous structures are unremarkable.
IMPRESSION: No acute cardiopulmonary process.
.
Renal US [**2-15**]: FINDINGS: The right kidney measures 11.2 cm and
the left kidney measures 10.3 cm. There is no hydronephrosis and
no stones or solid masses are identified in either kidney. There
is appropriate symmetrical flow identified in the main renal
artery of each kidney. The RIs on the right kidney range from
0.57 to 0.74 and on the left kidney from 0.58 to 0.73.
Appropriate flow is identified in the main renal vein of each
kidney.
IMPRESSION: No hydronephrosis and no renal masses identified. No
evidence of renal artery stenosis seen.
.
TTE [**2114-2-15**]:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Normal regional LV systolic function. No LV mass/thrombus.
Overall normal LVEF (>55%). TDI E/e' < 8, suggesting normal PCWP
(<12mmHg). Transmitral Doppler and TVI c/w normal LV diastolic
function. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. No 2D or
Doppler evidence of distal arch coarctation.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Trace AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR. No
MVP. Normal mitral valve supporting structures. No MS.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal tricuspid valve supporting structures. No TS.
Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. No
masses or thrombi are seen in the left ventricle. Overall left
ventricular systolic function is normal (LVEF 70%). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). Transmitral Doppler and tissue velocity
imaging are consistent with normal LV diastolic function. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. There is no aortic valve stenosis. Trace
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
Brief Hospital Course:
# Hypertensive urgency: The patient presented with complaints of
chest pain - non-specific EKG changes on arrival. SPB~ 200. No
evidence of ACS - CE negX3, no evidence of acute aortic
disection - BP and pulses equal B/L. CXR WNL. She was given
lopressor and started on a nitroglycerin gtt for BP control. The
patient was monitored in the CCU overnight. Nitro weaned slowly
with the addition of po medications lisinopril 20mg, HCTZ 25mg
and metoprolol 12.5mg with an improvement in BP to 160s
systolic. Her BP meds were up titrated throughout the remainder
of her hospitalization to lisinopril 40mg daily, HCTZ 25mg
daily, atenolol 25mg daily, and amlodipine 5mg daily. Given the
difficulty in controling her BP a workup for secondary
hypertension was intiated. Renal US negative for evidence of
stenosis. Renin and aldosterone levels pending at the time of
discharge. TTE performed - normal EF and no evidence of valvular
disease. She should consider stress testing as outpatient.
.
# Rhythm: normal sinus rhythm. Pt did have a short run of atrial
tachycardia on morning of discharge, approx 10 beat.
Asymptomatic.
.
# Heroin abuse - continued on methadone dose - 120mg daily
.
# Dispo - Social work consult was obtained for medication
assistance. The patient has a history of stopping BP meds due to
inability to pay. She has been enrolled in free care.
.
The patient was clinically improved and discharged home. Will
follow up in clinic in 1 week for BP check and on [**3-28**] with new
PCP.
Medications on Admission:
None
Discharge Medications:
1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Methadone 40 mg Tablet, Soluble Sig: Three (3) Tablet,
Soluble PO DAILY (Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*1 Tablet(s)* Refills:*2*
4. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hypertensive urgency
Secondary: Methadone maintenance
Discharge Condition:
Good, chest pain free, vital signs stable
Discharge Instructions:
You were admitted to the hospital with chest pain. Your blood
pressure was very high and you were started on several
medications to improve your blood pressure. These medications
are:
Norvasc 5mg daily
Lisinopril 40mg daily
Hydrochlorothiazide 25mg daily
Atenolol 25mg daily
You should also continue to take aspirin daily.
.
Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital1 **] Community
Health Center. Your appointment is scheduled for [**2114-3-28**] at 3pm.
You are also scheduled to follow up with [**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 13469**] NP on
[**2114-2-21**] at 1pm. Please call [**Telephone/Fax (1) 3581**] with any questions. You
will need to stop on the [**Location (un) 453**] of Adult Medicine on the day
of your appointment to fill out paperwork for [**Hospital1 **].
.
Please contact your doctor or return to the emergency room if
you develop worrisome symptoms such as chest pain, shortness of
breath, lightheadedness or begin to feel uwell.
Followup Instructions:
Health Center. Your appointment is scheduled for [**2114-3-28**] at 3pm.
You are also scheduled to follow up with [**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 13469**] NP on
[**2114-2-21**] at 1pm. Please call [**Telephone/Fax (1) 3581**] with any questions.
ICD9 Codes: 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1211
} | Medical Text: Admission Date: [**2165-2-18**] Discharge Date: [**2165-2-22**]
Date of Birth: [**2115-11-1**] Sex: F
Service: Blue Surgery
HISTORY OF PRESENT ILLNESS: Patient is a 49-year-old
African-American female who underwent a sigmoid colectomy in
[**2163-10-5**] for adenocarcinoma of the colon with one
positive lymph node. She also received chemotherapy
adjunctive to the surgery of 5FU and leucovorin. She has had
[**2165-1-2**]. A CT scan of the abdomen was performed on
[**2165-1-4**], which demonstrated two lesions in the
liver, a 3.2 cm lesion in segment for a 4.3 x 2.5 cm lesion
in the inferior aspect of the right lobe near the liver edge.
She was then referred to Dr. [**Last Name (STitle) **] for consideration of
hepatic resection for this metastatic disease to the liver.
1. Hypertension.
2. Atrial fibrillation.
3. Congestive heart failure.
4. IHSS status post pacemaker placement DDD in [**2157**].
5. Colon adenocarcinoma with positive lymph node and status
post surgery and adjuvant chemotherapy.
6. Sleep apnea.
7. Diabetes.
Past surgical history is significant for status post sigmoid
colectomy in [**2152**] and status post brain tumor resection in
[**2145**], status post uvulectomy and sinus surgery.
MEDICATIONS ON ADMISSION: Coumadin 2.5 mg po taken as
directed, verapamil HCL 180 mg po q day, triazolam 25 mg po q
hs prn, ranitidine 150 mg po bid, Micro-K 20 mEq q am,
lactulose two tablespoons [**Hospital1 **], hydrochlorothiazide 25 mg po q
day, Glyburide 5 mg po q day, Glucophage 1000 mg po bid,
Flonase one spray each nostril q day, Diovan 80 mg po q day,
atenolol 50 mg po q day, [**Doctor First Name **] 60 mg po bid prn.
ALLERGIES: She is allergic to sulfa and penicillin which
cause rash.
SOCIAL HISTORY: She denies any alcohol or smoking history.
No history of IV drug use.
Family history is significant for a mother who died of
cerebrovascular accident. Her father died of a myocardial
infarction and question of IHSS at age 45. Sister died at
age 47 of a myocardial infarction and question of IHSS.
PHYSICAL EXAMINATION: Patient is moderately obese female in
no acute distress. Temperature is 99.0, pulse 84. Blood
pressure is 140/84, respirations 20, and weight is 246 lb.
Skin has keloids under both mandibles and several scars on
the torso. HEENT: No scleral icterus. Oropharynx is clear.
No uvula. Neck is supple. No lymphadenopathy and no
thyromegaly. Lungs are clear to auscultation. Cardiac
examination is normal, S1 loud, split S2, there is a 3/6
systolic ejection murmur along the left sternal border.
Regular, rate, and rhythm with pacemaker. Abdomen is soft,
nontender, normal bowel sounds, and no masses. Extremities
have no peripheral edema. Neurologically she is intact.
LABORATORIES: Hemoglobin 12.6, hematocrit 37.7, white count
of 12.3, platelets 176,000. Sodium 139, potassium 4.5,
chloride 102, bicarbonate 23, glucose of 305, BUN of 12,
creatinine of 0.7, AST of 17, ALT of 27, alkaline phosphatase
of 88, total bilirubin of 0.2, direct bilirubin of 0.1, CEA
of 34.
She underwent a cardiac catheterization by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
which is only significant for an elevated pulmonary capillary
wedge pressure of 18-20, but her coronary arteries were open,
which is a moderate surgical risk.
Electrocardiogram showed paced rhythm with a rate of 78.
CTA showed one liver lesion in segment six of the right lobe
measuring 2.7 x 5.2 cm. Second lesion in segment 4A
measuring 3.8 x 4.6 cm. There are two additional low
attenuation foci. They were too small to characterize.
HOSPITAL COURSE: On the date of admission, the patient was
taken to the operating room where she underwent a segment six
and segment 4B resection, cholecystectomy, and intraoperative
ultrasound. She tolerated this procedure well and received
3,000 Crystalloid and estimated blood loss of 400 and urine
output of 640. She was transferred to the PACU in stable
condition.
She spent the first postoperative night in the Intensive Care
Unit for close monitoring where she remained hemodynamically
stable, and postoperative day #1, she was transferred to the
floor for remainder of recovery. Neurologically her pain was
controlled with epidural for the first postoperative day.
The epidural was discontinued and patient was placed on IV
Morphine prn. Her pain has appropriately decreased and her
use of pain medications has appropriately decreased. She has
remained alert and oriented, and neurologically intact.
Respiratory status has remained stable. Her O2 saturations
have been in the high 90s to 100%, and has been weaned off
oxygen successfully.
Cardiovascular status has remained stable. She is remaining
hemodynamically stable. She did have an episode on
postoperative day #3 where she described a "her throat was
closing." Due to the history of diabetes, it is unknown if
this was an atypical chest pain versus perhaps some laryngeal
edema secondary to intubation. She had an electrocardiogram
which showed paced rhythm which was unchanged from a previous
electrocardiogram. She also had a set of cardiac enzymes
sent which were negative with a troponin less than 0.3, CPK
of 639, MB fraction of 1.
She had one other episode, but has denied having any other
episodes of her throat closing. Much of her symptoms have
been focused only around her airway. During this period also
she did not have any periods of desaturation and remained
hemodynamically stable.
Her diet was advanced to a diabetic diet which she has been
tolerating. Her wound has remained clean, dry, and intact.
Her JP has continued to drain moderate amounts up to 50
cc/day of a darkly colored fluid. She will be discharged
with a JP in place with followup in clinic for evaluation and
then possible removal. Her Foley was discontinued. She has
been voiding without any problems.
Endocrine wise, the patient's blood glucose levels have
remained in the 200s ranging anywhere from as low as 172 to
as high as 288. Josalin consult was obtained and patient was
recommended to be started on insulin injections for better
hyperglycemic control. She was placed on NPH insulin 16
units in the morning and 12 units before bedtime in an
adjusted sliding scale. She received diabetic teaching while
in the hospital. She will be going home with VNA for
injections of NPH in the morning and in the evening. Will
follow up with Dr. [**Last Name (STitle) 82897**] in the [**Hospital 99937**] Clinic on Monday,
[**2165-2-25**]. She was restarted on oral hypoglycemic medication
once she was taken off the diabetic diet.
Hematologically, the patient's hematocrit has remained
stable. Has gone from 29 to 25. Her platelet count had
dropped down to 105 on postoperative day two from 151 on
postoperative day #0. Her Zantac was stopped. She is placed
on Protonix for gastrointestinal prophylaxis. Her Heparin
injections were continued and antibody was sent to the
laboratory.
The patient has been ambulating, stable, and ready for
discharge with followup with Dr. [**Last Name (STitle) **] on [**2165-2-27**] in the
clinic. Pathology has returned on the specimen with negative
margins 0.9 cm. The section 6 and 4 resection were positive
for metastatic adenocarcinoma of the colon.
DISCHARGE DIAGNOSES:
1. Status post liver resection of sections 4B and 4A,
cholecystectomy, and intraoperative ultrasound.
2. Metastatic colon adenocarcinoma to the liver.
3. Hypertension.
4. Diabetes mellitus.
5. IHSS.
6. Coronary artery disease.
7. Atrial fibrillation.
DISCHARGE MEDICATIONS: Verapamil 180 mg po q day, Zantac 150
mg po bid, hydrochlorothiazide 25 mg po q day prn, Glyburide
5 mg po q day, Glucophage 1000 mg po bid, Flonase one spray
each nostril q day, Diovan 80 mg po q day, atenolol 50 mg po
q day, [**Doctor First Name **] 60 mg po bid, NPH insulin 16 units am, 12
units q pm, lactulose two tablespoons po bid, oxycodone 5 mg
po q 4-6 hours prn, and Calor 20 mEq po q am.
CONDITION ON DISCHARGE: Stable.
DISCHARGE INSTRUCTIONS: The patient will go home with VNA
services for wound care, JP care, and insulin teaching, NPH
administration [**Hospital1 **]. Patient has been taught appropriately to
empty and record JP outputs. The patient has had diabetic
teaching for insulin shots. Patient will follow up with Dr.
[**Last Name (STitle) 82897**] on [**2-25**] and followup with Dr. [**Last Name (STitle) **] on [**2-27**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D 02-366
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2165-2-22**] 15:04
T: [**2165-2-25**] 11:17
JOB#: [**Job Number 99938**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1212
} | Medical Text: Admission Date: [**2141-7-18**] Discharge Date: [**2141-7-25**]
Date of Birth: [**2060-5-11**] Sex: F
Service: MEDICINE
Allergies:
Losartan / Lisinopril / Penicillins / Flagyl / Ultram
Attending:[**First Name3 (LF) 4654**]
Chief Complaint:
right sided pleuritic chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 81 yo F with h/o chronic eosinophilic lung disease,
COPD (FEV1 0.74, FEV1/FVC 72% predicted in [**5-25**]), diastolic CHF,
atrial fibrillation/atrial tachycardia, and HTN with recent
hospitalization at [**Hospital1 18**] from [**6-8**] - [**6-21**] for MSSA and
Psueodmonas RLL PNA requiring intubation, pressor support for
hypotension, L sided PTX, and C diff colitis who presents from
her nursing home with fever and increasing right sided pleuritic
chest pain. Pt describes sudden onset of lower right sided
pleuritic chest pain yesterday that was non-radiating, [**2142-9-24**].
Feels SOB at baseline and does not feel SOB is significantly
worse from baseline although she feels she is unable to take as
deep of a breath than usual. The pt also describes a chronic
cough for years that has not changed. The pt also complains of
subjective and objective fevers, up to 101 at rehab 2 days ago.
Denies diarrhea but describes some increased abdominal
distention. No nausea, vomiting, neck pain, photophobia,
increasing confusion, dysuria, urinary frequency.
.
In the ED, Tm 103.4, BP 89/42, HR 126, RR 27, O2 sat 98% RA.
Labs notable for WBC 10.5 without bands, Hct 32.2 (prior
baseline mid to upper 20s), Cr 0.9, CE neg X 1, and lactate 1.5.
EKG with sinus tachycardia and no signs of right sided heart
strain. CXR with RLL infiltrate. Chest CTA preliminarily read as
extensive right sided PE with RLL infiltrate possibly concerning
for infarcted lung. She was started on heparin gtt with bolus,
given Vancomycin 1 gm IV X 1, Cefepime 1 gm IV X 1, and
acetaminophen 1 gm po X 1. Admitted to [**Hospital Unit Name 153**] for further care.
.
ROS as above. Otherwise notable for some increased fatigue.
Denies myalgias, sore throat, recent travel. Has been in rehab
for past month.
Past Medical History:
-h/o C. diff colitis
-h/o MSSA PNA
-AF/AT
-COPD
-diastolic CHF, EF 55%
-Osteoarthritis
-H/o myocarditis in [**2137**] with EF 20-25% at that time, cath
negative
-Hyperlipidemia
-Peripheral artery disease
-HTN
-Migraine HA
-Chronic eosinophilic lung disease (chronic eosinophilic
pneumonia or Churg-[**Doctor Last Name 3532**] syndrome)
-Hypoalbuminemia
-History of angioneurotic edema on [**Last Name (un) **] therapy
Social History:
Pt has a previous 40 pack-year history of smoking (stopped 25
yrs ago). She does not drink alcohol and denies other drug use.
She lives with her husband and has three grown children.
Family History:
[**Name (NI) 1094**] mother's side notable for "extensive" heart disease
(several of her family members died from this); pt's father died
of "cancer of the spleen." No history of diabetes or stroke.
Physical Exam:
98.7 127 85/42 16 96% 2L NC
Gen - elderly female in NAD, speeaking in full sentences without
significant difficulty
HEENT - sclerae anicteric, dry MM, OP clear, JVD not distended,
no LAD appreciated
CV - tachycardic, nl s1/s2, no m/r/g appreciated
Lungs - fair air mvmt b/l, but otherwise CTA b/l without w/r/r
Abd - Soft, moderate distention, normoactive BS, no masses
Ext - no LE edema, WWP, cap refill < 2 sec
Neuro - AAO X 3
Pertinent Results:
[**Hospital Unit Name 153**] labs on admission:
[**2141-7-18**] 12:15PM BLOOD WBC-10.5 RBC-3.79* Hgb-10.3* Hct-32.2*
MCV-85 MCH-27.1 MCHC-31.9 RDW-18.2* Plt Ct-322
[**2141-7-18**] 12:15PM BLOOD Neuts-84.5* Lymphs-9.3* Monos-4.6 Eos-1.3
Baso-0.2
[**2141-7-18**] 12:45PM BLOOD PT-14.1* PTT-22.9 INR(PT)-1.2*
[**2141-7-18**] 12:15PM BLOOD Glucose-115* UreaN-12 Creat-0.9 Na-138
K-4.2 Cl-103 HCO3-26 AnGap-13
[**2141-7-18**] 12:15PM BLOOD CK(CPK)-26
[**2141-7-19**] 04:10AM BLOOD Calcium-7.4* Phos-2.9 Mg-2.1
[**2141-7-18**] 12:37PM BLOOD Lactate-1.5
.
Troponin:
[**2141-7-18**] 12:15PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2141-7-18**] 08:16PM BLOOD CK-MB-3 cTropnT-0.01
[**2141-7-19**] 04:10AM BLOOD CK-MB-3 cTropnT-<0.01
.
Labs on day of transfer to hospital floor:
[**2141-7-20**] 02:55AM BLOOD WBC-8.3 RBC-2.88* Hgb-8.1* Hct-25.0*
MCV-87 MCH-28.2 MCHC-32.5 RDW-18.0* Plt Ct-293
[**2141-7-20**] 02:55AM BLOOD Neuts-77.2* Lymphs-17.6* Monos-4.6
Eos-0.5 Baso-0.1
[**2141-7-20**] 02:55AM BLOOD Glucose-101 UreaN-9 Creat-0.6 Na-143
K-3.2* Cl-111* HCO3-22 AnGap-13
.
Imaging:
CXR [**2141-7-18**] 12:44:
1. Persistent left pleural effusion.
2. Right basilar opacification likely atelectasis.
3. Upper lobe lucency suggests emphysema. .
.
CTA chest [**2141-7-18**]:
1. Extensive PE on the right.
2. Airspace opacification in the right lower lobe, concerning
for pulmonary infarction, but superinfection, aspiration and/or
partial collapse cannot be excluded. Opacities at the left lung
base could be related to aspiration, atelectasis or small
infarct.
3. Multiple borderline enlarged likely reactive mediastinal
lymph nodes.
4. Emphysema.
5. Multiple bilateral calcified granuloma with several
noncalcified
micronodules.
.
LENI:
1. Nonocclusive thrombus in the right common femoral vein
extending into the greater saphenous and profunda femoris vein.
2. Left peroneal vein thrombosis.
.
ECHO: The left atrium is elongated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is 10-20mmHg. Left ventricular wall thicknesses and cavity size
are normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is low normal (LVEF 50-55%). There
is no ventricular septal defect. The right ventricular cavity is
mildly dilated with normal free wall contractility. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild to moderate ([**2-17**]+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. The pulmonary artery systolic pressure could not be
determined. There is a trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2140-11-4**] ,
the degree of MR [**First Name (Titles) **] [**Last Name (Titles) **] [**Doctor Last Name **] has decreased. The LV and RV look
similar.
.
CXR: Hyperlucency in the upper lobes corresponded to
the known emphysema. The opacity in the left lower lung
corresponds to a
combination of atelectasis and ground-glass opacity demonstrated
in the recent CAT scan. The ground-glass opacity could be due to
perfusion abnormality distal to the pulmonary embolism. Mild
cardiomegaly. Improvement of the atelectasis in the left lung
base. Mediastinal contours appear remarkable.
.
Micro data:
URINE CULTURE (Final [**2141-7-19**]): MIXED BACTERIAL FLORA ( >= 3
COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION.
.
Blood culture: ngtd
Brief Hospital Course:
81 yo F with a h/o eosinophilic lung disease, COPD, diastolic
CHF, recent admission for MSSA and pan-sensitive pseudomonas PNA
who presents with fevers and right-sided pleuritic chest pain,
found to have extensive right-sided PE and possible RLL
pneumonia on chest CT.
<br>
#)PE- The patient was admitted to the [**Hospital Unit Name 153**] after being
transported to the [**Hospital1 18**] ED via EMS from her rehab facility.
She had been quite immobile at that facility and it appears that
she was not receiving DVT prophylaxis with subcutaneous heparin.
CTA revealed large right-sided PE and LENIs revealed
significant clot burden in bilateral lower extremities. She was
given a heparin bolus and started on a heparin drip. She was
initially hemodynamically unstable with BP 89/42, P 126 and RR
27, however quickly improved with supplemental O2, heparin and
morphine. She was transfered to the [**Hospital Unit Name 153**]. She was initially
managed with a heparin drip, and was subsequently transitioned
to lovenox bridge to therapeutic coumadin. Neither TPA nor
surgical intervention were required. Therapeutic lovenox was
continued for 48 hours after INR was greater than 2. Goal INR
is [**3-21**].
-***Patient will follow up with coumadin clinic via [**Company 191**] - with
instructions to be seen this week with INR check by VNA service
[**7-25**] - pt noted with mild blood tinged sputum at time of
discharge - noted multiple chronic pulmonary processes, with
recent PNA - needs to be monitored closely at home as given
strict instructions -
(note called PCP office [**Name Initial (PRE) **] unable to get through (hold for 25min)
- family instructed to call/stop by office as with pt during
encounters last day)) - able to make appointment with PCP RN on
[**Name9 (PRE) 2974**] [**2141-7-28**]
-*****Note INR up at 3.8 day of discharge - pt instructed to
hold coumadin tonight - will be restarted at 2.5mg tomorrow
(unless INR still >3.0 as VNA will check TOMORROW and report to
PCP's office
-instructed pt and family of strict fall precautions
<br>
#)Fever- The patient's initial temperature on arrival to the ED
was 103.4 therefore an additional infectious process in the
lungs was considered possible. CT of the chest revealed a
possible area of consolidation in the RLL in the same region as
her previous pneumonia. She received 1 gm IV vancomycin and 1
gm cefapime IV in the ED. Her coverage was changed in IV vanc
and cipro in the [**Hospital Unit Name 153**] to cover for possible
healthcare-associated PNA in the setting of the patient's
penicillin allergy. She was afebrile throughout her time in the
[**Hospital Unit Name 153**] and antibiotics were discontinued on hospital day 2 when
she had been afebrile for 24 hours and it was felt that her
temperature, though somewhat high for a PE, was most likely due
to the PE and not an infectious process. A urinary tract
infection was considered possible with a borderline UA, and she
was started on Macrobid. This was discontinued after 4 days
when urine cultures were negative. Pt afebrile and stable from
infectious perspective at time of discharge.
<br>
#)Hypotension- This was likely primarily cardiogenic in etiology
given the patient's large PE. A possible septic component was
considered and the patient was appropriately covered with
antibiotics. A possible distributive component (due to adrenal
insufficiency in this patient who takes 5mg hydrocortisone
daily) was also considered and she was given a
"mini-stress-dose" of steroids (50mg q8hr for one day). Her
hemodynamics improved with fluid resuscitation with boluses prn
to maintain SBP >90 and UOP >30 cc/hr. She returned to low dose
prednisone without incident.
<br>
#)ST depression- The patient was found to have minimal ST
depression (<1mm) in leads V4-V6 in the ED. Cardiac enzymes
were negative x3. These EKG changes were therefore felt to be
related to demand in the setting of PE, not ACS. Pt CP free
without further issues at time of discharge with cont treatment
of PE as above.
<br>
#)COPD- The patient did not report increased SOB or cough,
however her O2 requirement increased to 2L NC likely due to PE.
She was given morphine for her chest pain with the added benefit
of decreasing air hunger. She was started on her home COPD
medications. O2 sats remained stable. Noted with ambulatory o2
sat of 93% on [**7-24**].
<br>
# diastolic CHF - pt mildly hypervolemic - noted Na 146
yesterday (mild hypervolemic hypernatremia. [**Name (NI) 9503**] pt's
home lasix dose - given pt will be in-house till [**7-25**] due to
refusal of discharge - repeated Na check - was 140 at time of
d/c - pt cont on 20mg lasix (Rx given to pt).
<br>
#)h/o A fib- The patient was in afib on presentation in the
setting of fever, tachycardia and hypotension. She was in NSR
throughout the remainder of her hospitalization. Note atenolol
was d/c due to hypotension - BP stable and HR controlled at time
of discharge - ******PCP to [**Name Initial (PRE) **]/u and re-start as appropriate.
<br>
#)Eosinophilic lung disease- Not an active issue during this
admission. She was restarted on her maintenance steroid dose
after receiving a mini-stress dose on hospital day 1. Note may
be contributing to sputum sx at time of dischage - **close
survelliance as above.
<br>
# Anemia, chronic disease - Hct controlled and stable at 27.9 at
time of d/c.
<br>
# Headache - ?migraines - pt states has had chronic HA in past -
only in early AM - only occasionally requirement pain relief
from medications - *(usually 1/week or so) - here regular
tylonol didn't give complete relief - positive relief with T3 -
gave 10 tabs at time of d/c - if needing qam - to contact
provider for further [**Name9 (PRE) **].
<br>
The patient was reluctant to go to [**Hospital 3058**] rehab, and
physical therapy was consulted and worked with the patient
during the hospitalization - with evaluation recs for HOME PT.
Pt was medically stable for discharge on [**7-24**] - however pt
refusing to go as she was not mentally prepared to leave on this
day - counciled extensively- on risks of hospital infections etc
and medical stability - pt agreed but still refused to go, PT/RN
counciled, and finally case-management discussed - pt cont to
refuse - will as a result was monitored overnight - no events
except noted INR elevation as noted above.
Medications on Admission:
Simvastatin 40 mg daily
Salmeterol/Fluticasone 1 puff [**Hospital1 **]
Tiotropium 1 puff daily
Aspirin 81 mg daily
Trazodone 25 mg qhs prn
Lorazepam 0.5 mg po q8h prn
Benzonatate 100 mg tid
Codeine-Guaifenesin 10 ml q4h prn
Metoprolol Tartrate 12.5 mg daily
Furosemide 20 mg daily
Prednisone 5 mg daily
Esomeprazole 40 mg daily
Montelukast 10 mg PO qhs
Gabapentin 100 mg PO qhs
Ergocalciferol 50,000 units q7d
Potussium tablet (unknown brand, dose) PO daily
Calcium carbonate 1250 mg PO tid
Saccharomyces Boulardii 250 mg PO bid
Docusate 100mg PO bid prn
Acetaminophen 650 mg q4hr prn
Acetaminophen/Butalbital/Caffeine po q6hr prn
Albuterol/Ipratropium 3ml neb qid prn
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Atorvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily): can resume your own simvastatin instead.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours): can
resume your own esomeprazole instead.
4. Furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
5. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization [**Hospital1 **]:
One (1) ML Inhalation q4h prn () as needed for sob, wheezing.
6. Codeine-Guaifenesin 10-100 mg/5 mL Syrup [**Hospital1 **]: 5-10 MLs PO Q6H
(every 6 hours) as needed for cough.
[**Hospital1 **]:*qs qs* Refills:*0*
7. Gabapentin 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO HS (at
bedtime).
8. Prednisone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
9. Montelukast 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Hospital1 **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device [**Hospital1 **]:
One (1) Cap Inhalation DAILY (Daily).
12. Trazodone 50 mg Tablet [**Hospital1 **]: 0.5 Tablet PO HS (at bedtime) as
needed for sleep.
13. Benzonatate 100 mg Capsule [**Hospital1 **]: Two (2) Capsule PO TID (3
times a day) as needed for cough.
[**Hospital1 **]:*50 Capsule(s)* Refills:*0*
14. Acetaminophen 650 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H
(every 6 hours) as needed for fever, pain.
15. Florastor 250 mg Capsule [**Hospital1 **]: One (1) Capsule PO bid ().
16. [**Hospital **] Rehab
Pulmonary Rehab - evaluation and treatment
17. Warfarin 2.5 mg Tablet [**Hospital **]: One (1) Tablet PO QDAILY at
16:00.
[**Hospital **]:*30 Tablet(s)* Refills:*0*
18. Acetaminophen-Codeine 300-15 mg Tablet [**Hospital **]: Two (2) Tablet
PO every six (6) hours as needed for pain: only take for HA in
am - if needing more than just in am for more than 2 days - call
provider for further recommendations.
[**Hospital **]:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
# Pulmonary embolism
# LE DVT's
# COPD
# eosinophilic lung disease
# deconditioning
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:
Followup Instructions:
Provider: [**Last Name (NamePattern5) 7224**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2141-7-25**]
2:00
Provider: [**Name10 (NameIs) **],TEACHING [**Hospital **] CLINIC-CC2 (SB)
Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2141-7-31**] 10:45
Provider: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2141-9-12**] 9:40
.
You need to have your INR followed closely via your PCP's
office. You will be scheduled for this appointment, or please
call [**Telephone/Fax (1) 250**] to make this appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 474**] MD [**MD Number(2) 4658**]
Completed by:[**2141-7-25**]
ICD9 Codes: 2762, 2760, 4280, 4019, 496, 4589, 2768, 2724, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1213
} | Medical Text: Admission Date: [**2153-6-29**] Discharge Date: [**2153-7-8**]
Service: MEDICINE
Allergies:
Sulfur / Zestril / Zithromax
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a [**Age over 90 **]M with h/o CAD, CHF, CKD, hyperlipidemia, HTN,
anemia presenting with rigors, fever, hypotension consistent
with septic shock, likely from pneumonia. Pt admitted to ICU for
pressors, fluid support, and antibiotics. BP improved and
antibiotics narrowed to levaquin only. Denies CP, SOB, HA,
fevers, chills, rigors, abd pain, N/V. States he has been eating
well though not so much today. Has had some diarrhea but can't
quantify it. Started on flagyl in ICU empirically for possible
Cdiff.
Past Medical History:
PVD
CAD s/p MI [**2105**], 4vCABG [**2137**]
CRI (baseline Cr 1.5-2.0)
HTN
Anemia of chronic disease
GERD
BPH
BCC L ear
Paget's dz
s/p cholecystectomy
s/p cataract surgery
Social History:
lives independently, son in the area, occasional alcohol, denies
tobacco use
Family History:
non-contributory
Physical Exam:
VS: Temp: 102/98 BP:90/60 HR:78 RR:16 96%4liters O2sat
.
general: pleasant, mentating well, NAD
HEENT: PERLLA, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, RIJ in place
lungs: CTA b/l with good air movement throughout
heart: RR, S1 and S2 wnl, 3/6 Systolic murmur, LUSB
abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
extremities: [**2-6**]+edema edema
skin/nails: no rashes/no jaundice/no splinters
neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout.
rectal:guiac negative
Pertinent Results:
[**2153-6-29**] 09:30AM BLOOD WBC-6.4 RBC-2.68* Hgb-9.5* Hct-26.6*
MCV-100* MCH-35.4* MCHC-35.5* RDW-12.9 Plt Ct-113*
[**2153-6-29**] 09:30AM BLOOD Neuts-87.8* Bands-0 Lymphs-7.1* Monos-3.9
Eos-1.1 Baso-0
[**2153-7-1**] 04:42AM BLOOD PT-14.7* PTT-28.9 INR(PT)-1.3*
[**2153-7-7**] 07:00AM BLOOD UreaN-34* Creat-2.0* Na-135 K-3.4 Cl-105
HCO3-22 AnGap-11
[**2153-6-29**] 09:30AM BLOOD Glucose-151* UreaN-58* Creat-2.6* Na-142
K-5.0 Cl-107 HCO3-25 AnGap-15
[**2153-7-2**] 04:40AM BLOOD CK(CPK)-337*
[**2153-6-29**] 07:24PM BLOOD LD(LDH)-258* CK(CPK)-351*
[**2153-6-29**] 09:30AM BLOOD ALT-21 AST-31 LD(LDH)-214 CK(CPK)-539*
AlkPhos-81 Amylase-134* TotBili-0.3
[**2153-6-29**] 09:30AM BLOOD Lipase-57
[**2153-7-2**] 04:40AM BLOOD CK-MB-9 cTropnT-0.16*
[**2153-6-29**] 09:30AM BLOOD CK-MB-3
[**2153-6-30**] 03:42PM BLOOD CK-MB-10 MB Indx-2.0 cTropnT-0.17*
[**2153-6-30**] 04:07AM BLOOD CK-MB-9 cTropnT-0.15*
[**2153-6-29**] 07:24PM BLOOD CK-MB-6 cTropnT-0.05*
[**2153-7-5**] 06:35AM BLOOD Calcium-8.2* Mg-2.0
[**2153-6-29**] 07:24PM BLOOD Calcium-6.6* Phos-2.8 Mg-1.6
[**2153-6-29**] 07:24PM BLOOD VitB12-638 Folate-17.7
[**2153-6-30**] 04:49AM BLOOD Cortsol-30.4*
[**2153-6-30**] 04:07AM BLOOD Cortsol-27.5*
[**2153-6-29**] 07:24PM BLOOD Cortsol-17.6
[**2153-6-29**] 08:51PM BLOOD Type-MIX pO2-33* pCO2-39 pH-7.34*
calTCO2-22 Base XS--5
[**2153-6-29**] 06:52PM BLOOD Lactate-1.4
[**2153-6-29**] 02:10PM BLOOD Lactate-2.8*
[**2153-6-29**] 06:52PM BLOOD Hgb-8.2* calcHCT-25 O2 Sat-60
[**2153-7-1**] 09:01AM BLOOD freeCa-1.01*
[**2153-7-6**] 10:25PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2153-7-6**] 10:25PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2153-6-29**] 03:00PM URINE RBC-0-2 WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
[**2153-7-6**] URINE URINE CULTURE-PENDING INPATIENT
[**2153-7-6**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2153-7-5**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2153-7-3**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT
[**2153-7-2**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT
[**2153-7-1**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
INPATIENT
[**2153-6-30**] URINE Legionella Urinary Antigen -FINAL INPATIENT
[**2153-6-29**] URINE URINE CULTURE-FINAL INPATIENT
[**2153-6-29**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2153-6-29**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
UNILAT LOWER EXT VEINS LEFT
Reason: r/o DVT
[**Hospital 93**] MEDICAL CONDITION:
[**Age over 90 **] year old man with swollen, tender left leg
REASON FOR THIS EXAMINATION:
r/o DVT
INDICATION: [**Age over 90 **]-year-old man with swollen tender left leg. No
comparison is available.
No comparison is a vailable.
[**Doctor Last Name **] scale, color flow and Doppler images of left lower
extremity were obtained. The common femoral vein, superficial
femoral vein, popliteal vein demonstrate normal compressibility,
respiratory variation in venous flow and venous augmentation.
IMPRESSION: No evidence of DVT in left lower extremity
LEFT TIBIA AND FIBULA
CLINICAL HISTORY: Pain and trauma.
AP and lateral views were obtained.
No fracture is seen. Vascular calcifications and surgical clips
are noted.
IMPRESSION: No bony abnormality is seen.
CT, LEFT LEG WITHOUT CONTRAST: There is no fracture. No erosive
changes, lucent or sclerotic lesions, or periosteal reaction is
evident. An enthesophyte is seen along the quadriceps insertion
on to the patella. There is non-specific diffuse circumferential
subcutaneous edema surrounding the lower leg. No loculated fluid
collection or muscle atrophy is evident. Only a minimal amount
of the right leg was imaged, but on the portion imaged, similar
subcutaneous edema findings are noted.
Extensive atherosclerotic vascular calcifications are present.
Scattered surgical clips are present within the medial soft
tissues. There is a small knee joint effusion. Within the limits
of technique, the tendons about the ankle are unremarkable.
IMPRESSION: Non-specific subcutaneous edema, probably similar to
that partially imaged on the right side without focal fluid
collection or underlying osseous abnormality.
Conclusions:
The left atrium is mildly dilated. There is mild symmetric left
ventricular
hypertrophy with normal cavity size. There is moderate regional
left
ventricular systolic dysfunction with focal akinesis of the
inferior wall and
hypokinesis of the inferolateral wall. The remaining segments
contract well.
Tissue Doppler imaging suggests an increased left ventricular
filling pressure
(PCWP>18mmHg). 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 masses or vegetations are seen on the aortic valve.
Moderate (2+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened.
There is no mitral valve prolapse. No mass or vegetation is seen
on the mitral
valve. Moderate (2+) mitral regurgitation is seen. [Due to
acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.]
There is moderate pulmonary artery systolic hypertension. There
is no
pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of
[**2152-1-28**], moderate pulmonary artery hypertension is now
identified (not
measured on prior study). No obvious vegetations are identified
on the current
study. The severity of mitral and aortic regurgitation are
probably similar.
Elevated left ventricular filling pressures are present.
AP chest compared to [**6-29**] through 27:
Small bilateral pleural effusions have decreased substantially
and pulmonary edema is no longer present. Heart is normal size.
Right jugular line ends at the superior cavoatrial junction. No
pneumothorax.
Non-contrast CT of the head was performed.
FINDINGS:
The posterior fossa structures are unremarkable. The cerebral
parenchyma is normal in [**Doctor Last Name 352**] and white matter differentiation.
There is no acute intracranial hemorrhage, mass effect, shift of
normally midline structures or hydrocephalus. Prominent
ventricles and extra-axial CSF spaces, consistent with age
appropriate involution of the brain parenchyma was noted.
Bilateral maxillary retention cysts are noted, incompletely
evaluated on the present study.
IMPRESSION:
No acute intracranial hemorrhage.
Brief Hospital Course:
SEPSIS: Resolved in the ICU with aggressive Rx. Likely source is
pneuminia. To complete a 14 days course of levofloxacin.
NSTEMI, CAD, CABG - likely from the stress of septic shock. He
was continued on ASA, beta blocker, statin, [**Last Name (un) **]. This was
discussed with his out-patient cardiologist - Dr [**Last Name (STitle) **] who
recommended no further testing at this time.
CHF, systolic: Secondary to known systolic dysfunction, after
vigourous fluids in ICU Improved with diuresis, however diuresis
stopped give rising creat.
ARF/CKD: Cr was high initially from the prerenal state.
stabilized at discharge.
Anemia: Hct stable s/p transfusion in ICU. he will require
follow up CBC with PCP.
Diarrhea: resolved with empiric flagyl. Cdiff x 3 = negative.
The patient had a non-gap acidosis from the diarrhea which also
was resolving at discharge.
Leg edema - asymmetric L>R - LENI neg for DVT, No fracture on XR
and CT revealed subcut edema. Given that the left leg had the
saph vein removed during CABG, this was likely venous stasis.
Vascular was consulted who did not feel ABI were needed. 2
pillow elevation of leg and teds were recommended and the edema
was markedly improved prior to dc. Dr [**Last Name (STitle) 3407**] from vascular to
follow up.
Medications on Admission:
1. Aspirin 81mg daily
2. diovan 40mg daily
3. toprol 12.5 mg daily
4. zocor 20mg daily
5. flomax 0.4 mg daily
6. Protonix 40mg daily
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 6 days.
Disp:*3 Tablet(s)* Refills:*0*
9. Zocor 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. Tamsulosin Oral
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 6 days.
Disp:*3 Tablet(s)* Refills:*0*
9. Zocor 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
10. Tamsulosin Oral
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Septic shock from community acquired pneumonia
NSTEMI
Venous stasis, likely (Left leg > rt leg)
Anemia
Acute renal failure
Chronic kidney disease
CAD, CABG
Diarrhea - resolved
Non anion gap metabolic acidosis
Discharge Condition:
stable
Discharge Instructions:
Return to the hospital if you have fevers, chils, chest pain,
trouble breathing or any other symptoms of concern to you.
Keep your appointments as below. Please call Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 410**] at
[**Telephone/Fax (1) 1144**] and reschedule an earlier appointment in the next
1-2 weeks.
Complete the course of antibiotics as prescribed. Your should
wear the [**Male First Name (un) **] hoses on both legs in the day and maintain an
elevated position for legs when you are sitting down. This
should help the swelling in the legs get better.
Followup Instructions:
Please call Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 410**] at [**Telephone/Fax (1) 1144**] and reschedule an
earlier appointment in the next 1-2 weeks.
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 2352**] - ADULT MEDICINE (SB)
Date/Time:[**2153-10-5**] 11:15
Also make a follow up appointment with Dr [**Last Name (STitle) **] - your
cardiologist in the next 2 weeks. ([**Telephone/Fax (1) 7236**].
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 7721**] VASCULAR LMOB (NHB) Date/Time:[**2153-10-16**]
1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2153-10-16**] 1:30
ICD9 Codes: 0389, 486, 5859, 4280, 5849, 2762, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1214
} | Medical Text: Admission Date: [**2108-11-16**] Discharge Date: [**2108-11-27**]
Date of Birth: [**2031-4-5**] Sex: F
Service: CARDIOTHORACIC SURGERY
HISTORY OF THE PRESENT ILLNESS: This is a 77-year-old female
with a history of hypertension, diabetes, coronary artery
disease, status post an MI and CABG in [**2090**] and subsequently
status post two coronary artery stents who presents with an
acute onset of chest pain and shortness of breath without any
radiation. No nausea, no vomiting, no dyspnea, no
palpitations. The patient also had an exercise intolerance
about one month prior to admission. She had a cardiac
catheterization three days prior to admission which showed a
78% stenosis in the right coronary artery, an almost 100%
stenosis within the stent, proximal graft, and the circumflex
showed diffuse sclerosis at 70-90%. Her left internal
mammary artery to LAD graft was patent.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Coronary artery disease, status post myocardial
infarction in [**2090**].
3. Diabetes mellitus.
4. Gastroesophageal reflux.
PAST SURGICAL HISTORY:
1. Status post CABG in [**2090**].
2. Status post coronary stents times two.
3. Status post cholecystectomy.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Norvasc 5 mg q.d.
2. Prilosec 20 mg q.d.
3. Protonix 20 mg once a day.
4. Lipitor 40 mg once a day.
5. Aspirin 325 mg once a day.
6. Diovan 160 mg once a day.
7. Plavix 75 mg once a day.
8. Atenolol 50 mg once a day.
9. Hydrochlorothiazide 12.5 mg once a day.
10. Insulin sliding scale.
11. Zoloft 1 mg once a day.
SOCIAL HISTORY: She has a 15 pack year history of smoking.
PHYSICAL EXAMINATION ON ADMISSION: General: She is a
pleasant cooperative female in no apparent distress. Vital
signs: She was afebrile with a pulse of 62, blood pressure
179/49, 20 respirations, 99% on room air. HEENT: The mucous
membranes are moist. Cardiovascular: Regular rate and
rhythm. Lungs: Clear to auscultation bilaterally. Abdomen:
Soft, nontender, nondistended. Extremities: No clubbing,
cyanosis or edema.
HOSPITAL COURSE: This is a woman who was admitted to the
Cardiac Surgery Service with severe coronary artery disease
in need of a coronary artery bypass graft surgery. She was
admitted for evaluation.
On hospital day number two, a chest x-ray showed mild
cardiomegaly with no signs of congestive heart failure. On
hospital day number four, an echocardiogram showed left
atrial enlargement, symmetric left ventricular hypertrophy
with an ejection fraction greater than 55%, some mild
inferoseptal hypokinesis with 1-2+ mitral regurgitation and
no discernable aortic regurgitation.
On[**Last Name (STitle) **]tal day number five, [**2108-11-20**], the patient
was taken to the Operating Room where she underwent a three
vessel coronary artery bypass graft by Dr. [**Last Name (Prefixes) **].
Please refer to the previously dictated operative note by Dr.
[**Last Name (Prefixes) **] from [**2108-11-20**] for specifics of this
operation.
The patient tolerated this procedure very well and was
transferred to the CRSU intubated in good condition. While
in the ICU, the patient remained intubated until
postoperative day number three and received several fluid
boluses to maintain her fluid status. On postoperative day
number four, [**2108-11-24**], the patient was transferred
to the floor in a stable condition. She was extubated and in
stable condition.
While on the floor, the patient was tolerating a regular
diet, was evaluated by Physical Therapy who recommended that
the patient undergo rehabilitation for endurance in strength
and mobility as well as weaning of oxygen.
On postoperative day number five, [**2108-11-26**], the
patient was doing very well. She was afebrile with stable
vital signs, saturating 95% on room air. Her laboratory
values showed a stable hematocrit and a creatinine of 1.8.
She was considered stable enough for discharge to a
rehabilitation facility.
Today, on [**2108-11-27**], the patient is being discharged
to [**Hospital **] Rehabilitation Facility.
DISCHARGE DIAGNOSIS:
1. Coronary artery disease, status post coronary artery
bypass graft.
2. Gastroesophageal reflux.
3. Hypercholesterolemia.
4. Diabetes mellitus.
5. Hypovolemia requiring fluid resuscitation.
6. Atrial fibrillation.
7. Postoperative atelectasis.
DISCHARGE MEDICATIONS:
1. Metoprolol 25 mg p.o. b.i.d.
2. Aspirin 325 mg p.o. q.d.
3. Lipitor 40 mg p.o. q.d.
4. Protonix 40 mg p.o. q.d.
5. Plavix 75 mg p.o. q.d. for 90 days.
6. Lasix 20 mg p.o. q.d. for ten days.
7. Potassium chloride 20 mEq p.o. b.i.d.
8. Zoloft 50 mg p.o. q.d.
9. Percocet 45 mg p.o. q.d.
10. Colace 100 mg p.o. b.i.d.
11. Dulcolax 5 mg p.o. b.i.d. p.r.n. constipation.
12. Benadryl 25 mg p.o. q.h.s. p.r.n. insomnia.
13. Regular insulin 4 units with breakfast and lunch.
14. NPH 12 units with breakfast and 10 units with dinner.
15. Regular insulin sliding scale as directed.
FO[**Last Name (STitle) **]P: She is recommended to have a follow-up
appointment with her cardiologist in about one week and with
Dr. [**Last Name (Prefixes) **] in four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 1179**]
MEDQUIST36
D: [**2108-11-26**] 10:24
T: [**2108-11-26**] 10:47
JOB#: [**Job Number 53789**]
ICD9 Codes: 9971, 4240, 2765, 5180, 5990, 4111 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1215
} | Medical Text: Admission Date: [**2171-3-21**] Discharge Date: [**2171-3-23**]
Date of Birth: [**2137-6-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Melena, bloody emesis
Major Surgical or Invasive Procedure:
EGD
IR Venogram w/ stent placement
History of Present Illness:
This is a 33 year-old male with a history of [**Male First Name (un) **]-Chiari Syndrome
dx at age 12 with associated cirrhosis who presents with melena
x3 days and emesis with blood streaks overnight. The patient
has been having black stools over the last 3 days approx 2
episodes per day. He does not recall if there was blood, but
perhaps a small amount. He reported abdominal pain that started
yesterday, located left-side, lower abdomen and periumbilical.
The pain is constant, crampy, [**5-18**]. He denied any fever or
chills and has not noticed increase ascites. Of note the
patient had a therapeutic paracentesis [**1-16**] during his
admission for drainage of a breast hematoma. Today he developed
one episode of emesis with blood streaks ("shot size" amount)
prior to arrive to the ED. He has not had any prior GI bleeds
since his portal caval shunt on [**2170-7-17**]. Denied NSAID use
.
In the ED, initial vital signs were Temp 98, HR:102, 120/81 RR:
12, 100%. The patient underwent NG lavage that showed coffee
counds, small clots, minimal red blood that did not clear after
300ml. He was started on a octreotide and protonix gtt. His
Hct was 39.2 (baseline 37-43), plts 176, INR: 1.5, leukocytosis
11.9, lactate 1.3. He was evaluated by Hepatology with plans for
EGD. Two 18G PIV were placed and he received 500ml IVF. He
remained hemodynamically stable in the ED and transferred to the
MICU.
.
On arrival the patient has complaints of mild abdominal pain.
Otherwise, no other complaints.
Past Medical History:
1. Budd-Chiari Syndrome dx age 12
- c/b esophageal varices - first in [**2164**] w recurrent episodes
- most recent EGD [**6-16**] w grade II and III esoph varices s/p
banding. Also with portal hypertensive gastropathy
- portocaval shunt [**2170-8-17**]
2. History of positive PPD, quantiferon +, s/p 9 months of INH
treatment
3. s/p cholecystectomy
Social History:
Originally from El [**Country 19118**]. Adopted, moved to the United States
at the age of 6 months. Former roofer, currently unemployed.
Lives with his girlfriend. [**Name (NI) **] does not smoke. Prior alcohol use
but not active. Denies drug use.
Family History:
Adopted
Physical Exam:
Vitals: T 97.4, BP 113/71, P 81, RR 15, O2sat 99RA.
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, no epistaxis or rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, BS+, NT, ND
EXT: No C/C/E,
NEURO: AAOx3, nonfocal
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
Admission:
[**2171-3-21**] 06:24AM BLOOD WBC-11.9*# RBC-4.22* Hgb-13.4* Hct-39.2*
MCV-93 MCH-31.6 MCHC-34.1 RDW-15.8* Plt Ct-176
[**2171-3-21**] 06:24AM BLOOD PT-16.5* PTT-34.4 INR(PT)-1.5*
[**2171-3-21**] 06:24AM BLOOD Glucose-104* UreaN-33* Creat-1.1 Na-126*
K-4.1 Cl-92* HCO3-26 AnGap-12
[**2171-3-21**] 06:24AM BLOOD ALT-85* AST-93* AlkPhos-325* TotBili-2.1*
[**2171-3-21**] 06:24AM BLOOD Lipase-156*
[**2171-3-21**] 06:31AM BLOOD Lactate-1.3
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2171-3-22**]):
NEGATIVE BY EIA.
MRSA SCREEN (Final [**2171-3-23**]): No MRSA isolated.
CXR ([**2171-3-21**]) Cardiomediastinal contours are normal. The lungs
are clear. There is no pleural effusion or pneumothorax.
RUQ US w/ Dopplers ([**2171-3-22**]) IMPRESSION:
1. Portacaval shunt is patent.
2. Known cirrhosis, splenomegaly and trace amount of ascites.
Hepatic Venography ([**2171-3-22**]) Preliminary report.. Pressure
gradient of 16 mmHg across shunt. Stent placed and then
pressure of 10mmHg gradient observed. well placed stent.
Brief Hospital Course:
#. Upper GI Bleed: Pt with [**Male First Name (un) **]-Chiari with cirrhosis s/p portal
caval shunt in [**7-17**]. H/o of prior variceal bleeding, but no
prior episodes since shunt was placed. The patient reported 3
days of melena and one episode of small amount of hematemsis.
His Hct was 39.2 on admission and not significantly lower then
his baseline. He has remained hemodynamically stable. He was
started on a Protonix gtt and octreotide gtt in the ED. In the
MICU he underwent EGD that showed esophageal varices that were
not bleeding, hypertensive portal gastropathy and gastritis.
There was not evidence of active bleeding. He was also given 1g
CTX for SBP ppx. A ultrasound was performed to evaluate his
shunt that showed a patent portocaval shunt. IR Venogram was
performed showing a pressure gradient of 16 mmHg across shunt.
A stent was placed and then a pressure gradient of 10mmHg
wasobserved. Patient's Hct was 29.1 upon discharge, which
should be followed up by his PCP.
.
#. Leukocytosis: On admission the patient had a leukocytosis,
but denied fevers or chills. He did have complaints of lower
abdominal pain. An abdominal U/S was performed that showed
minimal ascites. His CXR did not show an infilrate and UA/CX
was negative.
.
#. [**Male First Name (un) **]-Chiari Syndrome: On admission the patient's MELD was 12
(MELD-Na 22). He has never been on anticoagulation. He is
followed by Hepatology and has been evaluated for transplant.
His lasix and spironolactone were held in the setting of his GI
bleed. A stent was placed across his portacaval shunt with a
final pressure of 10mmHg.
.
#. Hyponatermia: Pt with sodium of 126. He appeared dry on
exam and likely represents hypovolemic hyponatermia. He was
given IVF and sodium improved to 130, which should be followed
up by his PCP.
.
#. [**Last Name (un) **]: Pt with baseline Cr 0.6-0.8, but was elevated to 1.1 on
admission. Likely pre-renal in the setting of vomiting, stools
and lasix/spironolactone. On discharge his creatinine improved
to 0.7.
.
Medications on Admission:
Furosemide 80 mg Tab Daily
Spironolactone 200 mg Daily
Multivitamin (MAXIMUM DAILY GREEN) 5 mg-133 mcg daily
Calcium Carb-Vit D3-Minerals 600 mg/400U 2 tab [**Hospital1 **]
Discharge Medications:
1. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
2. Multivitamin Oral
3. Calcium Oral
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Upper GI Bleed
Secondary:
[**Male First Name (un) **]-Chiari Syndrome
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 upper gastrointestinal
bleed. A scope revealed there was no active bleeding in your
gut, however there are changes to the lining of your stomach.
These changes are a complication of the high pressure in your
liver. The shunt in your liver was opened further with a stent
to make sure there would be no backup of blood. Some of your
lab tests were also low including your sodium, which is why your
diuretics were stopped. Your blood level was also low likely due
to your blood lost.
You should NOT take your diuretics: Furosemide and
Spirinolactone. Please follow up with your primary care doctor
in the next week to go over your lab tests [**Last Name (LF) **],[**First Name3 (LF) **]
[**Telephone/Fax (1) 80428**]
You should also call the Liver Center: ([**Telephone/Fax (1) 29435**] to set
up "Right Upper Quadrant Ultrasound with Dopplers" next week.
You will also need to set up a colonoscopy in the near future.
Followup Instructions:
Please follow up with:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13999**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2171-3-27**] 4:00
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2171-4-9**]
2:00
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2171-4-9**]
3:35
Completed by:[**2171-3-25**]
ICD9 Codes: 5849, 2761, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1216
} | Medical Text: Admission Date: [**2156-5-2**] Discharge Date: [**2156-5-12**]
Date of Birth: [**2110-1-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2932**]
Chief Complaint:
rash, fevers
Major Surgical or Invasive Procedure:
bone marrow biopsy
axillary lymph node biopsy
History of Present Illness:
46 year o;d female with no significant medical history presented
with fevers and chills for the last 3 months. Her symptoms began
when she was in [**State 108**] on [**1-29**] with teeth chattering.
A few days later she developed a rash on her chest that looked
like chicken pox. Soon after she developed joint soreness in her
fingers, wrists, and ankles, and stiffness in her neck and jaw.
She was started on Naprosen for the joint pain. She had fevers,
chills, rigors which continued for 1-2 months. Her fevers were
almost exclusively in the evening, accompanied by malaise. On
[**4-12**] she was given a 7 day Doxycycline course given concern for
richettsial disease (subsequently negative serologies). During
the course of her illness she developed a nonproductive cough
and lymphadenopathy. Denies weight loss or anorexia. Over the
past week she has been unable to control her fevers with the
Meloxicam. The morning of presentation she awoke from sleep with
chills at 4-5 AM. She took her temperature at that time and it
was 104. She got up and it remained elevated at 103.6. She
presented to the ED for evaluation. In the ED her vitals were
temp 101.9, pulse 115, BP 105/54, RR 16, 98% on RA. She was
treated with Motrin and admitted to the general medicine floor
for further evaluation of her fevers, arthralgias, and cough.
Given hypotension (sbp 60s-70s), she was transferred to the ICU
for further management.
On transfer to the ICU she had a slight headache. She denied
lightheadedness, vision trouble, sore throat, chest pain or
shortness of breath. She had no abdominal pain, diarrhea or
urinary symptoms. She says her joints generally feel OK at this
time. (the joints felt very bad this last week). Her cough is at
its baseline, productive of clear/whitish sputum. She has some
emesis with the severe coughing. She states that she continues
to have the rash, it is currently on her legs and lower torso
but moves around intermittently.
Extensive outpatient work-up: blood cultures (negative), LFTs
(transaminitis in the 200s), parvovirus seroligies (IgG
positive, IgM negative), varicella IgG (positive), RSMF/R.
typhi/Q fever/Eherlichia (negative), malaria screen (negative),
R. typhi (negative), lyme ab (negative-varicella Ig G positive,
throat culture (negative), dengue (negative), West [**Doctor First Name **]
(negative), monospot (negative), EBV panel (c/w prior
infection), echocardiogram (unremarkable), hepatitis A/B/C
(negative), [**Doctor First Name **] (negative), RF 9, ANCA negative, and Ro/La
negative, HIBAb/VL (negative), CMV VL (negative), CT scan of
torso (bilateral axillary adenopathy, otherwise unremarkable).
She also had a skin biopsy [**4-21**] which showed neutrophil [**Doctor First Name **]
perivascular and interstitial dermatitis with rare eosinophils.
Past Medical History:
b/l breast implants '[**45**]
Botox injections
Social History:
Lives with husband and two kids, no longer working, no recent
travel out of the country, last trip was to [**Location (un) **] 2-3 years
ago, does travel to [**State 108**] regularly. no Smoking, rare Etoh
prior to these episodes. No IVDU. No camping, does walk outdoors
around swampy reserve area in [**State 108**]. She did have some bug
bites while in [**State 108**].
Family History:
Father died of colon CA
Physical Exam:
VS: Temp 98.7, Pulse 114, BP 85/59, RR 20, 95% on RA
Gen: alert, oriented, cooperative female in NAD
HEENT: MMM, OP clear, PERRL
Neck: anterior and posterior cervical lymphadenopathy
Lungs: clear to ausculatation bilatterally
CV: tachycardic, nl S1S2, no murmers
Axillary adenopathy
Abd: soft, non-tender, non-distended, positive BS
Ext: no edema, rash over upper area of legs and lower abdomen
Neuro: grossly inact
Pertinent Results:
Laboratory test on admission:
[**2156-5-2**]
WBC-17.8* HGB-10.3* HCT-31.1* MCV-82 RDW-16.7 PLT COUNT-328
NEUTS-90.3* LYMPHS-4.7* MONOS-2.6 EOS-1.8 BASOS-0.7
PT-13.0 PTT-31.3 INR(PT)-1.1
calTIBC-234* FERRITIN-1119* TRF-180*
ALBUMIN-3.2* CALCIUM-8.5 PHOSPHATE-3.0 MAGNESIUM-2.0 IRON-11*
ALT(SGPT)-22 AST(SGOT)-54* LD(LDH)-488* ALK PHOS-76 AMYLASE-46
TOT BILI-0.2
GLUCOSE-118* UREA N-10 CREAT-0.8 SODIUM-135 POTASSIUM-3.9
CHLORIDE-101
U/A: URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG
KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG
LACTATE-2.8*
Laboratory tests on discharge:
WBC-15.8* Hct-29.2* MCV-81* RDW-17.5* Plt Ct-535*
Neuts-81.6* Lymphs-10.9* Monos-2.8 Eos-4.1* Baso-0.6
Neuts-66.7 Lymphs-17.8* Monos-4.6 Eos-10.1* Baso-0.9
ALT-56* AST-92* LD(LDH)-474* AlkPhos-139* TotBili-0.2
Albumin-2.5* Calcium-8.3* Phos-4.5 Mg-2.2
Other laboratory tests:
ESR 46, ANCA (-), parasite smear (-), CRP 254.2, Lyme Ab (-),
CMV VL (-), ACE 53, SM/RNP (-), ssDNA Ab (-), Ro/la (-),
aldolase 98
.
Radiology
[**5-2**] CXR: The heart size and cardiomediastinal contours are
normal. There is normal pulmonary vascularity. Breast implants
cause homogeneous attenuation of the lower lung fields. No
parenchymal consolidation, pleural effusion, or pneumothorax.
Moderate convex left thoracolumbar scoliosis.
[**5-3**] CXR: Severe bilateral consolidation has developed since [**5-2**], with no change in heart size or mediastinal vascular
engorgement to suggest that this is pulmonary edema. This could
be pneumonia, particularly viral infection or noncardiogenic
edema, including response to sepsis or a pulmonary reaction to
medication or transfusion. Under the appropriate circumstances,
this could represent acute diffuse alveolar hemorrhage.
[**5-4**] CXR: Compared with [**2156-5-3**], there has been modest partial
interval clearing of the pulmonary edema. Small-to-medium sized
bilateral pleural effusions. Bibasilar atelectasis, with
possible consolidation at the right base.
[**5-5**] CXR: Compared with [**2156-5-4**], and the prior studies from [**5-2**]
and [**5-3**], the diffuse bilateral pulmonary opacities, which
developed acutely from [**5-2**] to [**5-3**] and partially cleared on
[**5-4**] have probably cleared further today, allowing for
superimposed breast shadows. There are increased lung volumes.
There appears to be a small left pleural effusion. No obvious
confluent infiltrates are seen.
[**5-8**] CXR: Relatively symmetric basal predominance, infiltrative
pulmonary abnormality has improved in the upper lungs compared
to [**5-6**] and [**5-7**] probably a reflection of decreasing
pulmonary edema, not necessarily cardiogenic. The heart is
normal size. Azygos distention suggests elevated central venous
pressure or volume. No pneumothorax. Heart size normal.
[**5-4**] TTE: The left atrium is mildly dilated. The estimated right
atrial pressure is [**4-15**] mmHg. Left ventricular wall thickness,
cavity size, and systolic function are normal (LVEF>55%).
Regional left ventricular wall motion is normal. Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. There is abnormal septal motion/position. The
aortic valve leaflets are probably structurally normal but not
well visualized. There is good leaflet excursion. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. The estimated pulmonary
artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: No obvious vegetations visualized, although aortic
valve not
well-visualized. Normal biventricular systolic function. No
pathologic
structural valvular disease. Resting tachycardia.
Pathology:
[**5-7**] Bone Marrow Biopsy: Markedly hypercellular bone marrow
(80-90% cellular) with myeloid and megakaryocytic hyperplasia
and erythroid dysplasia. Absent iron stores. No granulomas or
lymphoid aggregates are seen; however a mild eosinophilia is
noted. Immunohistochemical studies will be performed to further
characterize interstitial lymphocytes and the findings reported
in an addendum. Overall, the findings are non-specific and
similar features can be seen secondary to an infectious,
toxic-metabolic, or immune insult. Primary myelodysplasia is
unlikely, however, correlation with clinical and cytogenetic
findings is recommended. CD20 highlights few scattered
interstitial B-cells (less than 5% of overall cellularity).
-cell markers CD3 and CD5 highlight a greater proportion of
interstitial T-cells present singly and in a loose cluster.
They are a mixture of CD4-positive T-helper cells and
CD8-positive T-suppressor cells. No CD30-positive cells are
seen. LMP stain for EBV is negative with nonspecific staining of
megakaryocytes noted.
[**5-7**] Bone marrow flow cytometry: Non-specific T-cell dominant
lymphoid profile; diagnostic immunophenotypic features of
involvement by a B- or T-cell lymphoproliferative disorder are
not seen in specimen.
Brief Hospital Course:
46 year old female presents with fever of unknown origin,
associated with rash, transaminitis, and progressive
lymphadenopathy. The patient was transferred to the ICU [**5-3**]
with hypotension and new pulmonary edema. Her blood pressure
stabilized, she was gently diuresed, and transferred back to the
general medical floor [**2156-5-8**].
1) Fever of unknown origin: As mentioned above, this was
associated with a rash, transaminitis, and progressive
lymphadenopathy (spread to involve axillary, groin, and
posterior cervical chain). See HPI for summary of outpatient
work-up. The patient was followed closely throughout her
hospital stay by the rheumatology, infectious disease, and
oncology services. Additional work-up included a parasite smear
(-), ASO screen (positive, however rheumatic fever was felt to
be unlikely), Lyme Ab (-), CMV viral load (negative), ACE 53,
SM/RNP (-) ss DNA Ab (-), ro & la (negative), aldolase 98
(mildly elevated). She underwent a bone marrow biopsy which
showed narkedly hypercellular bone marrow (80-90% cellular) with
myeloid and megakaryocytic hyperplasia and erythroid dysplasia.
No granulomas or lymphoid aggregates were seen; however a mild
eosinophilia was noted. Overall, these findings are non-specific
and similar features can be seen secondary to an infectious,
toxic-metabolic, or immune insult. She underwent a left
axillary lymph node biopsy, the final pathology of which was
pending at time of discharge. However, the preliminary pathology
report suggested atypical intrafollicular hyperplasia.
Molecular/clonality testing was pending at time of discharge,
which will help distinguish lymphoma vs reactive changes. The
patient will follow-up with infectious disease/oncology as an
outpatient to follow-up the final results of the biopsy. At time
of discharge, the patient was hemodynamically stable, afebrile X
72 hours on Naproxen and Tylenol. If the lymph node biopsy is
non-diagnostic, liver biopsy may be considered, given
transaminitis.
2) Pulmonary edema: This was felt to be secondary to capillary
leak in the setting of inflammation, along with third-spacing
due to low albumin (2.5). The patient had an echocardiogram,
which revealed an EF of >55% without regional wall motion
abnormalities. At time of discharge, the patient was stable on
room air and was auto-diuresing.
3) Anemia of chronic disease: The patient's iron studies were
consistent with anemia of chronic disease, however, her bone
marrow biopsy suggested low iron stores. For this reason, she
was started on iron supplementation. Outpatient work-up of
possible GI sources of bleeding (colonoscopy) can be pursued at
the discretion of the patient's PCP.
Full Code
Medications on Admission:
Meloxicam
Motrin prn
Discharge Medications:
1. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
Disp:*1 device* Refills:*0*
2. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12
hours).
Disp:*120 Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours): don't exceed 2 grams per day.
Disp:*120 Tablet(s)* Refills:*0*
7. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*60 Capsule(s)* Refills:*0*
8. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for itching.
Disp:*60 Capsule(s)* Refills:*0*
9. Albuterol 90 mcg/Actuation Aerosol Sig: [**12-9**] puff Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*1 MDI* Refills:*0*
10. spacer
Use as directed
dispense: 1
refills: 0
11. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO
Q6H (every 6 hours) as needed for cough.
Disp:*100 ML(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: fever of unknown origin
Secondary: anemia of chronic disease, pulmonary edema
Discharge Condition:
Stable, afebrile X 72 hours
Discharge Instructions:
1) Please follow-up as indicated below
2) Please take all medication as prescribed.
3) Please come to the emergency room or see your primary care
physician if you develop lightheadedness, nausea, vomiting,
abdominal pain, shortness of breath, or other symptoms that
concern you.
Followup Instructions:
1) Infectious disease/oncology
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9561**], M.D. Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2156-5-18**] 10:00 p.m.
- basement of [**Hospital **] medical building
- you should have a white blood cell count and liver function
test panel checked at this time
2) Primary Care: Please follow-up with Dr. [**First Name8 (NamePattern2) 6177**] [**Last Name (NamePattern1) 43672**]
([**Telephone/Fax (1) 71782**]) within 1-2 weeks following discharge
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2937**]
Completed by:[**2156-5-13**]
ICD9 Codes: 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1217
} | Medical Text: Admission Date: [**2149-6-10**] Discharge Date: [**2149-7-18**]
Date of Birth: [**2068-5-15**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
L1 vertebrectomy and instrumented reconstruction.
Bronchoscopy with biopsy
CT guided lung biopsy
CT guided spine biopsy
History of Present Illness:
81 yo M with h/o DM2, HTN, gout transferred from [**Hospital3 417**]
with concern for L1 osteomyelitis/compression fracture.
.
Patient underwent L TKA in [**Month (only) **], then has slow onset of lower
back pain on discharge to rehab. He had no focal
weakness/numbness or pasathesias, and was able to participate in
rehab activities. While in rehab he was diagnosed with a UTI was
treated with ciprofloxacin. Also per patient he spent 7 weeks in
rehab, and was discharged home. At home his back pain became
progressively worse over the next 5 days, to the point where he
became non-ambulatory. Again, he endorses no focal
weakness/numbness/parasthesia, and denies bowel or bladder
incontinence. He said that the pain was so severe that he could
not walk. He presented to the ED several times and was treated
with darvocet with some relief. He was admitted to [**Hospital3 **] on
[**6-6**] for pain control.
.
There he received a lumbar spine MRI (details below) that showed
likely osteomyelitis of L1 with compression fracture, and liekly
disckisits of adjacent disks. Based on this finding, patient was
transferred tot he [**Hospital1 18**] for neurosurgical evaluation.
.
On floor, patient was sleeping comfortably. He endoreses [**1-22**]
lowerback pain centered over his spine, non radiating. Denies
bowel/bladder incontinence.
Past Medical History:
Diabetes
Hypertension
Hyperlipidemia
Gout
Asthma/COPD
Spinal Stenosis
Osteoarthritis s/p L TKA in [**4-15**]
Social History:
Quit smoking 50 years ago. < 1 alcoholic drink per month. No
illicits. Former highschool teacher in [**Location (un) 583**].
Family History:
Non-contributory
Physical Exam:
On Admission:
VS - Temp 98.3F, BP 121/85, HR 73, R 20, O2-sat 96% RA
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
Back - TTP over lumbar veterbrae
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**3-19**] throughout, specificaly, senation intact lower extemities,
strength 5/5 LE b/l.
On Discharge:
GENERAL - cachectic, comfortable, pleasant
LUNGS - inspiratory crackles on R side [**11-16**] way up
SKIN - L thoracotomy incision w/ very minimal erythema
NEURO - awake, oriented to person, place, year, POTUS, strength
[**3-19**] BLE, sensation intact
Pertinent Results:
On Admission:
[**2149-6-10**] 11:32PM GLUCOSE-112* UREA N-16 CREAT-0.8 SODIUM-140
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-30 ANION GAP-14
[**2149-6-10**] 11:32PM estGFR-Using this
[**2149-6-10**] 11:32PM ALT(SGPT)-42* AST(SGOT)-46* ALK PHOS-119 TOT
BILI-0.4
[**2149-6-10**] 11:32PM CALCIUM-10.1 PHOSPHATE-4.1 MAGNESIUM-1.6
[**2149-6-10**] 11:32PM WBC-7.8 RBC-4.13* HGB-13.2* HCT-40.3 MCV-98
MCH-31.9 MCHC-32.7 RDW-14.9
[**2149-6-10**] 11:32PM PLT COUNT-298
[**2149-6-10**] 11:32PM PT-12.6 PTT-28.1 INR(PT)-1.1
On Discharge:
Pertinent Imaging (Impressions only)
[**6-12**] MRI: L/T Spine
IMPRESSION:
1. Compression fracture at L1 vertebral body, associated with
retropulsion
resulting in moderate anterior thecal sac effacement and
moderate canal
stenosis at this level. The post-contrast images show abnornal
enhancement in
the anterior epidural space which could represent neoplasm
(15:10).
2. Increased intervertebral disc signal changes at T12-L1 and
L1-L2 levels.
Appearances can be due to a fracture, the possibility of a
pathologic
compression fracture cannot be excluded.
3. Focal area of T2 and FLAIR high signal on the left at T12
vertebral body
concerning for a matastasic lesion.
CT: L/T Spine
IMPRESSION:
There is compression deformity of L1 with lucency within the
vertebral body. Additional lucencies are seen at T12 and L5.
Possibility of a pathologic compression fracture at L1 cannot be
entirely excluded.
Dilatation of the abdominal aorta and bilateral iliac arteries.
Recommend
correlation with CT of the abdomen with contrast
[**6-13**] CT: Torso/Pelvis w/ Contrast:
IMPRESSION:
1. Right upper lobe lung mass with enhancing components and
small central
cavitation with associated hilar and mediastinal lymphadenopathy
concerning
for neoplastic process. Infectious etiology considered less
likely.
2. Stable T12 and L1 with enhancing epidural soft tissue
component at L1,
concerning for metastatic process.
3. Cholelithiasis without evidence of acute cholecystitis.
4. Infrarenal abdominal aortic aneurysmal dilatation up to 3.1
cm just above the bifurcation of the common iliacs.
[**6-19**] MRI: Head
IMPRESSION:
No enhancing brain lesions are seen to indicate metastatic
disease. No acute infarcts. 7-mm focus of enhancement in the
anterior portion of the odontoid process could be due to bony
metastatic lesion given the patient's history of other areas of
bony metastasis. No evidence of impending fracture seen or
epidural mass identified. Mild narrowing of the spinal canal is
noted on sagittal post-gadolinium images at C3 and C4 level.
[**6-30**] CT: L-Spine:
IMPRESSION:
1. The fractured L1 vertebral body demonstrates slightly
increased loss of
height and slightly increased retropulsion. The spinal canal
appears more
narrowed, but this is difficult to quantify on noncontrast CT.
The appearance remains suggestive of a pathologic fracture.
2. Slight interval enlargement of the T12 lytic lesion, likely a
metastasis.
3. Unchanged L5 lytic lesion.
4. 3.2 cm infrarenal abdominal aortic aneurysm is again noted.
[**7-14**]: L-Spine AP/Lateral:
IMPRESSION: There is no change in hardware position or alignment
compared to the intraoperative images from [**7-7**].
Pathology:
L1 Vertebral Body Biopsy:
Vertebral body, L1, biopsy:
Poorly differentiated squamous cell carcinoma, consistent with
pulmonary origin, see note.
Note: The malignancy is keratin cocktail and CK7 positive, as
well as p63 and focally TTF-1 positive. It is CK20 negative.
.
Bone, L1 vertebra, vertebrectomy (B-F):
Metastatic poorly-differentiated carcinoma. See note.
Note: Immunohistochemical staining shows that the tumor cells
are positive for CK7 and focally positive for TTF-1. These
findings are consistent with metastatic poorly-differentiated
carcinoma of lung origin. The prior vertebral body biopsy
(S10-[**Numeric Identifier 87643**] L) has been reviewed. The patient's history of a
lung mass is noted.
Brief Hospital Course:
81 yo M with h/o DM2, recent L TKA, p/w severe back pain, now
found to have L1 compression fracture and found to have
metastatic squamous cell lung cancer. Patient had palliative
vertebrectomy.
.
#. L1 Compression Fracture/Vertebrectomy: His outside MRI
sugggestive of osteo and fracture of L1, with diskitis of
T12-L1, L1-L2. Also high grade stenosis of L4-L5. CT/MRI were
performed at [**Hospital1 18**] that were suspicious for lytic lesions of the
spine and a lung lesion rather than the initial suspicion of
infection. A pelvis and torso CT showed a R lung mass concerning
for a primary malignancy. His antibiotics were discontinued,
and his lower back pain was controlled with morphine. On [**6-16**] he
underwent palliative vertebrectomy. 28 staples were removed from
his thoracotomy incision on [**2149-7-17**]. Strength was [**3-19**] in all
extremities, 2+ reflexes B/L. He will follow-up with Dr. [**Last Name (STitle) 548**]
in neurosurgery. Lovenox was started given orthopedic surgery
and immobility. Lovenox does not need to be continued
indefinitely. Once ambulatory, pt. does not need to be continued
on enoxaparin.
.
# Squamous Cell Lung Cancer: Due to CT findings of right lung
mass, the patient underwent a CT guided biopsy of his spine,
which revealed metastatic squamous cell lung cancer. He was
ruled out for TB and treated with clindamycin empirically for
the lung cavitation. Mr. [**Known lastname 87644**] was followed by oncology and
radiation oncology while in the hospital. Prior to his surgery
he was determined not to be a chemotherapy candidate due to poor
functional status (he could only lay flat in bed). He is going
to follow-up with the thoracic oncologists for future management
and consideration of possible palliative chemotherapy options.
He is also going to undergo palliative radiation of some of the
spine metastases. He underwent simulation with radiation
oncology on [**7-17**] and will begin 5 daily treatments, first on [**7-22**]
at 1:30pm and last [**7-28**], to be done Tues, Wed, [**Last Name (un) **], Fri, Mon.
Amulance transport to and from these radiation appointments is
medically necessary. There was an extensive family meeting with
daughters [**Name (NI) **] (HCP), [**Name (NI) **], and [**Name (NI) **], along with SW and
palliative care reps, on [**7-17**]. They determined that their goal is
to get their father home as soon as possible so that he can be
closer to his wife, once he is strong enough to pivot to the
commode from bed. They do wish to have a consultation with
medical oncology at a future date to discuss possible
treatments, if any. They are aware of their father's poor
prognosis. They do not wish to have artifical nutrition supplied
to their father. [**Name (NI) **] was made DNR/DNI at this meeting per their
wishes.
.
# Pain Management: Mr. [**Known lastname 87644**] was managed on MS Contin 15 mg
q8 hours for pain post-op. It is key to control pain so that
mobilization is not limited by pain. He is also taking standing
acetaminophen 1000 mg TID, lidocaine patch, calcitonin nasal
spray.
.
# Delirium: After surgery Mr. [**Known lastname 87644**] was intermittently
delirious. His pain medications were carefully titrated. He
was found to have a UTI and C. Diff, both of which are being
treated. The delirium waxes and wanes, and when he is
delirious, he is very easily re-oriented.
.
# Nutrition: Mr. [**Known lastname 87644**] had poor PO intake throughout
hospitalization. He was started on megace, but it was stopped
after surgery. We started remeron post-op, but the patient was
delirious in the same time frame, so we held the remeron. Prior
to surgery, the patient was started on TPN to optimize wound
healing. We stopped the TPN one week after his vertebrectomy.
He continued to receive Boost supplements, which he seemed to
enjoy. We also restarted remeron for appetite stimulation,
titrating up from 7.5mg QHS.
.
# Urinary Tract Infection: The pt was found to have GNR on UCx
during hospitalization. He was started on Ciprofloxacin.
Speciation showed pseudomonas aeruginosa intermediate for Cipro.
He was switched to Ceftazadime on [**7-17**] for total 7 day course,
last dose 9/8. PICC line was left in place to continue IV
antibiotics with plan to remove [**7-23**].
.
# C. diff: The patient was found to be positive for C. diff
toward the end of admission. He was started on PO Metronidazole
for total 14 day course, last dose 9/12 (or 7 days
post-completion of antibiotics for Pseudomonal PNA). He did not
have diarrhea at time of discharge.
.
# Hypercalcemia: He initially had a mildly elevated Calcium
during his hospitalization, and he received fluids. The
elevated calcium may be secondary to his lung mass. His PTH is
normal. His hypercalcemia worsened during the hospitalization
and he was treated with pamidronate and calcitonin. Calcium
improved following this intervention.
.
#. Diabetes: His oral medications were held, and he was placed
on an insulin sliding scale. His diabetes remained stable
throughout the hospitalization.
.
#. Hyperlipidemia: He was continued on his home regiment of
simvastatin.
.
#. Hypertension: He was normotensive on arrival and his home
lisinopril was continued. Throughout the hospitalization, his
PO intake decreased due to lack of appetite and he was started
on narcotic pain medication. His lisinopril was held as his
blood pressure was low and he had one episode of orthostatic
hypotension.
.
#. Osteoarthritis: He was kept on his home regiment of celebrex
and given PPI prophylaxis. His surgical scar from his previous
L TKA was clean, dry, and intact.
.
#. COPD: He was not SOB during his hospital stay. He maintained
his O2 saturation, and his lungs were clear. He was kept on his
advair and albuterol PRN.
Medications on Admission:
Home Medications:
Simvastatin 20mg Po daily
Lisinopril 10mg PO daily
Allopurinol 300mg PO daily
Metformin 500mg PO bid
Prilosec 20mg PO daily
Celebrex 200mg PO daily
ASA 81mg PO daily
Advair 100/50 INH [**Hospital1 **]
.
On transfer:
Vancomycin 1000mg IV q12
Simvastatin 20mg Po daily
Lisinopril 10mg PO daily
Allopurinol 300mg PO daily
Metformin 500mg PO bid
Prilosec 20mg PO daily
Celebrex 200mg PO daily
ASA 81mg PO daily
salmetrerol/fluticasone INH [**Hospital1 **]
albuterol/ipratropium INH qid
percocet prn
acetaminophen prn
morphine prn
oxazepam prn
colace, maalox
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Celecoxib 200 mg Capsule Sig: One (1) Capsule PO daily ().
3. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Puff Inhalation [**Hospital1 **] (2 times a day).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q4H (every 4 hours) as needed for
sob/wheezing.
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
8. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) spray Nasal DAILY (Daily): alternate nostrils daily.
9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain.
10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
11. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q8H (every 8 hours).
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) for 12 days: Course complete [**7-29**].
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
16. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily).
17. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
18. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous DAILY (Daily).
19. Ceftazidime 1 gram Recon Soln Sig: One (1) Recon Soln
Injection Q8H (every 8 hours) for 6 days: Last dose 9/8, please
d/c PICC after last dose.
20. Morphine 15 mg Tablet Sig: 0.5-1 Tablet PO Q4H (every 4
hours) as needed for pain: Hold for sedation, RR<12.
21. Mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime)
for 2 days.
22. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime:
To be started [**7-20**].
23. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
24. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] at [**Location (un) 701**]
Discharge Diagnosis:
Primary:
- L1 pathological fracture
- Stage IV poorly differentiated NSCLC lung (RUL)
- C. difficile colitis
- Delirium
- Pseudomomal urinary tract infection
Secondary:
- Hypertension
- Diabetes mellitus
- Gout
- Asthma
- COPD
- GERD
- L TKR
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires back brace if not lying
flat.
Discharge Instructions:
Dear Mr. [**Known lastname 87644**],
You were transferred to [**Hospital3 **] for an L1 compression
fracture and osteomyelitis, an infection of the bone. However,
new imagining suggested that your lower back pain was due to a
compression fracture at L1. There was no evidence of infected
bone. However, there were small lesions in other bones that
were concerning for a malignancy. You had a CT scan of the
torso and pelvis which revealed a mass in the right lung. We did
a biopsy showing that you have cancer in your lung that spread
to your back. You had a surgery called a vertebrectomy to
relieve the pain in your back.
The following medication were changed during your
hospitalization:
Added:
1. Added MS Contin 15 mg every 8 hours
2. Added Flagyl 500 mg twice a day for 13 more days to end on
[**2149-7-29**]
3. Added Ceftazadime 1g IV every 8 hours for 6 more days to end
on [**2149-7-23**]
4. Added tylenol 1000 mg three times a day
5. Added a lidocaine patch
6. Added calcitoninin nasal spray
7. Added trazodone 25 mg at bed time when you need help
sleeping.
8. Added mirtazapine (remeron) 7.5mg at bed time for 2 days,
then 15mg at bedtime for appetite stimulation
Stopped:
1. Stopped your lisinopril - please discuss restarting this
medication with your primary doctor
Followup Instructions:
You should call the thoracic oncology clinic at ([**2149**]
to set up an appointment for 2-4 weeks from now.
Department: SPINE CENTER
When: FRIDAY [**2149-8-1**] at 11:15 AM
With: [**Known firstname **] [**Last Name (NamePattern4) 6214**], MD [**Telephone/Fax (1) 3736**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Please make an appointment with your primary doctor when you
leave rehab.
ICD9 Codes: 5990, 2930, 4019, 2749, 2724, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1218
} | Medical Text: Admission Date: [**2124-5-30**] Discharge Date: [**2124-6-5**]
Service: MEDICINE
Allergies:
A.C.E Inhibitors
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
altered MS, PNA
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
The patient is a [**Age over 90 **] year old woman with a history of seizures
and a prior CVA who came to the ED from home with concerns for
acute stroke. She presented with left arm weakness/swelling and
? facial droop. Upon arrival in the [**Name (NI) **], Pt was triaged as a code
stroke. According to family and friends, she has expressed
altered mental status over the past week. She seemed to be
increasingly confused and weak. When Pta wake this AM she was
speaking only in [**1-17**] word sentences, which was a significant
change from last night. She called her PCP and explained this
sudden change and an apparent swollen left arm and she was
instructed to come to the ED for evaluation.
.
ED Course: [Per Code Stroke Flow Sheet] GCS=8, non-verbal but
responded to voice with eyes, not following commands, moves and
responds to pain in all ext. Pt was subsequently intubated for
airway protection given MS [**First Name (Titles) **] [**Last Name (Titles) 97436**] gag. Imaging as below,
which in brief showed no acute stroke or ICH. EEG obtained
without active epileptic activity. Pt started on Levo/Flagyl for
LLL PNA. Transferred to [**Hospital Unit Name 153**].
.
Pt in [**Hospital Unit Name 153**] with Son and Daughter-in-law. [**Name (NI) 1094**] son clearly
outlined their wishes for comfort and non-aggressive measures.
Pt is DNR. We will continue with intubation and antibiotics.
[**Name (NI) 1094**] son wishes to avoid invasive procedures but would be
agreeable to pressors if indicated. Family to discuss amongst
themselves further wishes.
Past Medical History:
1. Seizure disorder, frontal lobe - followed by Dr [**Last Name (STitle) **]
2. h/o falls
3. Hypertension
4. Hypercholesterolemia
5. Angina
6. s/p Cerebrovascular accident in 05/99
7. s/p DDD pacemaker placement in 06/99 [**2-17**] syncope and
bradycardia.
8. s/p hip replacement
9. s/p TAH
10. cervical spondylosis
11. Glaucoma
12. moderate MR - TTE [**2117**]
Social History:
Has person who lives with her to assist with ADL.
No etoh, tobacco.
Family History:
non-contributory
Physical Exam:
Vitals: T 95 BP 132/58 P 60, 100% [AC 500 x 16 0.50]
.
Gen: intubated & sedated
HEENT: PERRL, anicter, ETT
NECK: c-collar
CARD: RRR, nl S1 S2 crescendo murmer best over left lower
Pulm: decreased BS at bases ant. r-CTAB
ABD: Soft, ND, hypoactive BS
EXT: 2+ post tibial pulses, no edema
SKIN: WWP
NEURO: sedated, moves all ext in response to pain
(Upon arrival to medicine floor)
Vitals: 97.5 ax 132/60 58 20 100% on 40% FM
Gen: ill-appearing elderly woman laying in bed in NAD
HEENT: EOMI, sclerae anicteric, mucous membranes moist
Neck: supple, JVP ~8cm
Lung: decreased BS at bilateral bases with crackles worse on
left
Cor: RRR, nl S1/S2, 3/6 SEM crescendo heard best at LLSB
Abd: Soft, NT/ND, + BS
Ext: 2+ PT pulses, no edema
Skin: warm and well-perfused
Neuro: opens eyes to voice, shakes head to questions, follows
commands to moves extremities
Pertinent Results:
CT C-Spine ([**5-30**]): 2.6mm retroisthesis of C2 upon C3-
degenerative vs. traumatic subluxation. Multilevel degenerative
changes, causing primarily neural foraminal stenosis. Heavy
atherosclerotic calcification of the common carotid
bifurcations. Large left sided partially calcified thyroid mass-
etiology unknowm/ Large bilateral pleural effusions.
.
CT Head ([**5-30**]): No overt new infarct. Mild atherosclerotic
irregularity of the basilar artery. Mild vertebral and heavy
cavernous carotid atherosclerotic calcification.
.
CXR ([**5-30**]): Endotracheal tube terminates 3.7 cm above the
carina, and nasogastric tube terminates in the stomach. Large
right pleural effusion. Moderate left pleural effusion with
adjacent atelectasis and/or consolidation in the left lower
lobe.
.
EEG ([**5-30**]): Marked diffuse encephalopathies seen as highlighted
by the marked voltage reduction and the bursts of slowing
observed
.
[**2124-5-30**] 02:11PM PT-14.9* PTT-24.9 INR(PT)-1.3*
[**2124-5-30**] 02:11PM WBC-13.7*# RBC-3.62* HGB-9.9* HCT-31.3*
MCV-87 MCH-27.5 MCHC-31.8 RDW-15.0
[**2124-5-30**] 02:11PM NEUTS-94.3* BANDS-0 LYMPHS-3.1* MONOS-2.4
EOS-0.1 BASOS-0.1
[**2124-5-30**] 02:11PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2124-5-30**] 02:11PM TSH-1.8
[**2124-5-30**] 02:11PM ALBUMIN-3.8
[**2124-5-30**] 02:11PM CK-MB-NotDone
[**2124-5-30**] 02:11PM cTropnT-0.04*
[**2124-5-30**] 02:11PM LIPASE-19
[**2124-5-30**] 02:11PM ALT(SGPT)-27 AST(SGOT)-26 LD(LDH)-355*
CK(CPK)-53 ALK PHOS-113 AMYLASE-62 TOT BILI-0.5
[**2124-5-30**] 02:11PM GLUCOSE-306* UREA N-52* CREAT-1.2*
SODIUM-150* POTASSIUM-3.2* CHLORIDE-107 TOTAL CO2-31 ANION
GAP-15
[**2124-5-30**] 03:08PM %HbA1c-6.8* [Hgb]-DONE [A1c]-DONE
[**2124-5-30**] 04:01PM LACTATE-3.2*
[**2124-5-30**] 02:27PM URINE BLOOD-SM NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
Brief Hospital Course:
This is a [**Age over 90 **] year old F with history of CVA and seizure who
presented with altered mental status, LLL pneumonia, and
hypernatremia. Hospital course outlined by problem below.
.
# Altered MS: Likely multifactorial toxic-metabolic
encephalopathy. Neurology evaluated the patient and felt that
there is was no acute neurologic event to explain her mental
status changes. Head CT was negative for acute process. EEG
showed diffuse encephalopathy but no focal seizure activity.
She had normal LFTs, Vitamin B12, and folate. She was treated
with levoflox and flagyl for pneumonia. Her hypernatremia was
corrected with free water. LP was deferred since the family
wanted to avoid invasive procedures.
.
# Fever: The patient had a fever on admission with WBC count of
14 with 94% neutrophils, consistent with an infection. CXR
revealed consolidation in LLL with pleural effusions. UA and
urine cx negative. She was treated with levoflox and flagyl for
pneumonia. Thoracentesis and LP were deferred due to family's
preferences for comfort.
.
# Seizure: She had no active epileptiform discharges on
admission EEG. Her home lamictal was discontinued since she did
not have oral access. The family understood that by deferring
NG tube placement, the patient was at risk for seizure.
.
# ARF: The patient was admitted with creatinine of 1.2, which
was up from baseline of 0.9. This improved with gentle
hydration in [**Hospital Unit Name 153**].
.
# Disposition: In the [**Hospital Unit Name 153**] the patient was extubated. Her son
clearly outlined the family's wishes for comfort and
non-aggressive measures (including no NG tube). On trasnfer to
the floor, she received IV fluids and antibiotics overnight to
see if her mental status would improve. The Palliative Care
service was consulted to assist the son, and Health Care Proxy.
After discussion with the patient's family, PCP, [**Name10 (NameIs) **] team,
and Palliative Care consultants, the patient was made comfort
measures only and antibiotics were stopped. She received
morphine & ativan as needed. She died comfortably on [**2124-6-5**].
Medications on Admission:
Lamictal 300 mg [**Hospital1 **]
HCTZ 25 qd
ASA 325
Lipitor 10 mg qd
Paxil
Plavix 75 mg qd
Omeprazole
Imdur
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Pneumonia
Discharge Condition:
expired
Discharge Instructions:
not applicable
Followup Instructions:
not applicable
ICD9 Codes: 5070, 2760, 5849, 5119, 4240, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1219
} | Medical Text: Admission Date: [**2170-6-26**] Discharge Date: [**2170-7-17**]
Date of Birth: [**2088-5-12**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Found Down x4 days
Major Surgical or Invasive Procedure:
Endotracheal Intubation
PICC line placement, right brachial vein
Blood transfusion - 1 unit PRBC
Fresh frozen plasma - 2 units
Colonoscopy
EGD
History of Present Illness:
This is an 82 year old male who lives alone, last time normal
was likely Thursday (4 days of newspapers stacked up outside of
house). Found in house in bathtub per nephew may have been lying
next to bathtub breathing shallowly. Has history of prostate ca,
CVA x 2, NKDA. Burn on L shoulder. GCS at the scene was 4. He
was intubated in the field and given 1400cc IVF.
.
In the ED, initial vs were: 98.8, 128, 100/palp, 100% intubated.
Patient was given vanc/zosyn. C-collar placed. Patient had a
temp to 101.8 and was given tylenol. He was started on propofol
in the ED. Acute Care Surgery (ACS) evaled patient in the ED. A
FAST scan was negative. Urine tox was negative and UA revealed
large blood, 500 protein, trace ketones, [**11-10**] RBC and
occasional bacteria. Sodium was found to be 159, Cl at 125,
Bicarb at 17, initial lactate was 2.4 which trended down to 1.5.
CK was 3363. WBC was 12.9, plts 82, INR was 1.3, Fibrinogen at
547. Cr was elevated to 2.6 (b/l 1.2-1.4), BUN 91. Pt had a CT
head/spine/chest/ab/pelv which was significant for probably
aspiration pneumonia at the right base. He recieved about 4L
total. Blood and urine Cx were sent. At the time of transfer the
vitals were 101, 109, 114/68, 17, 100% FiO2 100%. After CXR ET
tube pulled back 3cm.
.
On the floor, patient intubated and unable to provide history.
Past Medical History:
stroke - MRI reveals subacute infarcts in the inferior division
of the L MCA
Prostate CA -'[**54**]; Tx with radiation seeds, casodex and lupron.
Radiation proctitis
Severe Depression: recently stopped all meds
HTN
Carotid stenosis s/p stenting [**10-26**] on L CEA in [**4-29**]
Nephrolithiasis
Echo in 98 with mod-severe MR, rheumatic deformity, mod pulm HTN
GERD
HLD
Pagets Disease bone diagnosed in '[**57**]
Dilated esophogus in 04
Barretts esophagus
CRI
Interstitial lung disease
Question of subclinical seizures on Keppra
autonomic neuropathy
impaired glucose tolerance
Social History:
He lives alone in [**Location 1268**]. Widowed from his second
marriage, son lives in [**State 531**] City - [**Name (NI) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name 105692**].
Nephew [**Name (NI) **] is HCP, lives in [**Name (NI) 2498**], sister Sabre, also HCP
lives in [**State 15946**]. He is retired from a medical supplier
shipping business. He has an 80-pack-year smoking history; he
quit 18 years ago. He denies any ETOH or illicit drug use.
Family History:
Unkown
Physical Exam:
Discharge Physical Exam
O: Tc: 98.1 BP: 158/71 HR: 109 RR: 20 O2: 94% RA
General: Lying comfortably in bed, conversive
HEENT: MMM, no scleral icterus
Neck: no JVD
CV: RRR, +S1, S2, no m/r/g
Resp: expiratory wheezing bilaterally, bibasilar crackles
Abd: soft, NT/ND, +bowel sounds, no HSM
Ext: 2+ DP/PT pulses - unstageable sacral pressure ulcer ~4x10
cm, minimal surrounding induration with raised edges. Rim of
granulation tissue with yellow base with an area of black
eschar. Stage 2 on left shoulder and upper middle back, both
healing well with granulation tissue and some pigmentation
starting again.
Neuro: AAOx3, able to lift legs off bed ~1 feet, can raise knees
to same level, 4/5 strength upper extremities
Pertinent Results:
I. Labs
A. Admission
[**2170-6-25**] 11:45PM BLOOD WBC-12.9* RBC-6.82* Hgb-15.9 Hct-49.8
MCV-73* MCH-23.3* MCHC-31.9 RDW-16.7* Plt Ct-82*
[**2170-6-25**] 11:45PM BLOOD Neuts-88.9* Lymphs-4.1* Monos-6.4 Eos-0.1
Baso-0.5
[**2170-6-25**] 11:45PM BLOOD PT-14.7* PTT-21.1* INR(PT)-1.3*
[**2170-6-25**] 11:45PM BLOOD Plt Smr-LOW Plt Ct-82*
[**2170-6-25**] 11:45PM BLOOD Fibrino-547*
[**2170-6-25**] 11:45PM BLOOD UreaN-91* Creat-2.6*
[**2170-6-25**] 11:45PM BLOOD ALT-28 AST-72* LD(LDH)-828* CK(CPK)-3363*
AlkPhos-209* TotBili-0.5
[**2170-6-25**] 11:45PM BLOOD Lipase-24
[**2170-6-25**] 11:45PM BLOOD Albumin-2.9*
[**2170-6-25**] 11:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2170-6-25**] 11:45PM BLOOD LtGrnHD-HOLD
[**2170-6-25**] 11:51PM BLOOD Type-ART pH-7.34*
[**2170-6-25**] 11:51PM BLOOD Glucose-135* Lactate-2.4* Na-159* K-4.7
Cl-125* calHCO3-17*
[**2170-6-25**] 11:51PM BLOOD Hgb-17.1 calcHCT-51 O2 Sat-99
[**2170-6-25**] 11:51PM BLOOD freeCa-1.08*
[**2170-6-25**] 11:50PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.026
[**2170-6-25**] 11:50PM URINE Blood-LG Nitrite-NEG Protein-500
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-NEG
[**2170-6-25**] 11:50PM URINE RBC-[**11-10**]* WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
[**2170-6-25**] 11:50PM URINE CastGr-[**2-23**]* CastHy-[**11-10**]*
[**2170-6-25**] 11:50PM URINE Hours-RANDOM Creat-292 Na-11 Cl-25
[**2170-6-25**] 11:50PM URINE Osmolal-726
[**2170-6-25**] 11:50PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
II. Microbiology
[**2170-6-25**] URINE CULTURE-FINAL {LACTOBACILLUS SPECIES}
BCx x 2 ([**2170-6-25**])
Blood Culture, Routine (Final [**2170-6-29**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SECOND MORPHOLOGY.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. THIRD MORPHOLOGY.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
STAPHYLOCOCCUS, COAGULASE N
| | |
CLINDAMYCIN-----------<=0.25 S <=0.25 S <=0.25 S
ERYTHROMYCIN----------<=0.25 S <=0.25 S <=0.25 S
GENTAMICIN------------ <=0.5 S <=0.5 S <=0.5 S
LEVOFLOXACIN----------<=0.12 S 0.25 S <=0.12 S
OXACILLIN-------------<=0.25 S <=0.25 S <=0.25 S
TETRACYCLINE---------- <=1 S <=1 S <=1 S
VANCOMYCIN------------ 1 S 1 S <=0.5 S
Aerobic Bottle Gram Stain (Final [**2170-6-26**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
REPORTED BY PHONE TO [**Month/Day/Year **] [**Doctor First Name 105693**] @1050PM ON [**2170-6-26**].
Anaerobic Bottle Gram Stain (Final [**2170-6-26**]):
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
REPORTED BY PHONE TO [**Last Name (LF) **], [**First Name3 (LF) 105693**] @1050PM ON [**2170-6-26**].
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SECOND MORPHOLOGY.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
CLINDAMYCIN----------- =>8 R <=0.25 S
ERYTHROMYCIN----------<=0.25 S =>8 R
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN----------<=0.12 S <=0.12 S
OXACILLIN-------------<=0.25 S <=0.25 S
TETRACYCLINE---------- <=1 S <=1 S
VANCOMYCIN------------ 1 S 1 S
**FINAL REPORT [**2170-6-26**]**
Legionella Urinary Antigen (Final [**2170-6-26**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
MRSA SCREEN (Final [**2170-6-28**]): No MRSA isolated.
[**2170-6-27**]: Bcx x 2 pending
[**2170-6-30**]: Bcx x 1 pending
III. Radiology
MRI BRAIN: In the posterior left middle cerebral artery
distribution, there
are several foci of slow diffusion, indicating acute infarct.
These are in
the same [**Month/Day/Year 1106**] territory, but in different locations compared
to the [**2169-4-15**] MRI. The pattern and distribution is again most
suggestive of
thromboembolic disease. There is no intracranial hemorrhage or
edema.
Periventricular and subcortical white matter T2 hyperintense
foci have
progressed since the [**2168**] study, again compatible with chronic
small vessel
ischemic change.
There are no masses, mass effect or other area of infarct.
Ventricles and
sulci are normal in size and configuration. The major
intracranial [**Year (4 digits) 1106**]
flow voids are unremarkable.
MRA BRAIN:
TECHNIQUE: Three-dimensional time-of-flight MR arteriography was
performed.
FINDINGS: The intracranial vertebral and internal carotid
arteries and their
major branches demonstrate diffuse irregularity, although
without overt
occlusion or severe stenosis. This pattern is compatible with
diffuse
atherosclerotic disease. No aneurysm is identified.
IMPRESSION:
1. Scattered foci of restricted diffusion in the left MCA
[**Year (4 digits) 1106**] territory
distribution most compatible with thromboembolic infarcts. These
are in the
same [**Year (4 digits) 1106**] distribution, but in different locations compared
to the [**2168**]
MRI.
2. Diffuse atherosclerotic disease, without occlusion or severe
stenosis.
3. Chronic small vessel ischemic change, progressed since [**2168**].
Findings discussed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 12 p.m., [**2170-6-28**].
CT C-spine
IMPRESSION:
1. No fracture or malalignment.
2. Multilevel degenerative changes. In the setting of trauma,
cord injury
may occur and if there is concern for cord injury, MRI would be
recommended.
3. Apical emphysema.
Carotid Series
Impression: Right ICA stenosis 40-59%.
Left ICA stenosis 40-59%.
CT Chest
IMPRESSION:
1. No evidence for traumatic injury in the chest, abdomen or
pelvis.
2. Prostate brachytherapy seeds.
3. Left hemipelvis Paget disease. Sclerotic T10 vertebral body
likely
reflects earlier Paget disease, but metastatic disease cannot be
excluded.
3. Ground-glass opacity in bilateral bases, concerning for
aspiration
pneumonia, more pronounced on the right where there is high
density material
that could be barium aspirtated in the past or calcification.
4. Extensive atherosclerotic disease including coronary
calcifications.
Distal aortic stent graft. Possible pulmonary hypertension.
5. ET tube 3.5 cm from the carina.
CT Abdomen
IMPRESSION:
1. No evidence for traumatic injury in the chest, abdomen or
pelvis.
2. Prostate brachytherapy seeds.
3. Left hemipelvis Paget disease. Sclerotic T10 vertebral body
likely
reflects earlier Paget disease, but metastatic disease cannot be
excluded.
3. Ground-glass opacity in bilateral bases, concerning for
aspiration
pneumonia, more pronounced on the right where there is high
density material
that could be barium aspirtated in the past or calcification.
4. Extensive atherosclerotic disease including coronary
calcifications.
Distal aortic stent graft. Possible pulmonary hypertension.
5. ET tube 3.5 cm from the carina.
CT Head
IMPRESSION:
1. No evidence for acute intracranial pathology.
2. Chronic microvascular infarcts and parenchymal atrophy.
3. Chronic-appearing deformity of the medial left orbital wall.
IV. Cardiology
A. ECHO
The left atrium is normal in size. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity is
unusually small. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size is probably normal
and free wall motion is probably preserved (views are
suboptimal). There is probably right ventricular hypertrophy
(views suboptimal). The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is moderate thickening of the mitral valve
chordae. There is mild to moderate functional mitral stenosis
(mean gradient 6 mmHg) due to mitral annular calcification. Mild
(1+) mitral regurgitation is seen. [Due to acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.] There is no pericardial effusion. There is an
anterior space which most likely represents a prominent fat pad.
B. EKG
Baseline artifact. Sinus tachycardia. Short P-R interval. Left
atrial
abnormality. T wave abnormalities. No previous tracing available
for
comparison.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
127 100 72 284/[**Telephone/Fax (2) 105694**]
[**2170-7-16**]: Sinus tachycardia. Compared to the previous tracing of
[**2170-7-1**] the rate has increased.
CXR [**2170-7-1**]: REASON FOR EXAMINATION: Evaluation of the patient
with new hypoxia and
suspected aspiration.
PORTABLE AP CHEST RADIOGRAPH
COMPARISON: Chest radiograph from [**2170-6-29**].
The right PICC line is at the level of mid low SVC. There is
slightly more
pronounced cardiac silhouette, which may be attributed to
relatively low lung
volumes. The bibasal areas of pleural calcifications and minimal
interstitial
changes are stable. There are no new consolidations that might
represent
areas of aspiration. There is no pleural effusion or
pneumothorax.
Overall, no significant change since the prior study has been
demonstrated.
[**2170-7-13**]: HISTORY: Lower GI bleeding with acute onset of wheezing
and shortness of breath.
FINDINGS: In comparison with the study of [**7-1**], there is
continued mild
enlargement of the cardiac silhouette. However, there is an
increase in the interstitial markings bilaterally, suggesting
elevated pulmonary venous pressure. Blunting of the costophrenic
angles is consistent with small pleural effusions. If the
condition of the patient permits, lateral view would be most
helpful.
KUB [**2170-7-10**]: COMPARISON: Abdominal radiograph from [**2162-8-16**].
FINDINGS: Four abdominal radiographs, one supine and three left
lateral
decubitus, were acquired showing multiple loops of redundant,
air-distended colon. Air fluid levels are seen on the left
lateral decubitus films. There is no evidence of free air in the
abdomen. The visualized osseous structures appear unremarkable.
An intraaortic stent is noted just proximal to the origin of the
iliac arteries. Multiple punctate opacifications over the pelvis
are likely seeds from brachytherapy.
IMPRESSION: Moderately distended colon likely secondary to
ileus.
Colonoscopy [**2170-7-16**]: Procedure: The procedure, indications,
preparation and potential complications were explained to the
patient, who indicated his understanding and signed the
corresponding consent forms. The efficiency of a colonoscopy in
detecting lesions was discussed with the patient and it was
pointed out that a small percentage of polyps and other lesions
can be missed with the test. A physical exam was performed. The
patient was administered moderate sedation. The physical exam
was performed prior to administering anesthesia. Supplemental
oxygen was used. The patient was placed in the left lateral
decubitus position.The digital exam was normal. The colonoscope
was introduced through the rectum and advanced under direct
visualization until the cecum was reached. The cecal sling folds
were seen. The appendiceal orifice and ileo-cecal valve were
identified. Careful visualization of the colon was performed as
the colonoscope was withdrawn. The procedure was not difficult.
The quality of the preparation was fair. Visualization of the
transverse colon and descending colon was poor. The patient
tolerated the procedure well. There were no complications.
Findings:
Contents: Brownish or yellowish liquid stool was found in the
ascending colon, transverse colon and descending colon. There
was no red blood or melena.
Flat Lesions A few medium localized angioectasias that were not
bleeding were seen in the rectum. It is compatible with
radiation proctitis.
Other We did not find the source of bleeding
Impression: Stool in the ascending colon, transverse colon and
descending colon
Angioectasias in the rectum
Otherwise normal colonoscopy to cecum
Recommendations: Please consider Capsule study
EGD [**2170-7-16**]:
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered
moderate sedation. A physical exam was performed prior to
administering anesthesia. Supplemental oxygen was used. The
patient was placed in the left lateral decubitus position and an
endoscope was introduced through the mouth and advanced under
direct visualization until the third part of the duodenum was
reached. Careful visualization of the upper GI tract was
performed. The vocal cords were visualized. The procedure was
not difficult. The patient tolerated the procedure well. There
were no complications.
Findings: Esophagus:
Mucosa: A salmon colored mucosa distributed in a segmental
pattern, suggestive of Barrett's Esophagus was found. Two cold
forceps biopsies were performed for histology at the
gastro-esophageal junction.
Stomach:
Mucosa: Patchy erythema and congestion of the mucosa were noted
in the whole stomach. These findings are compatible with
gastritis. Localized A few erosions of the mucosa with no
bleeding was noted in the stomach body. These findings are
compatible with gastritis.
Duodenum:
Mucosa: Localized erythema and congestion of the mucosa with no
bleeding were noted in the duodenal bulb compatible with
duodenitis.
Impression: Mucosa suggestive of Barrett's esophagus (biopsy)
Erythema and congestion in the whole stomach compatible with
gastritis
A few erosions in the stomach body compatible with gastritis
Erythema and congestion in the duodenal bulb compatible with
duodenitis
Otherwise normal EGD to third part of the duodenum
Recommendations: follow-up biopsy results
Please continue using PPI PO
Pt needs surveillance EGD for his barrett's esophagus
Antireflux regimen: Avoid chocolate, peppermint, alcohol,
caffeine, onions, aspirin. Elevate the head of the bed 3 inches.
Go to bed with an empty stomach.
Discharge Labs:
[**2170-7-10**] 02:02AM BLOOD WBC-12.0* RBC-4.32* Hgb-10.1* Hct-31.0*
MCV-72* MCH-23.3* MCHC-32.4 RDW-17.7* Plt Ct-197
[**2170-7-10**] 06:32AM BLOOD WBC-11.6* RBC-4.18* Hgb-9.8* Hct-30.3*
MCV-73* MCH-23.4* MCHC-32.3 RDW-18.1* Plt Ct-207
[**2170-7-10**] 01:57PM BLOOD Hct-29.6*
[**2170-7-10**] 10:28PM BLOOD Hct-31.6*
[**2170-7-11**] 09:54PM BLOOD Hct-28.1*
[**2170-7-12**] 05:54AM BLOOD WBC-8.2 RBC-3.69* Hgb-8.6* Hct-26.6*
MCV-72* MCH-23.2* MCHC-32.2 RDW-18.6* Plt Ct-238
[**2170-7-12**] 12:10PM BLOOD WBC-8.1 RBC-3.48* Hgb-8.0* Hct-25.1*
MCV-72* MCH-23.0* MCHC-31.9 RDW-18.5* Plt Ct-197
[**2170-7-12**] 10:22PM BLOOD Hct-30.9*
[**2170-7-13**] 05:16AM BLOOD WBC-12.1* RBC-4.30* Hgb-10.4*# Hct-31.5*
MCV-73* MCH-24.1* MCHC-32.9 RDW-19.1* Plt Ct-276
[**2170-7-15**] 05:47AM BLOOD WBC-13.2* RBC-3.87* Hgb-9.3* Hct-28.1*
MCV-73* MCH-24.2* MCHC-33.2 RDW-19.6* Plt Ct-273
[**2170-7-16**] 05:22AM BLOOD WBC-13.0* RBC-3.76* Hgb-9.1* Hct-27.9*
MCV-74* MCH-24.1* MCHC-32.5 RDW-20.2* Plt Ct-287
[**2170-7-17**] 04:57AM BLOOD WBC-13.5* RBC-3.76* Hgb-8.9* Hct-28.0*
MCV-74* MCH-23.7* MCHC-31.9 RDW-20.7* Plt Ct-334
[**2170-7-12**] 05:54AM BLOOD PT-20.3* PTT-30.5 INR(PT)-1.9*
[**2170-7-12**] 03:00PM BLOOD PT-21.7* PTT-31.8 INR(PT)-2.0*
[**2170-7-14**] 08:54AM BLOOD PT-15.2* PTT-30.3 INR(PT)-1.3*
[**2170-7-15**] 05:47AM BLOOD PT-15.1* PTT-28.2 INR(PT)-1.3*
[**2170-7-16**] 05:22AM BLOOD PT-16.3* PTT-27.7 INR(PT)-1.4*
[**2170-7-9**] 06:53AM BLOOD Glucose-90 UreaN-22* Creat-2.0* Na-138
K-3.5 Cl-104 HCO3-27 AnGap-11
[**2170-7-10**] 06:32AM BLOOD Glucose-97 UreaN-22* Creat-1.7* Na-139
K-3.3 Cl-109* HCO3-21* AnGap-12
[**2170-7-11**] 05:24AM BLOOD Glucose-75 UreaN-19 Creat-1.6* Na-138
K-3.5 Cl-106 HCO3-22 AnGap-14
[**2170-7-12**] 05:54AM BLOOD Glucose-86 UreaN-17 Creat-1.8* Na-141
K-3.1* Cl-109* HCO3-24 AnGap-11
[**2170-7-13**] 05:16AM BLOOD Glucose-134* UreaN-12 Creat-1.6* Na-139
K-3.2* Cl-107 HCO3-22 AnGap-13
[**2170-7-15**] 05:47AM BLOOD Glucose-92 UreaN-11 Creat-1.7* Na-140
K-3.0* Cl-106 HCO3-23 AnGap-14
[**2170-7-16**] 05:22AM BLOOD Glucose-94 UreaN-13 Creat-1.6* Na-141
K-3.3 Cl-108 HCO3-23 AnGap-13
[**2170-7-17**] 04:57AM BLOOD Glucose-88 UreaN-16 Creat-1.5* Na-141
K-3.3 Cl-107 HCO3-23 AnGap-14
[**2170-7-13**] 05:16AM BLOOD ALT-13 AST-22 LD(LDH)-326* AlkPhos-116
TotBili-0.4
[**2170-7-12**] 05:54AM BLOOD ALT-12 AST-18 LD(LDH)-275* AlkPhos-95
TotBili-0.4
[**2170-7-1**] 04:42PM BLOOD CK-MB-2 cTropnT-0.05*
[**2170-7-1**] 10:00PM BLOOD CK-MB-3 cTropnT-0.07*
[**2170-7-2**] 05:57AM BLOOD CK-MB-2 cTropnT-0.05*
[**2170-7-15**] 05:47AM BLOOD Calcium-8.9 Phos-2.8 Mg-1.8
[**2170-7-16**] 05:22AM BLOOD Calcium-8.9 Phos-2.6* Mg-1.9
[**2170-7-12**] 05:54AM BLOOD Albumin-2.5* Calcium-8.3* Phos-3.1 Mg-2.0
[**2170-7-11**] 05:24AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.9 Iron-47
[**2170-7-11**] 05:24AM BLOOD calTIBC-157* Hapto-186 Ferritn-350
TRF-121*
[**2170-7-7**] 06:16AM BLOOD VitB12-903* Folate-6.3
[**2170-7-7**] 06:16AM BLOOD TSH-2.2
[**2170-6-26**] 03:02PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
[**2170-7-17**] 04:57AM BLOOD IgA-462*
[**2170-7-17**] 04:57AM BLOOD tTG-IgA-PND
Brief Hospital Course:
Brief MICU course:
Patient arrived to the MICU intubated. He was extubated the
next day. He was quickly weaned to room air. He had some word
finding difficulties in the ICU. He did not remember more
history. His blood cultures returned positive for 4/4 bottles
with coag negative staph. An MRI was done which was consistent
with thromboembolic lesions in the brain. He was called out to
the floor for further work-up.
Floor course:
#Recurrent stroke:
MRI revealed new stroke with scattered foci of restricted
diffusion in the left MCA [**Month/Day/Year 1106**] territory most compatible
with thromboembolic infarcts in the
same [**Month/Day/Year 1106**] distribution but in different locations compared
to the [**2168**] MRI.
His PCP visited in the hospital and confirmed that his current
mental status and neurological function is at baseline. Carotid
series revealed [**Country **] and [**Doctor First Name 3098**] stenosis at 40-59 %. Stroke team
recommended continuing ASA and converting to plavix once
platelets stabilized continue lipitor, follow-up carotid doppler
in 6 months, and lipid panel. The anti-coagulation meds were
continued until the patient developed a GI bleed. The meds were
held for 1 week before restarting after the patient had his
colonoscopy/EGD.
# GI bleed - The patient developed GI bleeding on [**7-10**] with
maroon colored stools. His Hgb/Hct were serially monitored and
were stable, with a slow downward trend. He remained
hemodynamically stable the entire duration. GI was consulted
and recommended an EGD and colonoscopy. After a family meeting,
the patient agreed to undergo the procedures, however he did not
drink enough of the prep to have the procedure. He did receive
1 unit PRBC as his Hct dropped to a low of 25.1. After
transfusion, he increased to 31.5. He tried the prep again 2
days later and was cleaned out enough to undergo the scopes. GI
performed the procedure on [**7-16**]. They found gastritis and
duodenitis but no obvious source of bleeding. He was noted to
have Barrett's esophagus on EGD, biopsies were taken, the
results of which were pending on discharge. H. pylori was
negative. GI recommended the patient be continued on
pantoprazole and to have surveillance EGD of his Barretts.
Please recheck a CBC in the next 1-2 days to ensure no change in
anemia after restarting aspirin plavix on [**7-16**]
# Elevated INR - The patient did develop an elevated INR to a
high of 2.0. Hemolysis labs and liver synthetic function was
checked and was normal. It was thought that the coagulopathy
was due to nutritional deficiency as the patient was variously
on clears and NPO for several days before his colonoscopy. He
received vitamin K and responded quickly with reversal of his
INR.
# Hypertension - The patient was noted to be hypertensive during
the last 2-3 days of his hospitalization. His metoprolol was
doubled to 50mg PO BID from 25mg PO BID. If there is more
control needed for his BP, we would recommend amlodipine,
hydralazine, and HCTZ as medications to be used.
# Coagulase-negative Staph Bacteremia: Pt had multiple blood
cultures with coag negative Staph with different morphologies.
This unlikely represents contamination with potential source of
entry from skin penetration given prolonged period down with
resultant pressure ulcers. He was initially started on
vancomycin with PICC placement secondary to loss of access and
subsequently switched to nafcillin given sensitivities. The
patient does have a heart murmur, is afebrile, and has no
vegetations on ECHO. A TEE was not done as the patient did not
have signs/symptoms of endocarditis. Subsequent blood cultures
were negative. The patient was instructed to take antibiotics
for 6 more days to finish a 14 day course. He remained afebrile
during his stay on the floor.
# Acute on chronic Renal failure secondary to possible
rhabdomyolysis: The patient likely had rhabdomyolysis on
admission given his high CK measurement. His Cr trended down,
then increased again. Urine eosinophils were checked twice, but
were negative, making AIN unlikely. Renal was consulted, they
were able to look at a urine sample however saw no muddy brown
casts indicative of ATN, or WBC casts indicative of AIN. The
patient's creatinine stabilized at 1.6-1.8.
# Thrombocytopenia and Anemia: The patient was noted to have
very low platelets in the 40-60s without evidence of superficial
bleeding. HIT was unlikely given no previous heparin exposure in
the past few months and low platelets on admission before
heparin administration. TTP was a concern given
thrombocytopenia, anemia, worsening renal function, and
neurological issues. Medication side effect with plavix and
aspirin was a secondary consideration. A smear revealed true
thrombocytopenia with target cells and microcytosis. Per
hematology consult, his thrombocytopenia likely represents ITP
and is unlikely HIT. His anemia may be secondary to thalassemia
based on the blood smear. He was monitored with daily CBC for
occult blood loss. Once his platelet level returned to greater
than 100, his plavix was restarted. The platelets continued to
trend upwards and remained normal through discharge. An iron
panel was obtained and was consistent with anemia of chronic
disease. A TTG level was pending at the time of discharge as an
alternate cause of his anemia.
# Hypoxia - The patient was noted to be hypoxic at various times
during his stay, however this was primarily due to the
plethysmograph being placed on a finger. When the forehead
monitor was used, his saturations were above 93%.
# Shortness of breath - The patient had 2 sudden-onset episodes
of shortness of breath. The first was ~2-3 hours after
finishing his blood transfusion. A chest x-ray was obtained
which showed increased right sided pulmonary edema. It was
thought that he flashed, got lasix 40mg IV with rapid resolution
of his symptoms. The second time, his SBP was 190/80, with
audible expiratory wheezing. He received a duoneb treatment
which again, rapidly resolved his symptoms. Both times, EKGs
were obtained and were unchanged from prior. The patient
remained asymptomatic during both episdoes and he did not
experience any hypoxia.
#) Pressure ulcers: The patient has several pressure ulcers
presumed from his prolonged time down prior to admission from
prolonged time down prior to admission. Wound care was
immediately consulted to address this issue and their
recommendations were:
TO Wound care:
Site: Left scapula
Type: Pressure ulcer
Cleansing [**Doctor Last Name 360**]: Saline
Dressing: Wound Gel (DuoDerm Gel)
Change dressing: qd
Comment: apply large Sofsorb to area, change daily
.
TO Wound care:
Site: right toes
Type: Pressure ulcer
Cleansing [**Doctor Last Name 360**]: Saline
Dressing: Gauze - dry
Change dressing: qd
.
TO Wound care:
Site: sacrum (unstageable)
Type: Pressure ulcer
Cleansing [**Doctor Last Name 360**]: Saline
Dressing: Wound Gel (DuoDerm Gel) and Mepilex Foam
Change dressing: Other
Comment: change every 3 days
.
TO Wound care:
Site: Left shoulder
Type: Pressure ulcer
Cleansing [**Doctor Last Name 360**]: Saline
Dressing: Gauze - dry
Change dressing: qd
.
TO Wound care:
Site: Right hip
Type: Pressure ulcer
Cleansing [**Doctor Last Name 360**]: Saline
Dressing: Gauze - dry
Change dressing: qd
.
.
#) Depression: The patient did become combative and refusing to
participate in his medical care around the time his GI bleed
started. A family meeting was held with the patient's nephew
and his PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. They spoke to the patient and were
able to convince him to participate in his own care. He was
much more cooperative after this meeting. His citalopram was
continued at his home dose. Psych was consulted and had no
further medication input. He did sign a health care proxy
naming his nephew, [**Name (NI) **] [**Name (NI) 26160**] ([**Telephone/Fax (1) 105695**]).
.
#) Seizure disorder: The patient had no seizures during his
hospitalization. He was kept on Keppra.
.
#) Placement issues - The patient was discharged to [**Hospital1 **].
Medications on Admission:
Unclear what meds patient has actually been taking; recent OMR
note reporting that patient stopped all meds.
ATORVASTATIN 80 mg Tablet daily
CITALOPRAM 40 mg daily
CLOPIDOGREL 75 mg Tablet daily
FUROSEMIDE 20 mg Tablet daily
LEVETIRACETAM 250 mg Tablet daily
METOPROLOL TARTRATE 25 mg Tablet
ASPIRIN 325 mg
DOCUSATE SODIUM 100 mg Capsule [**Hospital1 **]
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO
BID:PRN.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID:PRN.
5. Levetiracetam 250 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1)
inhalation Inhalation Q6H (every 6 hours).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed for wheeze.
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO
twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]
Discharge Diagnosis:
Primary: Stroke, dehydration, pressure ulcers, acute on chronic
renal failure, thrombocytopenia, bacteremia
Secondary: Depression, seizure disorder, hypoglycemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 105691**],
It was a pleasure taking care of you during your
hospitalization. You were admitted after being found lying in
your bathtub for 4 days. It was determined that you had a
stroke which led you to be unresponsive. You were treated in
the Medical Intensive Care Unit for 2 days getting fluids, then
were treated on the floor. Your blood had a bacteria in it that
was treated with antibiotics. You were found to have pressure
ulcers from lying down so long that were treated by the Wound
Care nurses. It was also found that you had a low platelet
level when you were admitted. This level was watched and it
returned to a normal level. You developed bleeding from your
gastrointestinal tract. This caused your blood levels to drop
enough that you needed 1 unit of blood to raise your levels.
The Gastroenterologists (stomach doctors) performed a
colonoscopy and EGD where they used a small camera to look at
your colon and your stomach. They found some inflammation in
your stomach and first part of the small intestine, but found no
active bleeding in your GI tract. They also found some changes
in the first layer of the esophagus which will need to be
followed in the future. You also had worsening of your kidney
function. We did not figure out why this happened. We watched
your kidney function and it stablilized.
We provided you with a new medication list. Please take these
medications unless told otherwise by a doctor.
Followup Instructions:
There will be a doctor at the rehab center you are going who
will see you daily. When you are discharged from the rehab
center, you should make an appointment to see your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. Her office number is [**Telephone/Fax (1) 250**].
Completed by:[**2170-7-17**]
ICD9 Codes: 5070, 5849, 2760, 2762, 7907, 5180, 311, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1220
} | Medical Text: Admission Date: [**2103-7-9**] Discharge Date: [**2103-8-25**]
Date of Birth: [**2054-6-24**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3918**]
Chief Complaint:
S/p fall with altered mental status and fever
Major Surgical or Invasive Procedure:
Bone Marrow Biopsy
Lumbar Puncture x2
Bronchioalveolar Lavage
PICC line placement
History of Present Illness:
49 yoM with h/o HIV and intermittent adherence to therapy (diag.
in [**2087**], last CD4 on [**2103-6-13**] = 22 w/ VL 891,000, on intermittent
HAART, last started on [**2103-6-15**]), EtOH abuse, anal HPV, and recent
admission from [**2103-6-12**] - [**2103-6-21**] for malaise and weakness who was
admitted [**2103-7-9**] for altered mental status and mechanical fall
at home and was found to be pancytopenic. The patient had been
recently discharged from rehab (where he had gone after the
admission ending on [**6-21**]) to his home at the [**Company 3596**]. The patient
reported that he was feeling well at rehab/home and did not have
any specific complaints but on [**7-9**] he had a mechanical fall and
was thought to be more confused by his home VNA so he was
brought into the hospital. Denied head strike or head/back pain
from fall, stated that he felt weak and just collapsed at 1pm.
Denies any CP,sob, n/v. no f/c. Denies BRBRP or melena. History
difficult to take due to his mental status, proxy contact
attempted but no answer, left message to call back for ICU
consent and further hx taking. Of note, during his earlier
admission in [**Month (only) **] for AMS, had an unremarkable LP and MRI, was
labeled as HIV dementia.
In the ED, initial vs were: 101.8 110 81/53 20. HCT 18
Patient was talking, but AAOx0. Patient was given 2L NS, 2 units
of pRBC. Got dose of Vanc, zosyn, BCx drawn.
Past Medical History:
#HIV/AIDS--CD4-57/4%, VL [**Numeric Identifier 14614**] on [**2101-10-5**], not on meds since
then; Nadir CD4 57 prior to [**5-/2103**] admit, no documented thrush
or CMV in past
Prior treatment includes: LAM/ZDV/EFV, ?NFV; TDF/FTC with FD
LPV/r (started [**2096-11-26**], stopped [**2096-12-19**] due to diarrhea but
restarted by [**1-3**], discontinued by [**7-/2097**]); TDF/FTC and ATV/r
(started [**7-/2098**], self-discontinued [**12/2098**])
RPR non-reactive [**2099-5-5**].
Toxo IgG negative [**2097-6-11**].
HCV Ab negative [**2094-8-10**].
#pneumonia [**11/2096**] (Admitted [**Hospital1 112**]) thought to be viral
#History of anorectal HPV. Last High resolution anoscopy
[**2099-6-30**], path with AIN I x 2. Last anal pap done on that day.
Social History:
Patient lives alone at [**Company 3596**]. Patient works with [**Hospital1 9060**], processing donations.
Tobacco: 1 ppd x 12 years
ETOH: none
Recreational drugs: none
Family History:
No family history of cancer, neurological issues, heart disease.
Physical Exam:
Admission PE:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, no visible
signs of thrush
Neck: supple, JVP not elevated, no LAD
Lungs: Good air movement b/l, +wet crackles at R base
CV: Sinus tach, 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
Neuro: LE equal [**5-17**], UE equal [**5-17**]. Sensation grossly intact,
-babinskis.
Discharge PE:
VS: 97.4, 116/70, 77, 18, 97%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, no visible
signs of thrush
Neck: supple, JVP not elevated, no LAD
Lungs: Good air movement b/l, +wet crackles at R base
CV: Sinus tach, 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
Neuro: LE equal [**5-17**], UE equal [**5-17**]. Sensation grossly intact,
-babinskis.
Pertinent Results:
Admission labs:
[**2103-7-9**] 03:00PM BLOOD WBC-2.1* RBC-2.16*# Hgb-6.7*# Hct-18.7*#
MCV-87 MCH-30.9 MCHC-35.6* RDW-16.8* Plt Ct-24*#
[**2103-7-10**] 09:02AM BLOOD WBC-2.7* RBC-2.54* Hgb-7.7* Hct-21.4*
MCV-84 MCH-30.3 MCHC-36.0* RDW-16.2* Plt Ct-17*
[**2103-7-9**] 03:00PM BLOOD Neuts-47* Bands-6* Lymphs-38 Monos-2
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-2* NRBC-1* Other-4*
[**2103-7-9**] 03:00PM BLOOD PT-13.4 PTT-22.6 INR(PT)-1.1
[**2103-7-10**] 12:56AM BLOOD PT-15.1* PTT-28.4 INR(PT)-1.3*
[**2103-7-9**] 03:00PM BLOOD Glucose-121* UreaN-33* Creat-1.4* Na-128*
K-4.3 Cl-99 HCO3-20* AnGap-13
[**2103-7-10**] 09:02AM BLOOD Glucose-106* UreaN-20 Creat-1.1 Na-134
K-3.3 Cl-107 HCO3-19* AnGap-11
[**2103-7-9**] 03:00PM BLOOD ALT-15 AST-48* LD(LDH)-1143* AlkPhos-86
TotBili-0.6
[**2103-7-10**] 12:56AM BLOOD LD(LDH)-576*
[**2103-7-10**] 12:56AM BLOOD Calcium-7.2* Phos-2.1* Mg-2.0
[**2103-7-10**] 09:02AM BLOOD Calcium-7.6* Phos-2.7 Mg-1.9
[**2103-7-10**] 01:52AM BLOOD Type-ART Temp-39.4 pO2-103 pCO2-28*
pH-7.44* calTCO2-20* Base XS--3 Intubat-NOT INTUBA Comment-101F
AXILL
[**2103-7-9**] 03:04PM BLOOD Glucose-112* Lactate-2.3* K-3.7
[**2103-7-9**] 04:46PM BLOOD Hgb-5.8* calcH SEROLOGY/BLOOD
.
Other labs:
BAL: Negative for PCP, [**Name10 (NameIs) 14616**], AFB negative
Quantiferon Gold TB test: indeterminate
[**2103-7-10**] 02:45PM BLOOD PEP-NO SPECIFI IgG-1245 IgA-360 IgM-73
IFE-NO MONOCLO
[**2103-7-18**] 05:12PM CEREBROSPINAL FLUID (CSF) WBC-4 RBC-631*
Polys-1 Lymphs-89 Monos-10
[**2103-7-18**] 05:12PM CEREBROSPINAL FLUID (CSF) TotProt-34 Glucose-75
[**2103-7-18**] 05:12PM CEREBROSPINAL FLUID (CSF) CSF-PEP-POSITIVE *
[**2103-7-18**] 05:12PM CEREBROSPINAL FLUID (CSF) HISTOPLASMA
ANTIGEN-PND
.
Micro:
CRYPTOCOCCAL ANTIGEN (Final [**2103-7-10**]):
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
URINE HISTO AG: +
.
Imaging:
CT Head: IMPRESSION: No acute intracranial process.
.
MRI Head: Prominence of ventricles and sulci consistent with
global
cerebral atrophy given the history of HIV/AIDS. Few T2 and FLAIR
hyperintensities in the subcortical and periventricular white
matter
consistent with chronic small vessel ischemic disease.
.
CT chest [**7-11**]:Multifocal ground-glass pulmonary abnormality is
relatively [**Name2 (NI) 14617**] terms of extent, but in the setting of severe
neutropenia it could indicate relatively widespread and serious
infection, including pathogenic bacteria aswell as viral
infection. Pneumocystis is less likely because of therelatively
small voluem of pulmonary involvement. Pulmonary hemorrhage is
analternative explanation for the lung findings. Widespread
adenopathy, more significant for number and distribution than
size, is more likely HIV related than lymphoma although
abdominal adenopathy and
splenomegaly are considerable.
.
CT Abdomen/Pelvis [**2103-7-13**]:
Multiple ill-defined hepatic hypodensities without appreciable
enhancement,
and porta hepatis lymphadenopathy. These findings may be
compatible with
infiltrative hepatic lymphoma, and a lesion in the lower aspect
of segment [**Doctor First Name **] may be amenable to percutaneous biopsy as long as
the hemangioma in that segment is avoided.
.
TTE [**2103-7-17**]: Normal global and regional biventricular systolic
function. No pulmonary hypertension or clinically-significant
valvular disease seen. Very small pericardial effusion. EF
>55%.
.
Path:
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY:
DIAGNOSIS:
DIFFUSE INVOLVEMENT BY NON-HODGKIN'S LYMPHOMA (DIFFUSE LARGE
B-CELL LYMPHOMA).
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
The smear is adequate for evaluation.
Erythrocytes are decreased in numbers, and exhibit moderate
anisopoikilocytosis with polychromatophils, echinocytes,
dacrocytes, and rare red cell fragments. Nucleated red blood
cells are noted on scan.
The white blood cell count appears decreased.
Platelet count appears markedly decreased; large and giant forms
are seen.
Differential shows: 49% neutrophils, 5% bands, 25% lymphocytes,
10% monocytes, 1% eosinophils, 5% myelocytes, 3% blasts, 2%
metamyelocytes.
Aspirate Smear: Not submitted.
Clot Section and Biopsy Slides:
The biopsy material is adequate for evaluation, and consists of
a 1.3 cm bone biopsy diffusely infiltrated with large cells with
moderate amounts of pink cytoplasm, irregularly shaped nuclei
with clumpy chromatin, and prominent nucleoli. No residual
marrow elements are appreciated.
By immunohistochemistry, these cells are positive for pan B-cell
markers CD20, CD79, PAX-5, CD5 (major subset), BCL-6 (subset,
dim), and BCL-2. They are negative for BCL-1, CD10, CD15, CD30,
TdT, MPO, C-kit, and CD34. LMP appears negative (non-specific
cytoplasmic positivity seen in scattered cells). CD3 highlights
admixed T-cells. The proliferation index is 70% by MIB-1
staining. Overall, the findings are consistent with involvement
by a high grade diffuse large B-cell lymphoma (de [**Last Name (un) 11083**] CD5
positive large cell lymphoma). Please refer to cytogenetics and
flow cytometry studies for further information.
ADDENDUM: Bone marrow [**Last Name (un) **]-in situ hybridization reveals few
scattered cells positively hybridized, far beyond the
non-reactive negative control. In the bone marrow, a few
scattered [**Last Name (un) **] positive cells provides sufficient evidence that
this lymphoid proliferation is EBV driven. Clinical correlation
is recommended.
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: HLA-DR, FMC-7,
Kappa, Lambda, and CD antigens 3, 5, 10, 13, 19, 20, 23, 34.
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize blast/lymphocyte yield.
Abnormal/lymphoma cells comprise 14% of total gated events.
B cells demonstrate a double (Kappa and Lambda) positive light
chain population. They co-express pan B-cell markers CD19 and
20, along with CD5. They do not express any other
characteristic antigens including CD10 or FMC-7. These abnormal
B-cells are present in the blast window.
INTERPRETATION
Immunophenotypic findings consistent with involvement by an
abnormal population of B-cells that are CD5-positive and seen
within the blast window. The findings are consistent with the
B-cell lymphoma recently diagnosed in the marrow.
Labs on discharge:
White Blood Cells 1.9* 4.0 - 11.0 K/uL
Red Blood Cells 2.53* 4.6 - 6.2 m/uL
Hemoglobin 7.5* 14.0 - 18.0 g/dL
Hematocrit 21.3* 40 - 52 %
MCV 84 82 - 98 fL
MCH 29.5 27 - 32 pg
MCHC 35.0 31 - 35 %
RDW 15.9* 10.5 - 15.5 %
DIFFERENTIAL
Neutrophils 94* 50 - 70 %
Bands 0 0 - 5 %
Lymphocytes 1* 18 - 42 %
Monocytes 4 2 - 11 %
Eosinophils 1 0 - 4 %
Basophils 0 0 - 2 %
Atypical Lymphocytes 0 0 - 0 %
Metamyelocytes 0 0 - 0 %
Myelocytes 0 0 - 0 %
RED CELL MORPHOLOGY
Hypochromia 1+
Anisocytosis 1+
Poikilocytosis 1+
Macrocytes OCCASIONAL
Microcytes OCCASIONAL
Polychromasia NORMAL
Target Cells 1+
Burr Cells OCCASIONAL
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Smear RARE
Platelet Count 10* 150 - 440 K/uL
MISCELLANEOUS HEMATOLOGY
Granulocyte Count 1795* 2200 - 8250 #/uL
Platelet Count 15* 150 - 440 K/uL post transfusion
Test Name Value Reference Range Units
[**2103-8-25**] 06:18
Source: Line-PICC
RENAL & GLUCOSE
Glucose 95 70 - 100 mg/dL
IF FASTING, 70-100 NORMAL, >125 PROVISIONAL DIABETES
Urea Nitrogen 22* 6 - 20 mg/dL
Creatinine 0.5 0.5 - 1.2 mg/dL
Sodium 135 133 - 145 mEq/L
Potassium 3.0* 3.3 - 5.1 mEq/L
Chloride 108 96 - 108 mEq/L
Bicarbonate 23 22 - 32 mEq/L
Anion Gap 7* 8 - 20 mEq/L
ENZYMES & BILIRUBIN
Alanine Aminotransferase (ALT) 22 0 - 40 IU/L
Asparate Aminotransferase (AST) 11 0 - 40 IU/L
Lactate Dehydrogenase (LD) 168 94 - 250 IU/L
Alkaline Phosphatase 71 40 - 130 IU/L
Bilirubin, Total 0.9 0 - 1.5 mg/dL
CHEMISTRY
Albumin 2.2* 3.5 - 5.2 g/dL
Calcium, Total 7.3* 8.4 - 10.3 mg/dL
Phosphate 2.9 2.7 - 4.5 mg/dL
Magnesium 2.0 1.6 - 2.6 mg/dL
Uric Acid 2.2* 3.4 - 7.0 mg/dL
Brief Hospital Course:
49 yo M w AIDS (CD4 22, VL 891K [**2103-6-15**]) presents s/p fall with
new anemia, pancytopenia, fever and altered mental status. He
was initially transferred to [**Hospital Unit Name 153**] for hypotension (FAST
negative). Hospital course has been notable for lymphoma
diagnosed on bone marrow biopsy, BAL with negative PCP,
[**Name10 (NameIs) **] and urine with positive histo ag, prolonged
pancytopenia, and hypotension.
.
Hospital Course by Problem:
.
#Hypotension: On presentation to the ED, he was febrile to
101.8, A&Ox0, and hypotensive to 81/53. Labs showed acutely
worsened anemia with Hct of 18.7 - stool was brown, guiaic +.
Plts had fallen to 24. WBC was 2.1 w/ left-shift. He was given
2U PRBC + 2L IVF in ED along with Vanc/Zosyn and admitted to the
[**Hospital Unit Name 153**]. In the [**Hospital Unit Name 153**], he was given additional 1U PRBC and 1L IVF
with improvement in his BPs. After stabilization, he was
transferred to the medicine floor. He later triggered several
times for hypotension, but was asymptomatic during these
episodes. A cosyntropin stimulation test diagnosed adrenal
insufficiency, likely from [**Hospital1 **] therapy and possible HIV. He
was put on hydrocortisone, then switched to prednisone. His
blood pressure has remained stable, and he was discharged on 5mg
daily prednisone.
.
#Anemia: GI was consulted for acute anemia and guiaic+ stool,
they recommended inpatient EGD/colonoscopy after further
stabilization. Pt stabilized and these procedures were not done.
Pt remained pancytopenic and required high number of
transfusions, likely secondary to underlying lyphoma, and also
ambisome that pt was put on. Transfusion requirement tapered
down after ambisome was stopped. Continues to require blood
transfusions approximately 2x/week.
.
#Lymphoma: Patient had a bone marrow biopsy to evaluate
pancytopenia which was a dry tap and pathology with diffuse
large B-cell lyphoma, Bcl-2 +, Bcl-6 +, and CD10 negative. The
hypodense liver lesions were thought to be [**2-14**] lymphoma and
liver biopsy was deferred given risk of bleeding with patient??????s
pancytopenia. LP flow was inconclusive, but did not demonstrate
many cells. Patient got IT MTX [**2103-7-18**]. was started on
Dexamethasone [**Date range (1) 14618**]. Started [**Hospital1 **] [**2103-7-21**] and completedd on
[**7-25**]. He then had a prolonged pancytopenia, and started to
recover his counts on [**8-10**]. However, he then started having
fevers once again, and a second cycle of [**Hospital1 **] was administered
starting [**2103-8-19**], and was well-tolerated. He will receive
daily neupogen starting [**2103-8-24**] until the next cycle of [**Hospital1 **]
commences on [**2103-9-9**].
.
#Histoplasmosis: Urine was histo ag positive. CSF histo ag was
negative. Patient was started on Ambisome but then later
switched to itraconazole, which per ID he will likely need for
life.
.
#Hyponatremia: On admission to BMT service on [**7-18**], Na was 125.
Likely hypovolemic hyponatremia given improvement with hydration
via NS.
.
#AIDS: Patient was seen by Infectious Disease and started on ART
along with ppx for PCP and MAC. Darunovir and Ritonavir were
discontinued because they interact with chemotherapy agents and
he was instead started on another protease inhibitor,
Raltegravir. He was given pentamidine on [**8-8**]. He will continue
on prophylactic acyclovir, azithromycin and atovaquone.
.
#Fever: Initially differential included infectious vs neoplastic
processes primarily. CT imaging was notable for patchy ground
glass opacities, hepatomegaly with hypodense liver lesions,
splenomegaly and diffuse adenopathy. Patient was isolated for TB
and was empirically treated for PCP with prednisone and Bactrim
(prednisone for transient hypoxia/[**Doctor First Name **]) until BAL was negative
for PCP. [**Name10 (NameIs) **] cxs were unremarkable, but given degree of
immunosuppression patient was empirically treated for bacterial
pneumonia with Vancomycin/Zosyn/Levofloxacin for a 14 day
course. In regards to TB, Quantiferon gold was indeterminate
but a [**Name10 (NameIs) **] culture from [**7-17**] was positive for acid-fast
bacilli. He had 3 negative [**Month/Day (1) **] smears, twice (done in early
[**Month (only) 205**], and again in late [**Month (only) 205**]). Fevers from lymphoma vs
infectious, but had resolved by mid [**Month (only) 205**]. Upon recovery of his
coutns following cycle 1 of [**Hospital1 **], he started having fevers once
again. Chest X-ray was unclear regarding possible pneumonia as
a source of fevers, and he was initially started on antibiotics.
However, repeat chest X-rays did not supprot a diagnosis of
pneumonia, and the patient clinically had no evidence of chest
pathology. Fevers were then thought to be due to malignancy.
Following initiation of Cycle 2 of [**Hospital1 **], the fevers resolved.
.
#Altered Mental Status: This was felt to be most likely [**2-14**] HIV
dementia. LP did not demonstrate bacterial infection and viral
CSF work up was deferred by recommendation of ID team given
recent negative work up in early [**Month (only) **]. An MRI head demonstrated
significant brain atrophy and large ventricles but no evidence
of CNS lymphoma. He was A&Ox3 with intermittent confusion
about recent events. Towards the end of [**Month (only) 205**], he was
substantially improved though, with much less confusion and more
orientation.
.
# Hypokalemia: pt had a persistant hypokalemia in the middle to
end of [**Month (only) 205**]. This was thought to be secondary to ambisome
therapy, which has a high incidence of electrolyte
abnormalities. Work-up revealed high levels of renal pottasium
wasting. If hypokalemia does not resolve, he may have an
underlying RTA.
#Thrombocytopenia: Patient was found to be thrombocytopenic
since admission. This is likely long-standing, and may be
unrelated to lymphoma. Review of his medication list and
elimination of medications that might possibly have been causing
thrombocytopenia did not improve thrombocytopenia. Splenic
sequestration may be contibuting to thrombocytopenia. Patient
also became refractory to platelet transfusions, and an
anti-platelet antibody screen was found to be positive. He was
therefore administered a five-day course of IVIG to neutralise
the anti-platelet antibodies. This resulted in some, but not
complete improvement in response to platelet transfusions.
Medications on Admission:
PATIENT WAS UNABLE TO VERIFY MEDICATIONS; THESE ARE DISCHARGE
MEDICATIONS FROM A PREVIOUS VISIT****
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
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. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day) as needed for thrush.
5. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for Groins/inner thigh.
6. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK
([**Doctor First Name **]).
8. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
9. darunavir 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. ritonavir 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
.
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
4. azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK
(MO).
Disp:*60 Tablet(s)* Refills:*2*
5. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day).
Disp:*450 ML(s)* Refills:*2*
6. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*2*
7. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. itraconazole 100 mg Capsule Sig: Two (2) Capsule PO Q8H
(every 8 hours).
Disp:*90 Capsule(s)* Refills:*2*
11. oral wound care products Gel in Packet Sig: One (1) ML
Mucous membrane TID (3 times a day).
Disp:*90 ML(s)* Refills:*2*
12. quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
13. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily).
Disp:*30 * Refills:*2*
14. 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*
15. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day) as needed for constipation.
Disp:*90 Capsule(s)* Refills:*0*
17. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO once a
day as needed for constipation.
Disp:*500 ML(s)* Refills:*0*
18. filgrastim 300 mcg/mL Solution Sig: One (1) Injection Q24H
(every 24 hours) for 15 days.
Disp:*15 * Refills:*0*
19. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
20. atovaquone 750 mg/5 mL Suspension Sig: Two (2) PO once a
day.
Disp:*60 * Refills:*2*
21. Lidocaine Viscous 2 % Solution Sig: One (1) Mucous membrane
three times a day as needed for mouth pain.
Disp:*60 * Refills:*0*
22. miconazole nitrate 2 % Powder Sig: One (1) Topical three
times a day as needed: apply to groin, other fungal skin rash as
needed.
Disp:*qs * Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
Lymphoma
Adrenal insufficiency
.
Secondary:
HIV/AIDS
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname 14619**],
It was a pleasure taking care of you during your admission to
[**Hospital1 69**]. You were admitted after a
fall with fevers and confusion. Your fever was thought to be
secondary to an infectious process and you were treated with
antibiotics after which your temperature normalized. We tested
you for tuberculosis and found that that you do not have it. A
fungal infection (histoplasma) was found in your urine and we
treated you with antibiotics. You also had low blood counts and
a bone marrow biopsy was done to investigate the cause. The
results of the biopsy demonstrated that you have lymphoma. A
lumbar puncture was done to determine whether or not you had
disease in the fluid and you were empirically treated with
injection of a chemotherapy [**Doctor Last Name 360**] into the spinal fluid. You
were treated for the lymphoma with intravenous chemotherapy.
Your counts went down very low, but then rose back up around
[**8-11**]. You also had low blood pressure, and were diagnosed
with adrenal insuffiency, for which you will need to take a
steroid. You were subsequently treated with a second round of
intravenous chemotherapy, which you tolerated well.
.
The following changes were made to your medications:
HAART regimen (for AIDS):
-DISCONTINUED: darunavir and ritonavir
-STARTED: raltegravir
It is VERY important that you take these medications daily
because not only do they treat AIDS but they also help your body
to fight the lymphoma
- Nicotine patch
- Prednisone
- Itraconazole - this is an anti-fungal for the histoplasma
- Azithromycin
- Atovaquone
- Acyclovir
- Oral Gel
- Viscous Lidocaine
- Quetiapine
- Omeprazole
- Bowel regimen (senna, sodium docusate, polyethylene glycol,
lactulose)
- Filgastrim
Please followup with your oncology and infectious disease
doctors, see below.
Followup Instructions:
Please followup with Dr. [**Last Name (STitle) **] on Wednesday [**2103-8-29**].
You will be contact[**Name (NI) **] by Dr. [**Last Name (STitle) 14620**] office with the final
time of the appointment on Wednesday. Please call [**Telephone/Fax (1) 3237**]
if you have not heard from them by Monday afternoon, or if you
have any other questions.
Department: INFECTIOUS DISEASE
When: MONDAY [**2103-9-10**] at 10:00 AM
With: [**Name6 (MD) 14621**] [**Last Name (NamePattern4) 14622**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]
Completed by:[**2103-8-27**]
ICD9 Codes: 2761, 5849, 2762, 5119, 2768, 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1221
} | Medical Text: Admission Date: [**2111-3-26**] Discharge Date: [**2111-4-28**]
Date of Birth: [**2069-12-1**] Sex: M
Service: TRAUMA
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 38821**] is a 41-year-old man
who fell approximately 40 feet from a ladder. There is a
question if there was an electrocution injury secondary to
contact with a wire. The patient loss consciousness at the
scene and was found to be opening his eyes spontaneously, but
confused and combative. He was intubated at the scene and
sedated with Versed. He was boarded and collared and arrived
at the [**Hospital6 256**] hemodynamically
stable with a GCS of 3T.
PAST MEDICAL AND SURGICAL HISTORIES: At the time of
admission, past medical, past surgical histories were
unknown.
MEDICATION: Lipitor
ALLERGIES: None known
EXAM:
GENERAL: The patient was intubated and sedated.
VITAL SIGNS: Heart rate 104, pulse 120/palp, 100% on being
bagged.
HEAD, EARS, EYES, NOSE AND THROAT: His pupils were equal.
His tympanic membrane on the right was bloody. He had a
right raccoon eye.
BACK: Cervical spine, no step-off.
CHEST: Clear to auscultation.
HEART: Regular.
ABDOMEN: Soft, nontender, nontender. The pelvis was stable.
EXTREMITIES: There were no obvious deformities of the
extremities. Small superficial laceration on the left elbow
and left fifth finger.
RECTAL: Heme negative with decreased tone.
LABORATORY STUDIES: White count 19, hematocrit 41. Normal
chemistries. INR of 1.5. Arterial blood gases 7.33, 46, 81,
25 and -1. CK of 289.
TRAUMA WORK UP: Head CT revealed a right cerebellar and left
temporal intraparenchymal hemorrhage with right posterior
fossa and subarachnoid blood. There is no herniation, but
effacement of the cisterns. There are multiple bilateral
temporal fractures, right occipital fracture, right orbital
fracture and right subdural hematoma. Abdominal CT showed no
evidence of injury. Small anterior right pneumothorax.
Right 5th and 10th rib fractures and right 1st or 5th lumbar
transverse process fractures. CT of the chest showed no
aortic injury, question of T11-T12 compression deformity and
right 1st, 4th, 5th and 6th rib fractures. Hand elbow films
showed no fracture or dislocation. Neurosurgical and
oral maxillofacial consultations were obtained in the trauma
bay. Neurosurgery placed a vault that showed an ICP of
greater than 40. A post procedure head CT showed increased
cerebellar hemorrhage and the patient was taken emergently to
the Operating Room for evacuation. The patient underwent a
suboccipital craniectomy with resection of right subdural
bleeding and dural expansion. He was taken intubated and
sedated to the trauma Intensive Care Unit where the rest of
his course will be summarized by system.
HOSPITAL COURSE:
1. NEUROLOGIC: The patient had undergone injuries as
described above and went to the Operating Room for evacuation
of the hematoma. A ventricular ostomy drain was placed in
the Operating Room and it was continued until approximately
[**2111-4-10**]. The patient slowly regained motor function of
initially of his left upper and lower extremities followed by
his right upper and lower extremities. Follow up head CT did
not show any extension of bleeding. Of note, the patient
remained sedated for an extended period of time given his
multiple injuries. As the sedation was weaned, he initially
had difficulty with agitation and difficulty weaning the
propofol, however this eventually resolved and at the time of
dictation the patient requires no sedation. The cervical
spine was cleared with an MRI. His thoracic and lumbar
spines were cleared with CT scans. CT did reveal an L4
vertebral body corner fracture and L1 through 5 right
transverse process fractures which are not treated
operatively.
2. CARDIOVASCULAR: The patient never had hemodynamic
instability throughout his course and required no pressors or
drips for blood pressure control.
3. RESPIRATORY: The patient was intubated on arrival at the
[**Hospital6 256**]. He remained on vent
support during the course of his stay due to his sedation.
His clinical course improved. He was weaned to extubation on
[**2111-4-5**], however he quickly developed upper airway stridor
and respiratory distress and was reintubated. A percutaneous
tracheostomy was placed at the bedside on [**2111-4-6**]. After
this point, the patient continued on vent support while he
was sedated. Once sedation was weaned, he was weaned to
trach mask. At the time of dictation, he has been on trach
mask for approximately 2.5 days. His respiratory course is
complicated by right middle lobe and right lower lobe
pneumonia. Culture data showed this to be Enterobacter which
was resistant to multiple antibiotic agents and he eventually
was started on a 30 day course of imipenem which started
approximately [**2111-4-14**]. Cultures also grew Methicillin
sensitive Staphylococcus aureus from his sputum no acute
distress he received an approximately 14 day course of gram
positive coverage consisting of vancomycin and oxacillin.
The patient was weaning well from the vent, however on
[**2111-4-10**], he was noted to have an acute desaturation. Chest
x-ray was unremarkable and CT angiogram of the chest was
performed that showed bilateral pulmonary emboli. On [**4-11**],
an IVC filter was placed. However, it was noted that the
patient had anomalous venous architecture and on [**4-14**] the
second IVC filter was placed in the lower IVC. A repeat CT
angiogram at this time also revealed no further extension of
the clot. Given his slight respiratory compromise from the
clot, anticoagulation was readdressed to the neurosurgery
team and after a follow up negative head CT, the patient was
started on heparin drip and subsequently is being
coumadinized.
4. GASTROINTESTINAL: The patient was initially kept NPO
without tube feeds. Post pyloric feeding tube was placed
under fluoroscopic guidance in the Intensive Care Unit. He
received regular tube feedings through this without
difficulty. The day prior to PEG placement, the tube feed
was inadvertently moved on transfer. The patient's PEG was
placed on [**2111-4-6**] and the patient tolerated feedings through
that well thereafter. Of note, the patient had a 10 point
hematocrit drop on [**2111-4-7**]. Esophagogastroduodenoscopy
revealed a 7 mm prepyloric ulcer that was cauterized. He had
been maintained on appropriate antacid prophylaxis, however
after this event he was changed to Protonix and then Prevacid
[**Hospital1 **]. At the time of dictation, the patient is tolerating two
K per cc tube feeds. This will be changed today to 1 K per
cc as the patient is no longer requiring fluid restriction.
5. GENITOURINARY: Foley was placed in the initial trauma
work up and has remained in place since. The patient has
never had issues of inadequate urine output or electrolyte
abnormalities. He is currently Hep-Locked.
6. HEME: The patient's hematocrit drifted down throughout
his stay and had the acute drop related to his upper
gastrointestinal bleed. He required several units of
transfusion at that time, but since his hematocrit has been
stable to slowly increasing. Anticoagulation for his
pulmonary embolus initially consisted of heparin drip with a
goal PTT of 50 to 70 followed by commencement of
coumadinization. At this point, the patient's INR is only
1.5, so he is being discharged on a heparin drip until his
INR is between 2 and 3. Please see the nursing notes as to
the doses the patient has received of Coumadin to this point.
7. INFECTIOUS DISEASE: As noted above, the patient's main
infectious complication has been pneumonia. He has had
right middle lobe and right lower lobe infiltrates. Cultures
have shown Enterobacter and Methicillin sensitive
Staphylococcus aureus and he is receiving a 30 day course of
imipenem which should complete around [**5-14**] to [**5-16**].
He also has been treated for Methicillin sensitive
Staphylococcus aureus pneumonia and has completed his course
of vancomycin and oxacillin. Of note, the only positive
blood cultures were coagulase negative Staphylococcus aureus
from an A-line which had been removed and the patient was not
considered to have had a blood stream infection.
8. ENDOCRINE: The patient has been maintained on a sliding
scale insulin regimen and has not had issues of hyper or
hypoglycemia during his stay.
9. PROPHYLAXIS: The patient remains on Prevacid down his
tube. He is getting tube feeds at goal. He is on a heparin
drip and being coumadinized. Again, goal PTT of 50 to 70 and
goal INR of 2 to 3. The heparin may be stopped once the
patient is therapeutic on Coumadin. Of note, the patient
also has two IVC filters. He also has Venodyne boots.
10. TUBES, LINES AND DRAINS: The patient has a tracheostomy
and percutaneous endoscopic gastrostomy tube which were
placed on [**2111-4-6**]. He also has a PICC line which was placed
on [**2111-4-26**]. The tipped confirmed to be at the right
atrium. He has a Foley catheter and that is all.
DISPOSITION: The patient has been screened and accepted to a
rehabilitation facility. Anticipated discharge day is
[**2111-4-28**].
DISCHARGE MEDICATIONS:
1. Heparin drip titrate for PTT 50 to 70 until the INR is
between 2 and 3.
2. Coumadin adjust dose daily for INR of 2 to 3.
3. ProMod with fiber 100 cc per hour via the PEG tube
4. Colace 100 mg per PEG tube [**Hospital1 **]
5. Prevacid 30 mg per PEG tube [**Hospital1 **]
6. Reglan 10 mg per PEG q6h
7. Imipenem 1 gm intravenous q6h through [**2111-5-16**]
8. Nystatin swish and spit 5 ml po tid
9. Tears 2 drops both eyes qid
10. Sliding scale regular insulin as outlined on page 1.
FOLLOW UP: Trauma Clinic in two weeks' time. Please call
([**Telephone/Fax (1) 18746**] for an appointment. The patient should also
follow up with neurosurgery, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1132**], phone number
([**Telephone/Fax (1) 11314**] in approximately two weeks' time. Please see
the physical therapy and occupational therapy recommendations
page 2 and 3 reports.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**]
Dictated By:[**Last Name (NamePattern1) 22884**]
MEDQUIST36
D: [**2111-4-28**] 09:18
T: [**2111-4-28**] 09:35
JOB#: [**Job Number 38822**]
ICD9 Codes: 5185 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1222
} | Medical Text: Admission Date: [**2176-12-1**] Discharge Date: [**2176-12-11**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Lacrimal duct infection, Bacterial UTI
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
87 year old [**Hospital **] transfered from [**Hospital3 **], with concern
for endophthalmitis and UTI. Also of note is acute renal
failure. The patient was apparently found down at his house by
his wife, and was down for a reported 10 minutes. He was seen at
[**Hospital3 7571**]Hospital by Dr. [**First Name8 (NamePattern2) 4468**] [**Last Name (NamePattern1) 10262**] in the ED, where
he was noted hypotensive, orthostatic, with a positive UA. He
was also noted with a severe right eye infection as follows in
the ED transfer note:
[**Location (un) **] ED: "Severe right eye infection - extropion, with
chemosis, injection, cloudy cornea with 100% flourescein uptake.
Visual Acuity 20/200 on left, finger count on right.
Pressures: 18-22 on right, 18-20 on left. Got IV cipro, and
cipro drops q 1 hour. There is no optho in house coverage to
see patient if admitted here. Of note - was dx with right
conjuntivitis 10 days ago which improved on cipro gtt."
The patient was also noted with a UTI, and was given IV Unasyn,
agressive hydration with improvement in his blood pressure. In
our ED, ophthamology was called, and will be seeing the patient
while in house. Vitals in the ED 100 109/49, 21, 100%3L.
Patient states that he gets his care at the VA, however the
patient has no records at the VA since [**2158**]. I will clarify this
with his wife.
Past Medical History:
Lower back pain s/p 2 back surgeries
Possible history of PUD
denies HTN, hyperlipidemia, diabetes
Social History:
lives with wife; retired from computer assembly plant; no EtOH;
no toboacco; enjoys golf; former runner
Family History:
Non-Contributory to this admission
Physical Exam:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: + Photophobia, + Severe Visual Changes as in HPI
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 97.6, 113/72, 85, 22, 100 2L%
GEN: Uncomfortable, Lethargic
Pain: 0/10
HEENT: EOMI, winces to light, cloudy cornea Right eye with lack
of red reflex, injected sclera, Able to resolve light/dark and
fingers, Dry MM, - OP Lesions although poor dentition, 4cm
keloid on occiptal area
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, CN II-XII grossly intact (other than eye as above)
Pertinent Results:
Admission labs:
[**2176-12-1**] 06:00AM GLUCOSE-100 UREA N-53* CREAT-1.4* SODIUM-139
POTASSIUM-4.3 CHLORIDE-104 TOTAL CO2-25 ANION GAP-14
[**2176-12-1**] 06:00AM ALT(SGPT)-12 AST(SGOT)-26 ALK PHOS-94
AMYLASE-130* TOT BILI-0.2
[**2176-12-1**] 06:00AM LIPASE-24
[**2176-12-1**] 06:00AM ALBUMIN-3.4*
[**2176-12-1**] 06:00AM WBC-12.9*# RBC-3.11* HGB-9.3* HCT-28.0*
MCV-90# MCH-29.9# MCHC-33.2 RDW-13.2
[**2176-12-1**] 06:00AM NEUTS-81.5* LYMPHS-15.6* MONOS-2.6 EOS-0.1
BASOS-0.3
[**2176-12-1**] 06:00AM PLT COUNT-242
.EGD Tuesday, [**2176-12-3**]
Impression: Ulcers in the fundus
Two clots adjacent to each other, which could not be removed
despite extensive washing. No active bleeding. The clot on the
right had a likely protruding visible vessel. (thermal therapy)
Appeared to have had prior vagotomy and pyloroplasty.
Otherwise normal EGD to second part of the duodenum
.
Portable TTE (Complete) Done [**2176-12-3**] at 3:43:34 PM FINAL
IMPRESSION: Normal global and regional biventricular systolic
function. Mild mitral regurgitation. Moderate pulmonary
hypertension.
.
ECG Study Date of [**2176-12-3**] 9:16:46 AM
Sinus rhythm with atrial premature beats. Earlier wide complex
beats may be atrial with aberration versus ventricular. Since
the previous tracing the rate is slower. Otherwise, findings are
unchanged.
TRACING #3
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
77 182 76 356/385 69 23 156
Imaging:
Orbit CT [**12-1**]:
IMPRESSION:
Mildly enlarged right lacrimal gland relative to the left,
possibly
inflammatory or infectious in etiology. However, rare occurrence
of lacrimal gland neoplastic process cannot be excluded.
Air-fluid level in right sphenoid sinus pterygoid recess
suggests an acute
inflamamtory process.
Orbit CT [**12-9**]:
IMPRESSION:
1. Unchanged mildly enlarged right lacrimal gland relative to
the left.
Interval decrease in periorbital and lid swelling. There is no
evidence to
suggest orbital cellulitis or abscess in the region of this
mildly enlarged lacrimal gland.
2. Slightly decreased air-fluid level in the right sphenoid
sinus suggests
resolving acute inflammatory process.
3. These findings were discussed with Dr. [**Last Name (STitle) **] at 2:15 p.m. on
[**2176-12-9**].
.
Head CT [**12-5**]:
CONCLUSION:
1. No evidence of hemorrhage, edema, masses, mass effect or
infarction.
2. Prominent sulci and ventriculomegaly, likely related to
age-related
atrophy.
3. These findings were discussed with Dr. [**Last Name (STitle) **] at 9:45 AM on
[**2176-12-5**].
.
Discharge labs:
[**2176-12-10**] 06:27AM BLOOD WBC-7.5 RBC-3.30* Hgb-9.7* Hct-29.0*
MCV-88 MCH-29.4 MCHC-33.5 RDW-17.2* Plt Ct-232
[**2176-12-10**] 06:27AM BLOOD Glucose-109* UreaN-16 Creat-1.2 Na-138
K-4.1 Cl-104 HCO3-28 AnGap-10
Brief Hospital Course:
1. Acute Blood Loss Anemia due to Gastric Ulcer with Hemorhage,
with hpylori infection. On HD # 2, he was found to have a acute
anemia, with a hct of 11. He was transferred to the ICU. He
was treated with large volume transfusion (9 units PRBC, 2 Units
FFP). EGD performed with ulcer with visible vessel. Central
access maintained until patient stabilized. GI consultation
followed. Of note, the patient is a difficult crossmatch due to
antibodies. He will require a repeat EGD in [**5-14**] weeks. He
should remain on [**Hospital1 **] PPI until then. He should remain on
carafate for a few more weeks. In addition, he should complete
2 weeks of treatment with amoxicillin/clarithromycin/prilosec
for H pylori disease.
.
2. Acute Eye inflammation: Threatened vision, due to patient has
suffered severe decrease in visual acuity, so an emergent
ophthomology consult was obtained. He was treated with
Ciprofloxacin optic and erythromycin ointment. Urgent orbital
CT of the right orbit did not demonstrate abscess or
endophthalmitis. He failed to improve with appropriate therapy,
and had worsening pain/exam on [**12-7**], at which time he was found
to have a new corneal ulcer in addition to ongoing
dacryadenitis. Once he completed a course of IV antibiotics
(for UTI, as below) he was changed to cefpodoxime. His eye did
not improve. Repeat CT showed persistent inflammation. He was
transferred to the [**Hospital 13128**] for a second opinion, and
Dr. [**First Name8 (NamePattern2) 2398**] [**Last Name (NamePattern1) **] of oculoplastics diagnosed him with most likely a
floppy eyelid syndrome with corneal ulcerations. He recommended
aggressive eye lubrication and ointments, and follow up in 1
month with a local eye doctor, for reassessment and
consideration of a wedge resection of his eyelid if his
functional status improves.
.
3. Acute Renal Failure: Likely due to initial infection and
hypotension. Resolved with IV fluid rescusitation.
.
4. Bacterial UTI: He was diagnosed with a urinary tract
infection. Unasyn changed to Cefepime in discussion with ID.
He has already completed a full course of IV antibiotics.
.
5. Metabolic Encephalopathy, Fall: Multifactorial Likely some
underlying dementia, but clearly delerious. Geriatrics consult
obtained. Patient fell on [**2176-12-5**] and a CT head and arm xray
were negative. Mental status markedly improved with
normalization of his day night cycle and treatment of his
infection.
.
Full Code
Medications on Admission:
states he takes no medications
Discharge Medications:
1. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day) for 2 weeks.
2. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
3. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic QID (4 times a day).
4. erythromycin 5 mg/gram (0.5 %) Ointment Sig: 0.5 inch
Ophthalmic four times a day.
5. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) mg PO DAILY (Daily).
7. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
8. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection [**Hospital1 **] (2 times a day).
9. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12
hours) as needed for agitation/delerium.
10. amoxicillin 500 mg Tablet Sig: Two (2) Tablet PO twice a day
for 2 weeks.
11. clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 2 weeks.
12. Artificial Tears Drops Sig: Two (2) drops Ophthalmic q 1
hour.
13. Tylenol Extra Strength 500 mg Tablet Sig: 1-2 Tablets PO
three times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 11496**] - [**Location (un) **]
Discharge Diagnosis:
Corneal ulcer
UTI, bacterial
Acute blood loss anemia
GI hemorrhage secondary to peptic ulcer disease
H pylori disease
Acute delirium
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 with a urinary tract infection and sepsis.
Additionally, you had an ulcer in your stomach which lead to a
life threatening GI bleed which required 9 units of blood
transfusion. You were also found to have a severe lacrimal duct
(tear duct) inflammation and an ulcer on your eye. The doctors
at [**Hospital 13128**] thought this was due to floppy eyelid
syndrome, which caused the inflammation.
All of these conditions improved with treatment. You are now
being transferred to rehab to regain your strength after this
serious illness.
.
Medication changes:
Complete 2 weeks of treatment for H. pylori with prilosec,
amoxicillin, and clarithromycin.
Use the eye drops every hour while you are awake.
Use the eye ointments four times per day.
.
Follow up with the opthalmologist as below.
Followup Instructions:
You will need to follow up with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 51461**] after discharge.
It is important for you to follow up for a repeat EGD in [**5-14**]
weeks. and a repeat eye exam in 1 month.
.
The eye doctor at [**Hospital 13128**] Infirmary that you saw is
[**First Name8 (NamePattern2) 2398**] [**Last Name (NamePattern1) **]. He is at [**Telephone/Fax (1) 32768**]. He thinks you may need
surgery on your eye - and if you recover from your acute
illness, you may want to follow up with him for surgery. You
can discuss this with your PCP when you see him.
ICD9 Codes: 0389, 5990, 2851, 5849, 2930, 5859, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1223
} | Medical Text: Admission Date: [**2131-5-18**] Discharge Date: [**2131-5-28**]
Date of Birth: [**2131-5-18**] Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: [**First Name8 (NamePattern2) **] [**Known lastname **], Twin number one,
was born at 30 and 3/7 weeks gestation to a 44 year old
gravida IX, para 0, now I, woman (spontaneous loss times
eight). The mother's prenatal screens are blood type A
positive, antibody negative, hepatitis B surface antigen
negative. This was a spontaneous twin pregnancy of
monochorionic diamniotic twins. The pregnancy was
complicated by ultrasound diagnosis of ventriculomegaly in
both twins, a normal magnetic resonance imaging, normal
amniocentesis and the condition resolved spontaneously.
Early cervical changes prompted a cervical cerclage placement
at 18 weeks gestation. The mother received a complete course
of Betamethasone at 28 weeks gestation. This twin was noted
to have intrauterine growth restriction and was followed with
serial ultrasounds. A study ten days prior to delivery
showed Baby A at the ninth percentile with increased systolic
to diastolic ratio. Twin B was absent diastolic flow.
Ultrasound on the day prior to delivery showed vertex/breech
presentation. Both fetuses had normal amniotic fluid volume
and absent diastolic flow. The obstetrician recommended
routine fetal testing. Therefore, they returned on the day
of delivery when variable fetal heart rate decelerations were
observed and then the mother was found to be having
contractions.
A decision was made to deliver by cesarean section. This
twin emerged with spontaneous cry, however, did require
continuous positive airway pressure to sustain color. Apgar
seven at one minute and seven at five minutes. The birth
weight was 1150 grams (10 to 25th percentile). The birth
length was 36.5 centimeters (10th to 25th percentile) and the
head circumference was 27.5 centimeters (10th to 25th
percentile).
PHYSICAL EXAMINATION: Admission physical examination reveals
a vigorous nondysmorphic preterm infant. Anterior fontanelle
open, soft and flat. Palate intact. Subcostal and
intercostal retractions, grunting, flaring when CPAP removed.
Diminished breath sounds bilaterally. The heart was regular
rate and rhythm, no murmur. Peripheral pulses present. No
hepatosplenomegaly. Three vessel umbilical cord. Normal
male genitalia for gestational age with testes in scrotum
bilaterally. Normal back and hips. Appropriate tone,
strength and activity.
HOSPITAL COURSE: Respiratory status - The infant required
nasopharyngeal continuous positive airway pressure from soon
after admission until day of life number five when he weaned
to room air where he has remained. On examination, he has
some mild subcostal retractions. Lung sounds are clear and
equal. He was started on Caffeine Citrate on day of life
number two for apnea of prematurity. He remains on that at
the time of transfer.
Cardiovascular status - The infant has remained normotensive
throughout his NICU stay. He does continue to have two to
five episodes of apnea and bradycardia in every 24 hour
period. On examination, he has a heart with regular rate and
rhythm, no murmur.
Fluids, electrolytes and nutrition status - At the time of
transfer, his weight is 1080 grams, his length is 36.5
centimeters and his head circumference is 27 centimeters.
Enteral feeds were begun on day of life number two and
advanced to full volume feedings on day of life number eight
of breast milk, 20 calorie per ounce formula by gavage every
four hours. Total fluids of 150 cc/kg/day. On the day of
discharge, he was tolerating 24 calories per ounce.
Mother plans to breast feed and has been pumping.
Gastrointestinal status - The infant has been treated with
phototherapy since day of life number one. Phototherapy was
discontinued between day of life number five and six, but was
turned on again for a rising bilirubin. The peak bilirubin
was on day of life number eight with total 7.0, direct 0.3.
Phototherapy was discontinued yesterday. A rebound bilirubin
prior to transfer was 4.9/0.2.
Hematology status - The infant received no blood product
transfusions during the NICU stay. His last hematocrit on
day of life number three was 48.8.
Infectious disease status - The infant was started on
Ampicillin and Gentamicin at the time of admission for sepsis
suspected. Antibiotics were discontinued after 48 hours when
the infant was clinically well and the blood cultures
negative.
Neurology - A head ultrasound on [**2131-5-28**] was normal.
Audiology - Hearing screening has not yet been done and is
recommended prior to discharge.
Psychosocial - The parents have been very involved in the
infant's care throughout the NICU stay. The infant is
discharged in good condition.
The infant is transferred to [**Hospital **] Hospital for continuing
care.
The parents have not yet identified a primary pediatric care
provider.
RECOMMENDATIONS AFTER DISCHARGE: Feedings - 24 calorie per
ounce breast milk or formula and to increase calories as
needed for consistent growth. Total fluids 150 cc/kg/day.
Feedings every four hours by gavage.
Medications:
1. Caffeine Citrate 9 mg PG daily.
2. Ferrous Sulfate (25mg/ml) 0.1 ml pg daily.
3. Vitamin E 5 international units pg daily.
The infant has not yet had a car seat position screening
test.
State Newborn Screen was sent on [**2131-5-21**] and [**2131-5-27**].
The infant has not yet had any immunizations.
DISCHARGE DIAGNOSES:
1. Prematurity 30 and 3/7 weeks gestation.
2. Twin number one.
3. Status post mild respiratory distress syndrome.
4. Sepsis ruled out.
5. Hyperbilirubinemia of prematurity.
6. Apnea of prematurity.
DR.[**First Name (STitle) **],[**First Name3 (LF) 36400**] 50-595
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2131-5-27**] 04:43:50
T: [**2131-5-27**] 10:27:33
Job#: [**Job Number 10609**]
ICD9 Codes: 769, 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1224
} | Medical Text: Admission Date: [**2101-4-26**] Discharge Date: [**2101-5-6**]
Service: CARDIOTHORACIC
Allergies:
Neosporin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
MVR/ MAZE/ patch repair innominate vein/removal left atrial
appendage on [**2101-4-29**] ( 31 mm CE pericardial valve)
History of Present Illness:
84 yo Caucasian female with increasing DOE/orthopnea.She has
known MR and had an admission for CHF at [**Hospital1 **] 2 weeks ago.
She was visiting family at the time, and actually resides in
[**State 5887**]. Originally scheduled for heart surgery in [**Month (only) **],
she was readmitted for CHF there on [**4-23**] and was transferred here
on [**4-26**] to move up her surgery. Prior echo showed EF 55-60%,
mod-severe MR, mild-mod AI, mod-severe TR, pulm. HTN. Cath done
[**3-24**] revealed LVEDP 67, PA 48/16, nl. cors, EF 60%, severe
MR.[**Name13 (STitle) 3003**] carotid US showed no significant stenosis.
Past Medical History:
iron deficiency anemia
CHF
MR/ AI
IBS
osteoporosis
PAFib
GERD
tachy-brady syndrome/ s/p pacer [**2082**]
Social History:
lives alone in PA
retired teacher
never used tobacco
no ETOH use
Family History:
son died of MI at age 52
brother died of Mi at age 60
Physical Exam:
alert with no apparent deficits
CTAB
RRR/ V pacing/holosystolic murmur
abd benign
extrems warm, trace ankle edema bilat.
97.4 HR 68 RR 18 132/67 96% RAsat.
64" 67.5 kg
Pertinent Results:
[**2101-5-4**] 06:06AM BLOOD WBC-12.1* RBC-3.14* Hgb-9.7* Hct-29.1*
MCV-93 MCH-30.9 MCHC-33.3 RDW-14.9 Plt Ct-113*
[**2101-5-5**] 03:35AM BLOOD WBC-10.4 Hct-28.0*
[**2101-5-5**] 03:35AM BLOOD PT-12.7 INR(PT)-1.1
[**2101-5-4**] 06:06AM BLOOD Plt Ct-113*
[**2101-5-4**] 06:06AM BLOOD Glucose-89 UreaN-19 Creat-0.8 Na-135
K-4.0 Cl-99 HCO3-29 AnGap-11
[**2101-5-5**] 03:35AM BLOOD K-4.6
[**2101-4-26**] 01:15PM BLOOD Glucose-102 UreaN-21* Creat-0.9 Na-136
K-4.4 Cl-95* HCO3-35* AnGap-10
[**2101-4-26**] 01:15PM BLOOD ALT-38 AST-23 LD(LDH)-252* AlkPhos-137*
Amylase-60 TotBili-0.4
[**2101-4-26**] 01:15PM BLOOD Lipase-30
[**2101-5-3**] 04:37AM BLOOD Calcium-8.2* Phos-3.5 Mg-1.8
Brief Hospital Course:
Admitted [**4-26**] by transfer and pre-operative work-up was
completed. Carotid US was repeated which showed right ICA
40-59%, and left ICA < 40%. Cipro started for a UTI that delayed
surgery for a few days. Chest CT done for a pulm. nodule found
on CXR, but this was unremarkable. Underwent MVR/MAZE/ patch
repair innominate vein / removal left atrial appendage with Dr.
[**Last Name (STitle) 914**] on [**2101-4-29**]. Trasnferred to the CSRU in stable condition
on epinephrine, neo, and propofol drips. She remained on
insulin, neo and epinephrine drips on POD #1, but had been
successfully extubated overnight. Swan and chest tubes removed
on POD #2. HIT panel sent for decreasing platelet count. EP
consult also done to readjust her pacer. Diuresis and digoxin
were started. Pacing wires removed on POD #4 and electrolytes
were corrected. HIT panel negative. Transferred to the floor on
[**5-3**] to begin increasing her activity level. Nutrition consult
also done. Coumadin/amiodarone started post-Maze. Bedside
swallowing eval also done. She continued to make good progress
and was cleared for discharge to rehab on POD #6. She should
follow up with her PCP and cardiologist Dr. [**Last Name (STitle) 6254**] as listed.
Medications on Admission:
nadolol 40 mg daily
dogoxin 0.125 mg daily
lisinopril 20 mg daily
lipitor 10 mg daily
ASA 81 mg daily
lasix 40 mg daily
protonix 40 mg daily
evista 60 mg daily
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
dose today only [**5-5**] is 2 mg; next doses [**Name6 (MD) **] rehab MD.
5. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours).
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
11. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 5 days: 400 mg [**Hospital1 **] for 5 days, then 400 mg daily for
7 days; then 200 mg daily ongoing.
13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Raloxifene 60 mg Tablet Sig: One (1) Tablet PO once a day.
16. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] rehab and skilled nursing of [**Location (un) **]
Discharge Diagnosis:
s/p MVR / Maze/ repair innominate vein/removal left atrial
appendage [**2101-4-29**]
CHF
anemia
PAFib
GERD
IBS
osteoporosis
tachy-brady syndrome/ pacer [**2082**]
Discharge Condition:
good
Discharge Instructions:
no lotions, creams or powders on any incision
may shower over incision and pat dry
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever, redness or drainage
Followup Instructions:
see Dr. [**Last Name (STitle) 4427**] or Dr. [**First Name (STitle) **] in [**12-20**] weeks
See Dr. [**Last Name (STitle) 6254**](card) in [**1-21**] weeks
see Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2101-5-5**]
ICD9 Codes: 5990, 2761, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1225
} | Medical Text: Admission Date: [**2119-6-1**] Discharge Date: [**2119-6-27**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
At time of encounter patient was intubated, thus history is from
patient's wife and prior records. Mr. [**Known lastname **] is an 87yo man who
was in his USOH until about 10:30am this morning, when he
"didn't feel right" while walking to the bathroom. He then lay
down again and told his wife he "felt fine," however a short
while later he went downstairs and his wife heard a "thud" and
found her husband on the floor in the kitchen with a chair
overturned on top of him. He told her he was fine but was
apparently holding his head. His wife called 911 and when she
returned he was unresponsive. No seizure activity noted. Per EMS
the patinet was confused and then one minute later was entirely
unresponsive with GCS 3.
.
There, head CT showed a small L posterior temporal SAH, which
was confirmed on head MRI/A. He was given thiamine and was
intubated. He was transferred to [**Hospital1 18**] for further evaluation.
.
In the ED, he was sedated with propofol and was seen by
neurosurgery who assessed that his SAH was too small for
operative management, and care was deferred to neurology. He was
evaluated by neurology, who believed that his SAH was likely
traumatic and related to his fall rather than the cause of his
fall. Electrolytes returned markedly abnormal and the patient
reported had a 7 beat run of vtach, followed by wavering heart
rates greater than 100 in afib, and then in NSR and in the low
60s. Cardiology was in the department, and saw the pt's rhythm
strips, declaring that this particular rhythm was unlikely the
cause of his syncopal episode. Neuro believed that, given his
electrolyte abnormalities, the most likely etiology was
"metabolic" versus cardiac. They recommended repeat head CT to
evaluate his SAH, and will assess for need for EEG based on his
course and responsiveness. They recommended repleting his
electrolytes, however after this recommendation, repeat studies
returned and were relatively unremarkable. The ER covered with
vancomycin and ceftriaxone for possible meningitis, but LP was
not performed in the ER due to the pt's "changing heart
rhythms." He was given a total of 1L of IVF, and he received
most of a 40mEq IV potassium repletion as well as 20meq of PO
potassium and 2g IV magnesium. He was transferred to the MICU
for further management.
.
ROS: unable to perform given intubated. Per wife, has not been
complaining of headache, has felt very sleepy for last few
weeks, no c/o CP, no SOB over usual baseline (dyspneic with
walking one flight of stairs), no c/o abd pain, no diarrhea,
+constipation. No fever/chills/sweats.
Past Medical History:
- Per prior cardiology note, had an echo with trivial to mild
TR, enlarged RV and possibly a PFO.
- Longstanding exertional dyspnea - has pulmonologist who
reportedly has done "multiple tests with no abnormalities"
- Polymyalgia rheumatica (ESR initially 100, now 6)
- HTN
- TIAs - per wife, 10yrs ago he had a few minutes of
unsteadiness
- Hyperlipidemia
- h/o prostate cancer, s/p resection [**2096**]
- Recent admission for rapid heart rate (wife does not know why)
- R postsurgical pupil
- MGUS
- Baseline Cr 1.4-1.7 in [**10-22**] (no earlier levels known)
- PALPITATIONS - shown to be ventricular premature beats in
multiple Holter monitors
- MITRAL VALVE DISORDER
- ATRIAL FIBRILLATION
- LUMBOSACRAL SPONDYLOSIS
- ATRIAL PREMATURE BEATS
- GERD
- Degenerative disk disease in the thoracic spine.
Social History:
retired engineer at [**University/College **]. No etoh/tob/illicits.Functions
independently. Lives home alone with wife. [**Name (NI) **] lives in
[**State 4565**].
Family History:
negative for stroke, seizures
Physical Exam:
VS 68, 124/64, 99.5, 16, 100%
Gen: sedated, intubated. Moves L arm and B legs spontaneously,
grimaces to sternal rub
HEENT: R surgical pupil, L pupil min reactive, dark blood in OG
tube
Cor: RRR, no r/g/m
Pulm: CTAB
Abd: soft, NTND, +BS
Ext: no c/c/e
Neuro: withdraws all 4 to pain, moves R arm and leg much less
than other extremities, B toes upgoing (per neuro note wife said
this is baseline increased tone in toes)
Skin: no obvious rashes
GU: yellow urine in foley
Pertinent Results:
Note that lab draw was repeated and electrolytes were WNL except
for low phosphate level. Ck/MB/trop negative. WBC 12.7 with no
bands and 77% pmns. Creatinine at baseline of 1.4 (unchanged
from [**10-22**]).
.
STUDIES:
.
Echo [**6-2**]: The left atrium is normal in size. No atrial septal
defect or patent foramen ovale is seen by 2D, color Doppler or
saline contrast (rest injection only). Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 70%) 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 mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
.
Head CT [**6-2**]: Small subarachnoid hemorrhage in left posterior
temporal lobe unchanged from study 14 hours prior. MRI would be
recommended if clinical concern for infarct remains.
.
CXR: Endotracheal tube as above. Advance nasogastric tube [**6-24**]
cm. No
acute process.
.
[**Location (un) 620**] chest CT with contrast performed for r/o dissection: NO
EVIDENCE OF AORTIC DISSECTION. ASCVD. HH. BILATERAL
COMPRESSIVE
ATELECTASIS. HEPATIC AND RENAL CYSTS. SMALL LOW DENSITY LESION
IN THE SPLEEN CONSISTENT WITH A CYST OR HEMANGIOMA.
- per discussion with radiology resident, also no central PEs
seen on this study. Cannot rule out subsegmental PE given timing
of contrast not ideal for this.
.
[**Location (un) 620**] head CT: PROBABLE SMALL SUBARACHNOID HEMORRHAGE IN THE
LEFT POSTERIOR TEMPORAL LOBE. NO OTHER ACUTE ABNORMALITIES ARE
DETECTED. THERE IS EVIDENCE OF CHRONIC ISCHEMIA WITH NUMEROUS
LACUNAR INFARCTIONS.
.
repeat head CT: Small subarachnoid hemorrhage in the left
posterior temporal lobe, without significant change in size from
12:30 p.m. today. Findings were posted to the ED dashboard at
10:30 p.m. on [**2119-6-1**].
.
CT C-spine: 1. No acute traumatic injury in the cervical spine.
2. Nasogastric tube coiled in the hypopharynx.
.
head MR/MRA (neuro attg read) from [**Location (un) 620**]: scattered FLAIR and
T2 abnormalities c/w small vessel disease. There was a small SAH
in the left parieto-temporal region. There were no DWI or T2*
abnormalities. His MRA was normal with good flow in the VA & BA
arteries. No aneurysms were noted.
.
(rads read) INCREASE SIGNAL SEEN IN THE UPPER MID BRAIN AND
MEDIAL THALAMI COULD BE CONSISTENT WERNICKE'S ENCEPHALOPATHY IN
PROPER CLINICAL SETTING. CLINICAL CORRELATION RECOMMENDED.
EVIDENCE OF SUBARACHNOID HEMORRHAGE IN THE LEFT TEMPORAL SULCI
CONSISTENT WITH THE FINDINGS SEEN ON THE RECENT CT. MILD TO
MODERATE BRAIN ATROPHY AND SMALL VESSEL DISEASE. NORMAL MRA OF
THE HEAD.
.
R shoulder XR: Three views of the right shoulder show no
fracture, dislocation, bone destruction, or diminution in the
acromio-humeral soft tissues. The partially visualized right
lung is clear. Incidental degenerative changes AC joint and
central line catheter via right arm.
.
EKg: NSR at 70, nl axis, nl intervals, no TWI, no STT changes,
no Qs. also have EKG rhythm strips showing several instances of
sinus pauses up to longest of about 2 seconds interspersed with
a narrow tachycardia.
.
UA: blood but negative for infection
Blood culture: pending
serum tox screen negative except for positive benzos
urine tox screen negative
.
.
Holter monitor [**6-21**]: 1. Predominantly sinus rhythm with a brief
episode of sinus bradycardia to 47 BPM at 9:34 am. Normal
intervals and no significant pauses. 2. Frequent isolated APBs
and 2 atrial couplets. 3. Moderate isolated ventricular ectopy.
4. One episode of "palpitations" showed sinus tachycardia at 107
BPM with a single isolated APB. 5. Compared to Day 1 (2-day
study), atrial tachycardia
was not seen.
.
stress echo [**5-22**]:
1. Limited exercise tolerance.
2. No symptoms of chest pressure or chest tightness.
3. No EKG changes of ischemia with exercise performed.
4. Echocardiographic images reported separately and attached.
.
Brief Hospital Course:
Mr. [**Known lastname **] is an 87M with a history of TIA and HTN who presented
s/p fall with loss of consciousness to [**Location (un) 620**] and was found to
have a small left subarachnoid hemorrhage, a thalamic CVA, and
atrial fibrillation with rapid ventricular rate.
Stroke: The patient was admitted to the MICU service, intubated
from the OSH. He was initially started on levofloxacin and
vancomycin for possible aspiration, however when sputum cultures
were negative antibiotics were discontinued. He quickly weaned
from the ventilator and was extubated on [**6-8**] when his mental
status was improved. EEG showed no epileptiform foci. Lumbar
puncture was negative for infection, and blood and urine
cultures were negative. Repeat head imaging showed a CVA in the
thalami and Left caudate nucleus. CVA is likely thromboembolic
related to atrial fibrillation. Echo showed no structural
abnormalities and no patent foramen. The patient was followed
closely by they neurology team, and he was maintained on heparin
drip (ASA and plavix were held per neurology recommendations)as
well as statin, and he was treated with thiamine and folate. He
continued to have waxing and [**Doctor Last Name 688**] mental status consistent
with hospital-related delirium and was treated with haldol prn
agitation. His deficits throughout hospital course and at
discharge were right sided hemiparesis and eyelid opening
apraxia. He had a G-J tube placed and he was transitioned from
heparin gtt to lovenox as bridge to coumadin.
Paroxysmal Atrial fibrillation: He had a newly diagnosed atrial
fibrillation on admission with RVR. He was treated with
metoprolol prn and was started on amiodarone load. He remained
in sinus rhythm throughout the remainder of his hospitalization.
He was treated with anticoagulation as above (the left sided
subarachnoid hemorrhage had resolved radiographically as of [**6-18**])
and was also started on a beta blocker.
Leukocytosis: WBC 31 on [**6-14**], blood culture on [**6-12**] right PICC
with coag neg staph in [**2-15**] sets (likely contaminant). All
cultures subsequently are negative to date. C. diff is negative
x 3 now. Toxin B is still pending. Completed 10 day course of
flagyl, PO vancomycin for empiric treatment of c.diff colitis.
Also completed 7 day course of vanc/cefepime for hospital
acquired pneumonia on [**6-25**].
Anemia: Hct remained stable over the last few days at around
24-25. This is down from his baseline (mid-30s), prior to
hospitalization. Nevertheless, he has been hemodynamically
stable. Hemolysis labs were negative. He did have FOBT stools
on [**6-20**], but no melena or BRBPR. He was continued on [**Hospital1 **] PPI.
He should have a colonoscopy as an outpt when his medical issues
become more stable.
Medications on Admission:
ASA 81mg po qday
Plavix 75 mg po qday (started after the TIA)
Enalapril 15 po qday
Metoprolol 25 [**Hospital1 **], started after recent rapid heartrate
Lipitor 40 mg po qday
Ditropan wife unsure of dose
Prednisone tapered down to 7mg daily (has been on for 2 months)
Prilosec 20mg po daily
Celexa dose unknown
Discharge Medications:
1. Atorvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
2. Prednisone 1 mg Tablet [**Hospital1 **]: Seven (7) Tablet PO DAILY
(Daily).
3. Thiamine HCl 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
4. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
5. Lidocaine HCl 2 % Gel [**Hospital1 **]: One (1) Appl Mucous membrane PRN
(as needed).
6. Amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
7. Enoxaparin 80 mg/0.8 mL Syringe [**Hospital1 **]: One (1) Subcutaneous
[**Hospital1 **] (2 times a day) for Until INR is therapeutic [**3-19**] for at
least 24 hours days.
8. Miconazole Nitrate 2 % Powder [**Month/Day (3) **]: One (1) Appl Topical TID
(3 times a day) as needed.
9. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (3) **]: One (1) PO BID (2
times a day).
10. Senna 8.6 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO BID (2 times a
day).
11. 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.
12. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Month/Day (3) **]:
One (1) Inhalation q6hours prn as needed.
13. Haloperidol 0.5 mg IV BID:PRN agitation
14. Warfarin 6 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO Once Daily at 4
PM.
15. Toprol XL 200 mg Tablet Sustained Release 24 hr [**Month/Day (3) **]: One (1)
Tablet Sustained Release 24 hr PO once a day.
16. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Primary
Subarachnoid hemorrhage left posterior temporal lobe
Thromboembolic stroke, left thalamic infarct
Atrial fibrillation with rapid ventricular rate
Anemia
Delirium
Secondary
Chronic renal insufficiency
Hypertension
Hyperlipidemia
Polymyalgia rheumatica
Discharge Condition:
stable, PEG tube in place, afebrile
Discharge Instructions:
You were admitted with a stroke and bleed in your head. Your
bleed was stable on discharge. Your stroke is likely from your
atrial fibrillation (irregular rhythm). You were treated with
several medications including blood thinners and medications for
your irregular heart rhythm. In addition, you were found to
have an infection and were treated with multiple antibiotics.
Several important medications have been started for you. These
include amiodarone, coumadin and lovenox. It is very important
that you take these medications.
If you have any of the following symptoms, you should return to
the emergency room:
Fevers, chills, cough, diarrhea, new weakness, headaches or any
other serious concerns.
Followup Instructions:
We have scheduled an appointment for you with the neurologist
who saw you.
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & [**Doctor Last Name 12454**] Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2119-8-9**] 1:00
In addition you should schedule an appointment with your primary
care provider in the next 2-3 weeks.
You should also follow up with cardiology as below.
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**]
Date/Time:[**2119-8-4**] 1:00
Completed by:[**2119-6-29**]
ICD9 Codes: 486, 5180, 5070, 5849, 4019, 2724, 5859, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1226
} | Medical Text: Admission Date: [**2131-1-26**] Discharge Date: [**2131-2-5**]
Date of Birth: [**2056-2-27**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfasalazine / Sulfa (Sulfonamide Antibiotics) / Parnate
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
dyspnea and hiatel hernia
Major Surgical or Invasive Procedure:
[**2131-1-26**] Laparoscopic hiatal hernia repair with fundoplication
History of Present Illness:
74 year old woman with interstitial lung disease and severe
respiratory impairment. She underwent a bronchoscopy and review
of her thoracic imaging by Dr. [**Last Name (STitle) **]. Based on the CT images,
there was evidence of ongoing inflammation and therefore she was
treated empirically for
non-specific interstitial pneumonitis (NSIP) as there was no
readily identifiable inciting [**Doctor Last Name 360**] for hypersensitivity
pneumonitis. It was thought that the trigger for the NSIP is the
aspiration and as such, she was evaluated for repair of her
sizable hiatal hernia. She recently completed a Prednisone taper
course prior to the surgery and presented this time for an
elective laparoscopic hiatal hernia repair repair and nissen
fundoplication.
Past Medical History:
- COPD
- CHF
- Pulmonary fibrosis diagnosed CT [**2126**]
- Osteoporosis with compression fractures
- Hypercholesterolemia
- Hypertension
- GERD
- Anxiety/Depression
- Insomnia
- Post-surgical hypothyroidism
- Melanoma removed from back, left axillary lymph node
dissection [**2107**].
- Right knee and hip replacement.
Social History:
Widowed. Has one child. Worked as a quality inspector for
[**Company 2892**],
retired [**2116**]. Denies ETOH. Quit smoking in [**2119**] and was a
45ppy
smoker. Does not have any pets. No birds in house. No recent
travels. No molds in house. Currently lives in [**Hospital3 **]
facility.
Family History:
Mother deceased from complications related to RA. Father
deceased age 52 from MI. Brother has CAD. Sister deceased from
traumatic fall.
Physical Exam:
VS: Temp 98.4, HR 92SR, BP 119/49, RR 18, pulse oximetry 94% on
3LNC
Physical Exam:
Gen: pleasant in NAD
Resp: slight rales t/o
CV: RRR S1, S2, no MRG or JVD
Abd: soft, NT, ND
Ext: no pressure sores, trace BLE edema
Pertinent Results:
[**2131-1-27**] Barium swallow study:
IMPRESSION: No evidence of leak. Contrast passes through the
duodenum and
into the small bowel.
[**2131-2-2**] US BLE duplex: neg DVT
[**2131-1-30**] CTA C/A/P:
IMPRESSION:
1. Known pulmonary fibrosis, roughly stable in appearance since
recent
examination from [**2130-11-24**]. New interval development of
bilateral, left
greater than right, superimposed parenchymal consolidation
concerning for
pneumonia.
2. No evidence of pulmonary embolism to the subsegmental levels,
though
evaluation of the lower lobes is limited by respiratory motion.
3. Dynamic abnormal concave bowing of trachea that is suggestive
of
tracheomalacia and dedicated imaging examination can be
performed as
indicated.
4. Prominent mediastinal lymph nodes, with some enlarged since a
recent exam from [**2130-11-24**], likely reactive in nature, though
given history of known melanoma, metastasis cannot be entirely
excluded, and attention could be paid on followup imaging as
indicated.
5. No abnormal fluid collections within the abdomen that would
be concerning for abscess formation.
6. Incompletely characterized 1.6 cm liver lesion in segment
III, recommend correlation with prior imaging or if not
available, ultrasound can be considered for further evaluation.
[**2131-2-4**] 05:00AM BLOOD WBC-6.3 RBC-3.59* Hgb-10.1* Hct-31.7*
MCV-88 MCH-28.1 MCHC-31.8 RDW-15.6* Plt Ct-307
[**2131-2-3**] 02:37AM BLOOD Glucose-117* UreaN-9 Creat-0.8 Na-138
K-3.5 Cl-102 HCO3-28 AnGap-12
[**2131-2-1**] 03:07AM BLOOD ALT-28 AST-34 AlkPhos-105 TotBili-0.4
[**2131-2-3**] 02:37AM BLOOD Calcium-7.9* Phos-2.5* Mg-2.0
[**2131-2-3**] 02:47AM BLOOD Type-ART pO2-82* pCO2-43 pH-7.46*
calTCO2-32* Base XS-5
[**2131-1-29**] 9:07 am SPUTUM Source: Expectorated.
**FINAL REPORT [**2131-2-1**]**
GRAM STAIN (Final [**2131-1-29**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2131-2-1**]):
SPARSE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. MODERATE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
Please contact the Microbiology Laboratory ([**7-/2427**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
Brief Hospital Course:
Ms. [**Known lastname 84254**] was taken to the operating room by Dr. [**First Name (STitle) **] on [**2131-1-26**]
for her paraesophageal hernia with laparoscopic Nissen. She
recovered in usual fashion. A barium swallow study was done on
[**2131-1-27**] which did not show any leak. She had some coughing on
[**2131-1-27**], at which time she was resumed on home meds, and given
aggressive pulmonary toilet. Pulmonology evaluated her and did
not feel she warranted bronchoscopy at that time. The patient
remained on her home oxygen. She was evaluated by PT/OT on
[**2131-1-29**] who determined she would best benefit from pulmonary
rehab. Her cough worsened and chest xray revealed CHF. She was
diuresed well, however on [**2131-1-30**] developed 102 fever, was
pancultured and started on vancomycin and zosyn. She required
transfer to the ICU for sepsis on [**2131-1-31**]. She required low dose
neosynephrine. She was found to have MRSA pneumonia which
resolved on IV vancomycin. Her last vancomycin trough level was
18 on [**2131-2-2**]. ID consulted and recommended PICC line with IV
vancomycin to continue until [**2131-2-14**] with CBC, Chem panel and
vanco trough [**2131-2-6**]. The patient was transfered to the floor on
[**2131-2-4**]. She has been medically stable without fevers or
hypotension on the floor and is stable for pulmonary rehab. It
is noted we do not have a recent echo documenting LV function,
and the patient did not come in with beta blockers or ace
inhibitors. She should have close outpatient follow up with her
primary care physician regarding initiation of these meds if
tolerated.
Medications on Admission:
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider; Pt
reports taking.) - 40 mg Tablet - 1 (One) Tablet(s) by mouth
once
a day.
CLONAZEPAM [KLONOPIN] - (Prescribed by Other Provider; Pt
reports taking.) - 1 mg Tablet - 1 (One) Tablet(s) by mouth
three
times a day.
DULOXETINE [CYMBALTA] - (Prescribed by Other Provider; Pt
reports taking.) - 30 mg Capsule, Delayed Release(E.C.) - 3
(Three) Capsule(s) by mouth Once a day.
FUROSEMIDE [LASIX] - (Prescribed by Other Provider; Pt reports
taking.) - 40 mg Tablet - 1 (One) Tablet(s) by mouth Once a day.
LEVOTHYROXINE - (Prescribed by Other Provider; Pt reports
taking.) - 75 mcg Tablet - 1 (One) Tablet(s) by mouth Once a
day.
OMEPRAZOLE - (Prescribed by Other Provider; Pt reports taking.)
- 40 mg Capsule, Delayed Release(E.C.) - 1 (One) Capsule(s) by
mouth Once a day.
ONDANSETRON HCL [ZOFRAN] - (Prescribed by Other Provider; Pt
reports taking.) - Dosage uncertain
ZOLPIDEM [AMBIEN CR] - (Prescribed by Other Provider; Pt
reports
taking.) - 12.5 mg Tablet, Multiphasic Release - 1 (One)
Tablet(s) by mouth At bedtime.
Medications - OTC
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other
Provider; Pt reports taking.,) - Dosage uncertain
POTASSIUM - (Prescribed by Other Provider; Pt reports taking.)
-
Dosage uncertain
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Three
(3) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) mL Inhalation Q6H (every 6 hours) as
needed for SOB, wheezing.
10. Ipratropium Bromide 0.02 % Solution Sig: Three (3) mL
Inhalation Q6H (every 6 hours) as needed for SOB, wheezing.
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain .
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
15. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
16. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
once a day: end [**2131-2-14**].
17. 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.
18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
20. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
21. Doxepin 25 mg Capsule Sig: Eight (8) Capsule PO HS (at
bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
[**2131-1-26**]
1. Laparoscopic repair of giant paraesophageal hernia.
2. Laparoscopic Nissen fundoplication.
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:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fever > 101 or chills or shakes
-Increased shortness of breath, cough, chest pains
-Difficulty or painful swallowing.
-Diarrhea or vomiting
-redness, drainage or swelling near lap sites
Followup Instructions:
Follow up with [**Last Name (NamePattern4) 4113**]; call for directions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2131-2-21**] 2:00 [**Hospital1 18**] [**Hospital Ward Name **] [**Hospital1 **] 116 CDC
Provider: [**First Name8 (NamePattern2) 828**] [**Name11 (NameIs) 829**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2131-2-21**] 1:00 [**Hospital1 18**] [**Hospital Ward Name **] [**Hospital1 **] 116 CDC
Completed by:[**2131-2-5**]
ICD9 Codes: 4280, 2720, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1227
} | Medical Text: Unit No: [**Numeric Identifier 66433**]
Admission Date: [**2162-2-21**]
Discharge Date: [**2162-3-15**]
Date of Birth: [**2162-2-21**]
Sex: F
Service: NB
REASON FOR ADMISSION:
1. Prematurity ( 33 6/7 weeks gestation).
2. Twin 2 of dichorionic-diamniotic twins.
MATERNAL HISTORY: Baby girl [**Known lastname 66428**] was [**Known lastname **] as twin 2 to a
33-year-old G1 P0 with prenatal screens A positive, antibody
negative, HBsAg negative, RPR NR, Rubella immune, GBS unknown.
Her current pregnancy was complicated by twin
pregnancy(dichorionic-diamniotic), maternal PIH, preeclampsia
(increased blood pressure, proteinuria and visual changes), and
gestational diabetes mellitus requiring insulin. In addition,
maternal medical history was notable for Crohn's disease,
polycystic ovarian disease and endometriosis. Due to evolving
preeclampsia in the mother, elective early delivery was
planned after mother was betamethasone complete.
BIRTH HISTORY: Baby was delivered by cesarean section under
spinal anesthesia. There were no perinatal risk factors for
sepsis in the form of maternal fever, prolonged rupture of
membranes or chorioamnionitis. Baby was [**Name2 (NI) **] in good
condition with Apgars [**8-4**]. This twin was noted to have a 2
vessel cord.
PHYSICAL EXAMINATION ON ADMISSION: Growth: weight 1795 grams
(25th percentile), length 43 cm (25th percentile), head
circumference 31 cm (25th to 50th percentile). Baby was
comfortable, pink, nondysmorphic, preterm infant in no
respiratory distress. Palate and clavicles intact. Neck supple.
Respiratory: no respiratory distress. Cardiovascular: normal rate
and rhythm, no murmur, bilateral femorals palpable. Abdomen:
soft, normal bowel sounds, 2 vessel umbilical cord. GU: normal
preterm female, Patent anus. Hips stable. Sacrum with 2
dimples, one at sacral base midline, second slightly higher
and off center. Extremities pink and well perfused.
Overlapping fourth toe digits bilaterally. Neuro: active,
alert, normal tone, strength, symmetrical movements and
moro reflex.
HOSPITAL COURSE:
1. Respiratory: Baby [**Known lastname 66428**] twin 2 was comfortably
breathing in room air throughout hospital admission and
showed no signs of RDS or apnea or prematurity.
2. Cardiovascular: There were no cardiovascular concerns in
the first 2 weeks of life. However, one week prior to
discharge she has been noted to have mild intermittent
tachycardia with a resting heart rate of up to 200/min.
Her EKG was normal. Her hematocrit was 33 and she
showed no signs of sepsis. The tachycardia has improved
at the time of discharge in that it is no longer present
at rest. As all the baseline investigations have been
normal, this is likely benign in view of her prematurity.
3. Fluids, electrolytes and nutrition: She was initially
started on IV fluids at 80 ml/kg/day. Enteral
feeds were gradually introduced so that she was on full
feed by day of life 3. This was further advanced to a
maximum of 150 mls/kg/day of 24 calorie feeds of
breast milk/E 24. At the time of discharge she is on ad
lib feeds of E24 and taking a minimum of 130 ml per kilo
per day. Weight at discharge 2215 grams.
4. GI: There were no gastrointestinal concerns. She received
phototherapy for physiological jaundice with maximum
bilirubin of 9.8 mg/dL on day of life 3.
5. Hematology: She did not receive any blood transfusion
during hospital admission.
6. Infectious disease: She had no episodes of suspected or
proven sepsis.
7. Neurology: clinically normal. She did not qualify for
routine cranial ultrasound screening.
8. She had a spinal and renal ultrasound scan performed in view
of the sacral dimples and 2 nuchal cord, which were both normal.
9. Audiology: she has passed the newborn hearing
screen. Ophthalmology: She does not qualify for routine
ROP screening.
10. Psychosocial. No concerns.
DISCHARGE CONDITION: Good.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY CARE PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 66434**],
[**First Name3 (LF) **] Pediatrics. The phone number is [**Telephone/Fax (1) 66430**].
CARE AND RECOMMENDATIONS:
1. Feeds at discharge is on ad lib E24 feeds with a minimum
of 130 ml per kilo per day. If she continues to gain
weight adequately she may be weaned to the standard E20
calorie formula.
2. Medications, ferrous sulfate 25 mg per ml-3.2 ml po once
a day.
1. State newborn screening status-normal.
1. Immunizations received, hepatitis B vaccine on [**2162-2-24**].
1. Immunizations recommended, Synagis RSV prophylaxis should
be considered from [**Month (only) **] through [**Month (only) 958**] for infants who
meet any of the following criteria, 1) [**Month (only) **] at less than
32 weeks, 2) [**Month (only) **] between 32 and 35 weeks with 2 of the
following, daycare during RSV season, smoker in the
household, neuromuscular disease, airway abnormalities or
school age siblings or with chronic lung disease, 3)
influenza immunization is recommended annually in the
fall for all infants [**Month (only) **] 36 months of age. Before this
age (and for the first 24 months of the child's life)
immunization against influenza is recommended to
household contacts and out of home caregivers.
1. Follow up appointment schedules with pediatrician 2 days
post discharge.
DISCHARGE DIAGNOSES:
1. Prematurity ( 33 6/7 weeks gestation).
2. Twin 2 of dichorionic diamniotic twins.
Rviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Doctor Last Name 65692**]
MEDQUIST36
D: [**2162-3-16**] 07:35:30
T: [**2162-3-16**] 08:43:44
Job#: [**Job Number 66435**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1228
} | Medical Text: Admission Date: [**2106-10-31**] Discharge Date: [**2106-11-15**]
Date of Birth: [**2028-12-1**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Codeine / Ciprofloxacin / Penicillins
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 77 year-old female with osteoporosis and multiple
vertebral compression fractures status post vertebroplasty and
kyphoplasty last [**10-8**] by Dr. [**Last Name (STitle) 5730**] at [**Hospital1 2025**] (T10), also with
COPD and bronchiectasis on home oxygen 2L/min for 1 month, and
chronic hyponatremia secondary to SIADH, who presents from home
with increasing back pain.
*
She reports that she has baseline back discomfort from her
multiple previous interventions, but has noted significant
worsening in the past 2 days, bilateral with midline sparing,
wrapping around to axilla bilaterally, worse at the level of her
most recent surgery but also diffuse. She denies paresthesia or
new extremity weakness, no difficulty urinating or defecating.
She denies fever or chills. On a different note, she reports
chronic severe shortness of breath, stable over the past month,
for which she uses 2L home oxygen. She denies phlegm production,
no chest pain, and endorses mild chronic LE edema which has been
attributed to her Norvasc. She sleeps with multiple pillows due
to her kyphosis and SOB, no change recently.
*
In ED, T 98.2, HR 76, BP 182/75, RR 24, Sat 100% on 2L/min. T
and L-spine X-rays did not reveal new fractures, CXR with
findings consistent with bronchiectasis, CT chest without PE but
with interval increase in bronchiectatic and peribronchial
inflammatory changes. She was evaluated by neurosurgery, deemed
to be intact neurologically. She is being admitted for ongoing
pain control.
Past Medical History:
# chronic back pain, compression fractures
# COPD with bronchiectasis dx [**2080**]. [**2103**] with MYCOBACTERIUM
KANSASII and pseudomonas.
# hemorrhoids
# hemorroidal prolapse with GIB
# SIADH
# perirectal abscess s/p I/D in [**3-7**]
# Pulmonary nodules
# Lower extremity edema
# osteoporosis
# mitral valve prolapse
# spinal stenosis
# 1+ MR, [**1-4**]+ TR, 1+ AR echo [**2103**]
# multi-nodular thyroid
Social History:
The patient has a 7.5 pack year history, but quit >40 years ago,
occasional alcohol use, and no other drug use. The patient
lives with adult daughter in [**Name (NI) 4288**].
Family History:
non contributory
Physical Exam:
T 97.6, HR 96 (73-96), BP 142/78 (138-142/76-78), RR 22,
100%2L/min.
GEN: Cachectic, kyphotic elderly female, in NAD.
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
MMM, no oral ulcerations, no LAD, no decreased ROM
NECK: No carotid bruit. JVP less than 5cm ASA.
RESP: Early inspiratory crackles, R>L, worse in upper thorax,
heard both anteriorly and posteriorly, without bronchial
breathing.
CVS: RRR, S1/S2, Faint systolic murmur heard at RUSB, without
radiation.
GI: Soft, non-tender.
EXT: Trace bilateral ankle edema.
NEURO: CN II-XII intact, 4/5 strength in all extremities
MSK: There is no midline spine tenderness. She has tenderness to
palpation in paraspinal areas bilaterally. no CVAT
Pertinent Results:
labs:
[**2106-10-30**] 04:50PM BLOOD WBC-11.8* RBC-3.95* Hgb-12.1 Hct-33.8*
MCV-86 MCH-30.7 MCHC-35.8* RDW-13.0 Plt Ct-445*
[**2106-11-2**] 06:57AM BLOOD WBC-10.7 RBC-4.03* Hgb-11.5* Hct-36.2
MCV-90 MCH-28.6 MCHC-31.9 RDW-13.0 Plt Ct-562*
[**2106-10-30**] 05:50PM BLOOD D-Dimer-1229*
[**2106-10-30**] 04:50PM BLOOD Glucose-87 UreaN-20 Creat-0.4 Na-129*
K-4.1 Cl-86* HCO3-33* AnGap-14
[**2106-11-1**] 06:35AM BLOOD Glucose-91 UreaN-17 Creat-0.4 Na-129*
K-4.4 Cl-87* HCO3-36* AnGap-10
[**2106-11-3**] 06:35AM BLOOD Glucose-104 UreaN-18 Creat-0.4 Na-126*
K-4.3 Cl-84* HCO3-37* AnGap-9
[**2106-11-1**] 06:35AM BLOOD Calcium-9.1 Phos-2.5* Mg-2.0
[**2106-11-1**] 06:35AM BLOOD TSH-0.37
.
Imaging:
CTA CHEST W&W/O C &RECONS [**2106-10-30**] 8:31 PM
IMPRESSION:
1. No evidence of pulmonary embolism or aortic dissection.
2. Extensive bronchiectasis and peribronchial inflammation is
again seen, with nodular opacities adjacent to these areas
suggesting mucoid impaction or inflammation. These findings have
increased in comparison to prior study.
3. Extensive compression deformities within the thoracic spine,
with changes related to vertebroplasty.
4. Hypodensity within the left thyroid gland and an exophytic
thyroid nodule extending inferiorly.
.
CT T-SPINE W/O CONTRAST [**2106-10-30**] 8:31 PM
IMPRESSION: Again seen are multiple compression deformities
within the thoracic and lumbar spine, with mild narrowing of the
spinal canal, greatest at T11/12 level. There is very limited
evaluation on CT of intrathecal contents, representing a concern
for cord abnormality, and further evaluation with an MRI should
be obtained.
NOTE ADDED IN ATTENDING REVIEW: Agree overall with above. There
is severe, diffuse osteopenia with thoracic kyphoscoliosis, but
no evidence of acute alignment abnormality. The severe T7 and
less marked T6 (and L4) compression deformities are of
indeterminate age, and an acute component cannot be excluded; in
this regard, comparison with prior (outside) cross-sectional
studies would be helpful. The moderate ventral spinal canal
narrowing at the T12 level reflects retropulsion of that dorsal
vertebral cortex. No definite vertebroplasty material is
identified within the epidural space.
.
L-SPINE (AP & LAT) [**2106-10-30**] 5:50 PM
IMPRESSION: Interval increase in the number of vertebral bodies,
status post kyphoplasty. Probable upper thoracic spine
compression fractures, however, this is inadequately evaluated
on this examination secondary to motion.
.
T-SPINE [**2106-10-30**] 5:50 PM
IMPRESSION: Interval increase in the number of vertebral bodies,
status post kyphoplasty. Probable upper thoracic spine
compression fractures, however, this is inadequately evaluated
on this examination secondary to motion
.
CHEST (PA & LAT) [**2106-10-30**] 5:50 PM
IMPRESSION:
1. Stable appearance of the chest with upper lobe interstitial
densities and bronchiectasis, stable.
2. COPD.
.
ECHO Study Date of [**2106-11-1**]
Conclusions:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). There is no left ventricular outflow obstruction at
rest or with Valsalva. The right ventricular cavity is mildly
dilated. Right ventricular systolic function is normal. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. Mild to moderate ([**1-4**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2103-9-10**], estimated pulmonary artery systolic
pressure is similar. Right ventricle cavity size may now be
larger.
.
MR THORACIC SPINE W/O CONTRAST [**2106-11-2**] 9:36 AM
IMPRESSION:
1. 1.3-cm well defined round lesion in the posterior part of the
T5 vertebral body, which is indeterminate. Malignancy cannot be
excluded based on this appearance.
2. Edema in the posterior parts of the T9 and T10 vertebral
bodies, which could be related to post-vertebroplasty edema.
3. Retropulsed fragments of the collapsed vertebral bodies at
various levels, contacting the cord with narrowing of the
ventral canal at T7 and T12 levels; nerve root impingement at
T12 level cannot be excluded, but not definitive.
.
Blood cultures: [**6-8**] GPCs (2 bottles speciated as MRSA)
Brief Hospital Course:
Mrs. [**Known lastname **] is a 77 year-old female with osteoporosis and multiple
compression deformities s/p several kyphoplasties, also with
bronchiectasis and COPD, admitted with intractable bilateral
back pain. Her pain proved difficult to control throughout her
stay, as she was especially sensitive to narcotic medications,
twice becoming nearly unresponsive after receiving them. On the
second episode, when the patient was unresponsive after
receiving her dose of dilaudid as well as Phenergan she was sent
to the ICU when she was found to be in hypercarbic respiratory
distress. She received Narcan x 2 with good effect, however the
following day the patient continued to retain carbon dioxide at
an amount that seemed greater than her baseline. She was started
on intermittent bipap with little effect.
At this time the patient's culture results returned with 6/6
bottles of GPCs, two of which were speciated as MRSA. The
patient had been started on vancomycin and her white count was
improving but her respiratory status continued to decline. CXR
was consistent with pneumonia. After 3 days of relatively
stable vital signs (expecte for respiratory) in the ICU, while
on vancomycin for her bacteremia, the patient suddenly went into
afib at 170s. Her BP dropped to as low as 53 systolic. These
values were only minimally responsive to a total of 3L of IVF,
and 7.5 metoprolol IV.
Several prolonged discussions were had with the patient and her
daughter [**Name (NI) 5731**], as well as her friend [**Name (NI) **], addressing code
status, beginning on her day of transfer to the MICU and
continuing throughout her stay. The patient was uncertain what
exactly she would want done and had difficulty with this
conversation, but did express several times that she did not
want to be intubated. At the time of her hypotension, the
patient was not able to communicate her wishes. Per discussion
with the overnight ICU attending, the patient's daughter, and
the resident on-call who was quite familiar with the patient and
her daughter, the patient was made DNR/DNI and the decision was
made not to insert a central line but to give support IVF only.
The patient's BP remained low, staying in the 60s for several
hours with minimal UOP. She remained on bipap and became less
responsive over the several hours. Her bipap was eventually
removed at her daughter's request. The patient became apneic
and was pronounced at 3:15am on [**2106-11-15**].
Medications on Admission:
Celexa 15 mg daily
Lopressor 12.5 mg PO TID
Norvasc 2.5 mg daily
Atrovent nebs [**Hospital1 **]-TID prn
Actonel 35 mg PO Qweek (Sun)
Lorazepam 0.5 mg PO BID-TID prn
Neurontin 300 mg PO BID
Darvocet 100 mg PO TID
Pepcid 20 mg daily
Colace 200 mg daily
Tums [**Hospital1 **]
Vitamin D 400 units daily
NaCl 1gm daily
Discharge Medications:
none
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnosis: Back Pain & Pneumonia, MRSA sepsis
.
Secondary Diagnosis:
1. Depression
2. COPD/BRONCHIECTASIS
3. SIADH
4. RECTAL FISSURE
5. OSTEOPOROSIS
6. H/O HYPOTHYROIDISM
Discharge Condition:
deceased, DNR/DNI
Discharge Instructions:
deceased
Followup Instructions:
deceased
Completed by:[**2106-11-15**]
ICD9 Codes: 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1229
} | Medical Text: Admission Date: [**2132-12-7**] Discharge Date: [**2132-12-9**]
Date of Birth: [**2087-5-18**] Sex: F
Service: Medicine
HISTORY OF THE PRESENT ILLNESS: Mrs. [**Known lastname 109075**] is a
45-year-old woman with a psychiatric history significant for
major depression with multiple psychiatric admissions,
section 12 admissions, and suicidal attempts and admission
for suicidal ideation, as well as posttraumatic stress
from her apartment stating that she needed "detoxification"
and she was found by the paramedics curled in the fetal
position surrounded by alcohol bottles. She was transported
to [**Hospital1 69**] Emergency Department
for treatment, where she was found to have a blood alcohol
level of 390. Decision was made to admit her to the medical
intensive care unit. The patient stated that she had been
is homesick. She states that she lives in [**Location 81834**], but came to
[**Location (un) 86**] to settle legal issues, but this has been a frustrating
process. She denied that the drinking was a suicidal attempt,
and she denied that she has ever tried to kill herself.
However, she has an extensive medical record in the medical
record system detailing her past medical history of psychiatric
illness going back to [**2123**]. She was most recently admitted to
the psychiatric service in [**2131-4-11**] under a section 12 an
inability to care for herself and resumption of drinking and
noncompliance with her medical regimen. At this point, she was
restarted on her psychiatric medications with good results, and
she was discharged in good condition with plans for followup to
come into [**Location (un) 86**] on a daily basis for treatment.
Again, at the time of this admission, the patient denied any
of this history and, in fact, states at this point that she
was living in Maui and only moved to [**Location (un) 86**] about one year
ago.
PAST MEDICAL HISTORY:
1. Major depression with multiple psychiatric admissions, as
well as Section 12 admissions.
2. Multiple suicidal attempts.
3. Posttraumatic stress disorder followed at [**Hospital6 14430**] by Dr. [**First Name8 (NamePattern2) 8513**] [**Last Name (NamePattern1) **].
4. Alcohol abuse, withdrawal seizures and hallucinations.
ALLERGIES: The patient is allergic to SUDAFED.
MEDICATIONS: (on admission) Klonopin 1-g p.o. b.i.d. (per
patient).
FAMILY HISTORY: The mother and sister have major depression.
SOCIAL HISTORY: Alcoholism. The patient denies tobacco and
other drugs.
LABORATORY DATA: Data revealed the WBC of 7.0; hematocrit
36.9; platelet count 113; sodium 145; potassium 3.8; chloride
108; bicarbonate 30; BUN 4; creatinine 0.5; glucose 98; ALT
105; AST 114; alkaline phosphatase 86; amylase 35; lipase 27;
albumin 4.1; lactate 1.9; free calcium 1.0; blood osmolality
395. Toxicology screen was positive for alcohol with a level
of 391, negative for aspirin, acetaminophen,
benzodiazepines, barbiturates, tricyclics, cocaine,
amphetamine, or methadone. PT 12.3, PTT 29.2, INR 1.0.
Chest x-ray showed a right to mid lower lung zone opacity
likely a focus of aspiration. Endotracheal tube was in good
position. Head CT without contrast, no evidence of
intracranial hemorrhage, otherwise, unremarkable.
PHYSICAL EXAMINATION: Examination on admission revealed the
following: VITAL SIGNS: Stable. Temperature 98.2; blood
pressure 111/75; heart rate 73, on ventilator. GENERAL:
Cachectic, responsive to commands. Pupils equal, round, and
reactive to light. Oropharynx clear. Left ear with scabs
and dried blood. Head without evidence of trauma. Gag
reflex showed no lymphadenopathy, no thyromegaly. HEART:
Carotid revealed DP and femoral pulses 2+, no carotid bruits.
LUNGS: Lungs were clear to auscultation bilaterally with goo
breath sounds. ABDOMEN: Soft, nontender, and nondistended.
No hepatosplenomegaly. Normal bowel sounds. EXTREMITIES:
Without edema. SKIN: Skin was significant for multiple
cigarette-sized burn scars, no notable ecchymosis, no rash.
EKG: Normal sinus rhythm, normal axis, no acute ischemic
changes, no Q waves, no flipped T waves, unchanged from
previous EKG of [**12-1**].
HOSPITAL COURSE: While in the emergency department the
patient suddenly became apneic and was emergently intubated.
This was found to be secondary to her acute ethanol
intoxication. She was admitted directly to the Medical
Intensive Care Unit for further management. In the Medical
Intensive Care Unit she received Valium per CIWA scale, as well
as fluid replacement, thiamine, multivitamins, and folate. She
had no evidence on her laboratory examination of alcohol
ketoacidosis. She was placed on Zantac 50 mg q.8h. for GI
prophylaxis. The next morning the patient spontaneously self
extubated without complication. Her mental status was clear, and
she was transferred to the floor.
The patient was seen by the Psychiatric Service for
evaluation. The patient was felt to have alcohol dependence
with two weeks of very poor self care and increased alcohol
use. It was felt that she would need psychiatric admission
once she was stabilized medically, and she was less sedated.
The TSH, RPR, B12 and folate were sent to rule out other
causes of mental-status changes. There are pending.
She was noted to have a platelet count of 75 on transfer to
the floor. This was felt to be secondary to both her chronic
and acute alcohol use, as well as potentially to her having
been started on Zantac. The Zantac was stopped and she was
started on Protonix. The following day, the platelet count
was 87. In the Intensive Care Unit she was noted to have a
CK of 562 on the 26th, and 773 on the 28th; felt to be either
secondary to a fall while inebriated or possibly seizure. It
was rechecked on the 30th and it was 191. She had negative
troponin and negative MBs, thus ruling out myocardial injury .
The hematocrit decreased over the period of her admission from 36
on the day of admission to 31 on the day of this dictation. It
was felt that this change was due to her extensive IV hydration.
She was also noted to have hepatitis C infection, with a viral
load of 86K. However, given her alcohol abuse, she is not a
candidate for therapy at this time. However, she should be
immunized for hepatitis B to prevent coinfection.
She was discharged to the psychiatric service for further
management of her psychiatric issues.
DISCHARGE DIAGNOSES:
1. Acute alcohol intoxication.
2. Major depression.
3. Posttraumatic stress disorder.
4. Hepatitis C infection
[**Name6 (MD) **] [**Name8 (MD) **], M.D. 12- AAD
Dictated By:[**Name8 (MD) 4733**]
MEDQUIST36
D: [**2132-12-7**] 16:50
T: [**2132-12-10**] 10:55
JOB#: [**Job Number 109076**]
ICD9 Codes: 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1230
} | Medical Text: Admission Date: [**2154-10-21**] Discharge Date: [**2154-10-27**]
Date of Birth: [**2094-3-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 562**]
Chief Complaint:
Reason for transfer : respiratory failure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
60 yo M w/PMHx sx for asthma, atrial fibrillation, bronchitis,
HTN, Pt presented to ED c left sided chest pain/pressure since 4
am today. Pain is described as stabbing , exacerbated by deep
inspiration and focal palpation over one of his ribs. Patient
has been having SOB on minimal activity such as getting up from
bed.
He has been using his inhalers more frequently. Has also been
having cough for the last 3 days and feeling "wheezy". Denies
fevers, nasal congestion, , chills, diarrhea, n/v, abdominal
pain, BRBPR.
.
In ED he was found to be febrile up to 100.3 , tachycardic
(afib)120,w/SBP95, SpO2 went to 88 % on minimal exercise (he was
on 3 lt NC). SpO2 back to 95% . CxR showed a L sided pleural
effusion. He received 1L LR, levofloxacin. He was administered
methylprednisolone 100, ceftriaxone 1gm, azithromycin 500mg
through it. Combineb X 4 . RR much improved.
.
Past Medical History:
PMH:
.
-Intrinsic asthma w/chronic obstruction: Last spirometry shows
FEV1 of 1.78 liters, FEV1-to-FEC ratio of 59%
-Bronchiectasis
-AFib
-HTN
-Dyslipidemia
-Erectile dysfunction
-GERD
-Allergic rhinitis
-Last admitted to [**Hospital1 18**] [**Date range (1) 107189**] for severe gastroenteritis c/b
ARF
Pertinent Results:
[**2154-10-23**] 02:34AM BLOOD WBC-17.5* RBC-3.33* Hgb-11.3* Hct-33.6*
MCV-101* MCH-34.0* MCHC-33.7 RDW-14.9 Plt Ct-187
[**2154-10-22**] 04:43PM BLOOD Hct-31.2*
[**2154-10-22**] 03:04AM BLOOD WBC-20.8* RBC-3.39* Hgb-11.4* Hct-33.8*
MCV-100* MCH-33.8* MCHC-33.9 RDW-14.9 Plt Ct-199
[**2154-10-21**] 11:23AM BLOOD WBC-16.3*# RBC-4.09* Hgb-13.9* Hct-40.0
MCV-98 MCH-34.0* MCHC-34.7 RDW-14.7 Plt Ct-263
[**2154-10-23**] 02:34AM BLOOD Plt Ct-187
[**2154-10-23**] 02:34AM BLOOD PT-16.9* PTT-28.6 INR(PT)-1.6*
[**2154-10-22**] 04:43PM BLOOD PTT-133.8*
[**2154-10-22**] 03:04AM BLOOD Plt Ct-199
[**2154-10-22**] 03:04AM BLOOD PT-17.1* PTT-28.5 INR(PT)-1.6*
[**2154-10-23**] 02:34AM BLOOD Glucose-157* UreaN-10 Creat-0.8 Na-142
K-3.6 Cl-103 HCO3-31 AnGap-12
[**2154-10-22**] 03:04AM BLOOD Glucose-189* UreaN-11 Creat-0.8 Na-140
K-3.8 Cl-104 HCO3-27 AnGap-13
[**2154-10-23**] 02:34AM BLOOD Calcium-8.0* Phos-2.7 Mg-2.1
[**2154-10-22**] 03:04AM BLOOD Calcium-7.5* Phos-2.5*# Mg-1.6 Iron-18*
[**2154-10-22**] 03:04AM BLOOD calTIBC-268 VitB12-388 Folate-11.4
Ferritn-404* TRF-206
[**2154-10-21**] 05:05PM BLOOD Type-ART pO2-82* pCO2-34* pH-7.51*
calTCO2-28 Base XS-3 Intubat-NOT INTUBA
[**2154-10-21**] 05:05PM BLOOD Lactate-2.9*
[**2154-10-21**] 11:22AM BLOOD Lactate-3.4* K-3.6
Brief Hospital Course:
A/P: 60M w/MMP including asthma, atrial fibrillation,
HTN, dyslipidemia and h/o prostate cancer here w/focal rib pain
and PNA w/effusion improved on antibiotics, steroids, and nebs.
#PNA: Patient had LLL infiltrate with L sided pleural effusion.
Most likely CAP c parapneumonic effusion. WBC elevation trended
down and pt has remained afebrile. Pt had elevation of BNP but
no other sx of heart failure. Patient's last HIV (-) in [**2154**],
unlikely PCP. [**Name10 (NameIs) **] scan neg for PE, viral panal neg and legionella
negative. Pt has h/o treated prostate ca treated with
prostatectomy 3 years ago and has has low PSA since then, here
PSA <0.1, unlikely metastatic and LN stable from last CT in
[**1-11**]. Pt was started on levaquin but given possible interaction
with sotalol for QT prolongation pt was switched to ceftriaxone
and doxy x 2 days and then was changed to PO doxy and augmentin
to go home.
.
# Respiratory failure : Patient had respiratory failure in
setting of COPD, bronchiectasis. Has has neg w/u for vasculitis,
alpha 1 anti-trypsin, and APBA. Has FVC/FEV1 59 %. Now decreased
SOB and stable on 4liters. Was started on steriods x 1 day in
ICU then d/c. Pt has exp wheeze but may be sign of airways
opening. Pt was started on prednisone 60mg with significant
improvement in just one day and will go home on O2, steroid
taper, and home neb treatments. Pt will also have pulm [**Hospital 3782**]
rehab and close follow up with Dr. [**Last Name (STitle) **].
# Chest pain-. Most likely [**2-7**] pna/efussion. CAD was considered
but CE neg x 3. CTA neg for PE. BNP elevated without a baseline,
echo in [**12-10**] showed NL EF(>55%) and a small ASD, question of
whether there is some component of heart failure related to his
SOB. was pain free at discharge with no changes in EKG.
# Afib: Initial EKG most c/w A flutter. Sotalol was initially
held [**2-7**] low BP but now restarted. Pt converted to sinus rhythm
in ICU. Coumadin was subtheraputic on admission 1.5, comadin
dose varied and pt was started on [**3-7**] but now change to 5mg
daily since subtheraputic. Heparin was initially started for
possible PE but was stopped on [**10-22**]. Pt sent home on coumadin
5mg QD with a lab check in 4 days. He remained in NSR.
.
# Hypotension on admission: Patient's BP recovered on arrival to
MICU.Lactate of 3.4 most c/w early sepsis. Stim test (-). BP
stable throughout hospital stay with IVFs and abx.
#Hypophosphatemia: Initially slightly low was replaced, now
stable
#Anemia: Normo/macrocytic, HCT stable throughout course, B12 and
folate levels normal, with high normal ferritin. Most likely
anemia of chronic disease.
.
#Prostate CA- PSA <0.1.
Dispo: home with oxygen and close follow up
Medications on Admission:
Advair 500/50 one inhalation twice daily
Combivent two puffs PRN
Flonase
Singulair 10mg QPM
Coumadin-varies
Protonix 40 mg in PM
diltiazem xt 180
Cozaar 50mg QD
Lasix 40 mg daily
sotalol 120 [**Hospital1 **]
Lescol 40 QPM
MVI
Potassium gluconate 595mg QAM
Androgel 1% QAM
Viagra 100mg
Cialis 20mg
Levitra 20mg
Discharge Medications:
1. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day).
9. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 8 days: Finish [**11-3**].
12. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 8 days.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6hr PRN as needed for cough.
14. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4-6hr prn as needed for cough.
15. Prednisone 10 mg Tablet Sig: as directed Tablet PO taper for
5 days: Day 1: 5 tabs QD
day 2: 4 tabs QD
day 3: 3 tabs QD
day 4: 2 tabs QD
day 5: 1 tab QD then stop.
16. Outpatient Lab Work
Go to Dr.[**Name (NI) 107190**] office on [**10-29**] to have your INR drawn.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 6549**] Medical
Discharge Diagnosis:
Primary: pneumonia
Secondary: asthma, anemia, atrial fibrillation
Discharge Condition:
stable
Discharge Instructions:
Finish the course of antibiotics for your pneumonia, use the
oxygen during the day and at night until you see your primary
care doctor or pulmonary doctor.
Finish the steroid taper as directed.
Continue to use your CPAP machine at night.
Take Coumdain 5mg daily until you see Dr. [**Last Name (STitle) 2392**] this week.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) 2392**] this week to have you coumadin levels
checked [**Telephone/Fax (1) 30015**].
You other following appointments are:
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3172**]/DR. [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2154-11-6**] 11:00
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2154-11-8**] 10:10
Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING
Date/Time:[**2154-11-8**] 10:30
ICD9 Codes: 486, 2859, 4019, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1231
} | Medical Text: Admission Date: [**2149-4-22**] Discharge Date: [**2149-5-2**]
Date of Birth: [**2075-11-24**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
Third Ventriculostomy
History of Present Illness:
HPI: Ms. [**Known lastname 78196**] is a 73 y/o female who was running outside on
[**2149-4-21**]. She stopped on a hard surface and fell forward
resulting
in hand lacerations, facial lacerations, and bilateral
mandibular
condyle fractures. She was taken to outside hospital where head
CT suggested bilateraly posterior fossa hyperdensities. She was
confused and amnestic to the event at that time, and she was
transferred to [**Hospital1 18**] ER for higher level of care. At [**Hospital1 18**] she
appeared to remember the details of the fall, and described a
history of breast cancer with bilateral mastectomies. Head CT
from OSH was suspicious for mass lesions with effacement of
fourth ventricle.
Past Medical History:
PMHx:
hypertension
diabetes type 2
breast cancer
PMHx:
hypertension
diabetes type 2
breast cancer
PSHx:
bilateral mastectomies [**2131**] and [**2140**]
Social History:
Social Hx:
lives alone, admits to 1-1/2 packs of cig. per week, no EtOH or
IVDU
Family History:
Family Hx:
noncontributory
Physical Exam:
on arrival
PHYSICAL EXAM:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-16**] bilaterally EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-17**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
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 [**5-19**] throughout, but unable to test
bilateral grip strenght effectively due to hand abrasions and
dressing. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Pertinent Results:
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2149-4-21**] 11:43 PM
CHEST (PORTABLE AP)
Reason: trauma series
[**Hospital 93**] MEDICAL CONDITION:
73F transferred from [**Location (un) **] s/p fall, w facial fx, lip lac,
cerebral contusion
REASON FOR THIS EXAMINATION:
trauma series
INDICATION: 73-year-old woman transferred from [**Location (un) 8641**] status
post fall, facial fractures, cerebral contusion.
COMPARISON: None.
AP UPRIGHT CHEST: The cardiac silhouette is at the upper limits
of normal. The thoracic aorta is slightly unfolded. The lungs
appear clear. There is mild cephalization of the pulmonary
vasculature. No pleural effusions are seen. There are clips
noted in the right axilla. No displaced rib fractures are seen.
IMPRESSION: Mild cephalization of pulmonary vasculature without
frank pulmonary edema.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 15097**] L. [**Doctor Last Name **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**]
Approved: TUE [**2149-4-22**] 7:43 AM
Cardiology Report ECG Study Date of [**2149-4-21**] 11:35:44 PM
Sinus bradycardia. Non-specific junctional ST segment changes.
Baseline
artifact. No previous tracing available for comparison.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] D.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
58 150 84 452/448 99 -7 33
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2149-4-22**] 3:57 PM
CT HEAD W/O CONTRAST
Reason: Intracranial bleed?
[**Hospital 93**] MEDICAL CONDITION:
73 year old woman s/p fall with bilateral mandibular condyle
fractures. Multiple cerebellar masses on CT.
REASON FOR THIS EXAMINATION:
Intracranial bleed?
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 73-year-old woman status post fall and multiple
cerebellar
masses. Please evaluate for intracranial hemorrhage.
TECHNIQUE: Routine non-contrast head CT.
COMPARISONS: MR [**Name13 (STitle) 430**] [**2149-4-22**], and outside hospital CT dated
[**2149-4-21**].
FINDINGS: As noted on the prior CT and MRI performed prior to
this
examination, there are multiple masses seen best in the
posterior fossa with
surrounding vasogenic edema and mass effect on the fourth
ventricle. These
masses were better evaluated on the MRI performed prior to the
study. There
is a small focus of hemorrhage in the subependymal/ventricular
system in the
occipital [**Doctor Last Name 534**] of the left lateral ventricle, which is increased
in size since
the outside hospital CT dated [**2149-4-21**] at 18:49, approximately 24
hours earlier.
This may represent evolution of post-traumatic hemorrhage given
the patient's
recent fall. Alternatively, this could represent hemorrhage of a
subependymal
metastasis although an enhancing lesion is not seen in this
region on the MRI
performed prior to this study. No other foci of hemorrhage are
identified.
There is no midline shift. Again noted is prominence of the
ventricles and
sulci. There is effacement of the fourth ventricle and
prepontine cisterns.
The surrounding osseous and soft tissue structures are otherwise
unremarkable.
The imaged paranasal sinuses are well aerated.
IMPRESSION:
1. In comparison to the outside hospital CT performed
approximately 24 hours
earlier, there has been interval increase in hemorrhage in the
region of the
posterior [**Doctor Last Name 534**] of the left lateral ventricle. This hemorrhage is
not
significantly changed in comparison to the MRI performed prior
to this exam.
2. Multiple mass lesions seen best in the posterior fossa with
surrounding
vasogenic edema are consistent with metastatic disease, which
was better
evaluated on the preceding MRI.
3. Prominence of the ventricles and sulci may be related to
age-related
involutional change; however, given the mass effect on the
fourth ventricle,
obstructing hydrocephalus may be evolving and close clinical
followup is
recommended.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5998**]
DR. [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) 11137**]
Approved: WED [**2149-4-23**] 8:21 AM
RADIOLOGY Final Report
MR HEAD W & W/O CONTRAST [**2149-4-22**] 2:06 AM
MR HEAD W & W/O CONTRAST
Reason: further elucidate intracranial hemorrhage vs. mass
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
73F transferred from [**Location (un) **] s/p fall, w facial fx, lip lac,
cerebral contusion
REASON FOR THIS EXAMINATION:
further elucidate intracranial hemorrhage vs. mass
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Status post fall with facial fractures.
TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained
through the head without and with intravenous contrast.
Diffusion-weighted images were obtained.
COMPARISONS: Outside hospital examination from [**2149-4-21**].
MR HEAD WITHOUT AND WITH CONTRAST: There are multiple enhancing
lesions throughout the brain, the largest of which are within
the posterior fossa. The largest lesion measures 4.2 x 3.4 cm
within the left cerebellar hemisphere. There is a 1.6 x 2.8 cm
enhancing lesion within the right cerebellar hemisphere
inferiorly and a 2.7 x 3.7 cm lesion in the right cerebellar
hemisphere superiorly. There is a 1.5 x 1.9 cm lesion centered
in the cerebellar vermis. There is a 1.0-mm lesion in the left
temporal lobe inferiorly and multiple smaller subcentimeter
lesions within the remainder of the temporal lobe. In the
posterior right frontal lobe is a 1.1-cm enhancing lesion.
Multiple smaller subcentimeter lesions are seen throughout the
frontal lobe, many of which are rim-enhancing. All of these
lesions demonstrate surrounding vasogenic edema. Multiple
lesions within the posterior fossa are heterogeneous in signal
intensity and enhancement characteristics which may reflect
underlying necrosis or calcification. There is a lesion in the
subependymal region of the left posterior occipital [**Doctor Last Name 534**] which
demonstrates increased susceptibility on gradient echo
consistent with hemorrhage.
There is effacement of the prepontine cisterns. The fourth
ventricle is narrow, however, there is no evidence for tonsillar
herniation at this time. There is no subfalcine herniation.
The ventricles and sulci are mildly prominent.
There are scattered T2 hyperintense foci in the periventricular
white matter consistent with small vessel ischemic changes.
The surrounding osseous and soft tissue structures are
unremarkable. The imaged paranasal sinuses are well aerated.
IMPRESSION:
1. Multiple large enhancing masses throughout the brain
parenchyma most consistent with metastatic disease. The largest
lesion is in the left cerebellar hemisphere and measures up to
4.2 cm. There is effacement of the prepontine cisterns and the
fourth ventricle, however, there is no evidence of tonsillar
herniation at this time. Prominence of the ventricles and sulci
may be related to age-related involutional change; however,
close followup is recommended to exlude developing
hydrocephalus.
2. Small focus of subependymal hemorrhage in the left posterior
occipital [**Doctor Last Name 534**] may represent a hemorrhage within a metastasis.
No other foci of hemorrhage are identified. This appears grossly
similar in size when compared to the outside hospital CT from
yesterday.
INDICATION: 73-year-old woman status post fall and multiple
cerebellar masses. Please evaluate for intracranial hemorrhage.
TECHNIQUE: Routine non-contrast head CT.
COMPARISONS: MR [**Name13 (STitle) 430**] [**2149-4-22**], and outside hospital CT dated
[**2149-4-21**].
FINDINGS: As noted on the prior CT and MRI performed prior to
this examination, there are multiple masses seen best in the
posterior fossa with surrounding vasogenic edema and mass effect
on the fourth ventricle. These masses were better evaluated on
the MRI performed prior to the study. There is a small focus of
hemorrhage in the subependymal/ventricular system in the
occipital [**Doctor Last Name 534**] of the left lateral ventricle, which is increased
in size since the outside hospital CT dated [**2149-4-21**] at 18:49,
approximately 24 hours earlier. This may represent evolution of
post-traumatic hemorrhage given the patient's recent fall.
Alternatively, this could represent hemorrhage of a subependymal
metastasis although an enhancing lesion is not seen in this
region on the MRI performed prior to this study. No other foci
of hemorrhage are identified. There is no midline shift. Again
noted is prominence of the ventricles and sulci. There is
effacement of the fourth ventricle and prepontine cisterns. The
surrounding osseous and soft tissue structures are otherwise
unremarkable. The imaged paranasal sinuses are well aerated.
IMPRESSION:
1. In comparison to the outside hospital CT performed
approximately 24 hours earlier, there has been interval increase
in hemorrhage in the region of the posterior [**Doctor Last Name 534**] of the left
lateral ventricle. This hemorrhage is not significantly changed
in comparison to the MRI performed prior to this exam.
2. Multiple mass lesions seen best in the posterior fossa with
surrounding vasogenic edema are consistent with metastatic
disease, which was better evaluated on the preceding MRI.
3. Prominence of the ventricles and sulci may be related to
age-related involutional change; however, given the mass effect
on the fourth ventricle, obstructing hydrocephalus may be
evolving and close clinical followup is recommended.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5998**]
DR. [**First Name8 (NamePattern2) 11136**] [**Last Name (NamePattern1) 11137**]
Approved: TUE [**2149-4-22**] 8:48 PM
RADIOLOGY Final Report
HAND (AP, LAT & OBLIQUE) BILAT [**2149-4-22**] 2:37 AM
HAND (AP, LAT & OBLIQUE) BILAT
Reason: eval for fractures
[**Hospital 93**] MEDICAL CONDITION:
73 year old woman with s/p fall from standing, ttp diffusely
over dorsum of hands bilaterally
REASON FOR THIS EXAMINATION:
eval for fractures
INDICATION: 73-year-old woman status post fall, diffusely tender
to palpation over the dorsum of the hands bilaterally.
BILATERAL HANDS, SIX VIEWS:
On the left, the patient is unable to straighten the fourth
digit at the PIP joint, subluxation/dislocation in this region
cannot be excluded. No other area concerning for fracture or
malalignment is identified. There is a well corticated osseous
density along the volar region of the fourth middle phalanx,
perhaps related to prior trauma, but incompletely evaluated.
On the right, the patient is unable to straighten her third
digit at the PIP joint, no other area concerning for fracture or
dislocation is identified. There are vascular calcifications
noted. The bones have a patchy appearance, which may relate to
demineralization.
IMPRESSION: At least subluxation of the PIP joints in the left
fourth and right third digits. This suggests unopposed flexor
muscles possibly due to extensor injury. The bilateral nature is
peculiar. Please correlate with exam. No fracture identified.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 15097**] L. [**Doctor Last Name **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7411**]
Approved: TUE [**2149-4-22**] 7:58 AM
NOTE: TEAM NEUROSURGERY:
NONE OF THE [**2149-4-24**] AND LATER STUDIES WERE ADDED [**2-15**] NOT BEING
FINALIZE
Brief Hospital Course:
Ms. [**Known lastname 78196**] was admitted to the neurosurgery service on [**2149-4-22**]
after falling while running outside. Her initial head CT showed
masses in her posterior fossa. The patient initially had
multiple bruises on her face, she sustained bilateral mandibular
condyle fractures, and had lacerations on her hands. After being
admitted to the TSICU, the patient was able to recall the events
leading to her fall and was able to give a past medical history
including bilateral mastectomies. Several hours after admission,
she became agitated, confused and had a repeat head CT which
showed a new small hemorrhage in the left ventricle. She
received a low dose of haldol in order to allow her to tolerate
the head CT.
On [**2149-4-22**], a radiation oncology consult was obtained and they
recommended whole brain radiation. On the same day OMF consult
was obtained. They stated that there was no surgery needed at
the time for her mandibular fractures and recommended keeping
her NPO initially.
On [**2149-4-23**] the patient was transferred to the neuro step-down
unit. Her mental status waxed and waned and she required some
additional doses of haldol in order to keep her from falling out
of bed. Her sister in [**Name (NI) 108**] was contact[**Name (NI) **] and she gave consent
over the phone for the patient to have a 3rd ventriculostomy
placed.
On [**2149-4-24**] the patient had a CT chest which showed a 3-cm right
lower lobe mass lesion and extensive associated lymphadenopathy,
which was likely primary lung CA. There were also two liver
masses and extensive abdominal lymphadenopathy found. She had a
bone scan which showed no evidence of osseous metastatic
disease.
On [**2149-4-25**] the patient went to the OR for a 3rd ventriculostomy
which went well without complication. She was transferred back
to the step-down unit after recovering in the PACU. Her mental
status was improving and she was oriented x 3 post-operatively.
On [**2149-4-26**] the patient was transferred out of step-down to the
floor. Her diet was advanced to purred solids and thickened
liquids, which she tolerated well. Her mental status continued
to improve and she had a physical therapy evaluation. They
recommended rehab.
The patient was seen by social work to facilitate completing
health care proxy paperwork and to help deal with coping with
her illness.
On [**2149-4-28**] the patient continued to do well neurologically and
she was scheduled to begin radiation the following day. OMF was
contact[**Name (NI) **] again and they recommended increasing her diet to soft
solids and thin liquids. She will remain on this diet until they
see her in follow-up.
On [**4-29**] she was started on Keppra for seizure prophylaxis. She
also started XRT that day. The following day, she had been
scheduled for a lung biopsy to evaluate her multiple lesions,
however she then declined both the biopsy and radiation. These
were therefore canceled and there were extensive conversations
with the patient about her goals of care. She stated that she
did not want hospice and did not want further treatment, however
after discussion explaining that these interventions were
intended to provide her with additional comfort and care, she
agreed to continue with radiation. She stated she would also
consider the biopsy. On the 17th and 18th, she had radiation,
after which she was discharged to rehabilitation to continue
with her radiation, therapy and further discussion of possible
lung biopsy.
Medications on Admission:
glyburide
toprol XL
ASA
Discharge Medications:
1. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Fever/pain.
9. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Metastatic Brain Tumors
Discharge Condition:
neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
?????? Have a 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,
excessive bending
?????? You may wash your hair only after sutures have been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
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, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE RETURN TO THE OFFICE IN 7 DAYS FOR REMOVAL OF YOUR
SUTURES.
Call [**Telephone/Fax (1) 1669**] to make an appointment.
You need to follow up in the Brain [**Hospital 341**] Clinic located on the
[**Location (un) **] of the [**Hospital Ward Name 23**] Building on the [**Hospital Ward Name 516**]. Your
appointment is with [**Name6 (MD) 5005**] [**Last Name (NamePattern4) 5342**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2149-5-12**] 3:00 pm.
Follow-up with ORAL MAXILLOFACIAL [**Doctor First Name 147**] Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2149-5-15**] 2:00pm. The office is on the [**Hospital Ward Name 516**] -
[**Location (un) **] of the [**Hospital Ward Name 23**] Building in the Surgical Specialties
area.
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1232
} | Medical Text: Admission Date: [**2157-4-28**] Discharge Date: [**2157-5-16**]
Date of Birth: [**2098-5-16**] Sex: F
Service: CARDIAC SURGERY
HISTORY OF PRESENT ILLNESS: This is a 58-year-old female
with a known descending thoracic aneurysm who was referred to
[**Hospital6 256**] for cardiac
catheterization as part of her preoperative work up. The
patient reports a history of a myocardial infarction
appropriately 10 years ago with occasional chest discomfort.
It should be noted that the patient preoperatively was a poor
historian. The patient reported this was due to prior CVAs.
PAST MEDICAL HISTORY:
1. Hypertension
2. Hypercholesterolemia
3. Positive tobacco
4. Status post myocardial infarction approximately 10 years
ago
5. Anxiety
6. Chronic obstructive pulmonary disease
7. Chronic back pain
8. Status post multiple CVAs, most recently one year ago
9. Rheumatoid arthritis
10. Descending thoracic aneurysm approximately 6.3 cm
PAST SURGICAL HISTORY:
1. Status post cholecystectomy
2. Status post appendectomy
3. Status post tonsillectomy
4. Status post bilateral carotid endarterectomies
5. Status post hysterectomy
Preoperatively, the patient reported the residual deficits
from her CVA were occasional aphasia and poor memory.
ALLERGIES: No known drug allergies.
PREOPERATIVE MEDICATIONS:
1. Celebrex 200 mg po qd
2. Lopressor 100 mg po q a.m., 50 mg q p.m.
3. Plavix 75 mg po qd
4. Norvasc 5 mg po qd
5. Celexa 20 mg po qd
6. Hydrochlorothiazide 25 mg po qd
7. Darvocet prn
8. Alprazolam 0.5 mg po bid
9. Albuterol inhaler prn
10. Vanceril inhaler prn
PREOPERATIVE LABORATORY DATA: White blood cell count 10.2,
hematocrit 38.7, platelet count 271. Sodium 142, potassium
4.5, chloride 107, bicarbonate 30, BUN 17, creatinine 1.2,
glucose 128.
PREOPERATIVE Physical exam
VITAL SIGNS: Pulse 72, blood pressure 112/80, respiratory
rate 12.
HEAD, EARS, EYES, NOSE AND THROAT: Negative
NECK: Bilateral surgical scars. Carotids without bruit.
CHEST: Clear to auscultation. The patient was noted to have
erythema under both breasts and over the lower aspect of the
sternum thought to be due to fungal infection.
HEART: Regular rate and rhythm without murmur.
ABDOMEN: Obese, positive bowel sounds, nontender,
nondistended.
HO[**Last Name (STitle) **] COURSE: The patient was admitted to [**Hospital6 1760**] on [**2157-4-28**] for cardiac
catheterization. Cardiac catheterization showed left
ventricular ejection fraction of approximately 50%, 70% to
80% LAD lesion, 80% LCX lesion, 70% OM2 lesion, 90% RCA
lesion. The patient was taken to the Operating Room on
[**2157-4-29**] with Dr. [**Last Name (Prefixes) **] for a coronary artery bypass
graft x3, left internal mammary artery to ramus, saphenous
vein graft to PDA, saphenous vein graft to PL. Please see
operative note for further details. The patient as
transferred to the Intensive Care Unit on nitroglycerin,
milrinone and liquefied infusions. On the evening of
postoperative day 0, the patient was noted to have a
significant respiratory acidosis. Chest x-ray revealed a
left upper lobe collapse. The patient underwent bronchoscopy
which revealed a left upper lobe mucous plug which was
removed. Post bronchoscopy chest x-ray revealed mild
improvement in the aeration of the left upper lobe. The
patient initially had a low cardiac index which responded to
volume resuscitation and increasing the milrinone infusion.
On postoperative day #1, the patient underwent repeat
bronchoscopy which showed mild bilateral tracheobronchitis
and again a mucous plug in the left upper lobe which was
removed. The patient was continued on a propofol infusion
through the first postoperative day due to patient tenuous
respiratory status. On postoperative day #2, the patient's
propofol was weaned to off at which time the Levophed
infusion was discontinued as patient's blood pressure
increased and the patient was subsequently placed on
nitroprusside infusion to maintain her systolic blood
pressure less than 130. The patient was noted to have a
cough and gag with suctioning. The patient was noted to move
head with noxious stimuli and pupils were 3 cm equal and
reactive to light, but it was noted that there was no
movement of arms or legs.
On postoperative day #3, the milrinone was weaned to off with
a continued adequate cardiac output and index. The patient
continued on nitroprusside infusion for blood pressure
control. The patient had been started back on Plavix for her
previous carotid endarterectomies and patient had improving
respiratory status and was able to decrease the ventilatory
support, however the patient continued to have decreased
neurologic function and a neurology consult was obtained and
a head CT scan was obtained. CT scan of the head showed a
ACA hypodensity bilateral watershed hypodensity extending
posteriorly on the left and an old cerebellar stroke. Her
neurologic exam on postoperative day #3 was no spontaneous
eye opening, however opened eyes to noxious stimuli. The
patient had positive corneal reflex, positive gag reflex,
withdrew all limbs weakly to noxious stimuli. Neurology felt
that it was unclear whether or not that patient's status was
due to her preoperative neurologic findings or a new
neurologic event and requested an EEG to rule out subclinical
seizure activity.
On postoperative day #4, the patient underwent EEG study
which showed no epileptic features, generalized swelling with
suggestion of encephalopathic condition. On neurologic exam,
it was noted that the patient had bilateral Babinski sign.
The patient was started on enteral nutrition on postoperative
day #4. The patient had a sputum culture sent for increasing
tracheal secretions which subsequently are positive for
Haemophilus influenza and Pseudomonas. The patient was
started on levofloxacin and ceftazidine for double coverage
of the Pseudomonas. On postoperative day #4, the patient was
started on Lopressor for control of hypertension, as well as
placed on Isordil. The patient's neurologic status slowly
progressed on postoperative day #6. Patient opened eyes to
voice, but did not track.
On postoperative day #9, it was noted that the patient stuck
out her tongue to command and was able to track movement with
her eyes. It was felt by the neurology service that due to
the patient's early improvement in the first week,
substantial recovery over the next few weeks to months was
possible and it was decided that the patient would undergo
tracheostomy and PEG placement and would be evaluated for
neurologic rehabilitation. On [**2157-5-9**], the patient
underwent placement of tracheostomy percutaneously by Dr.
[**Last Name (STitle) 952**]. A 7.0 Portex as well as a PEG placement. After the
tracheostomy placement, the patient as noted on chest x-ray
to again have a whiteout of the left side and underwent
bronchoscopy for large amounts of bloody secretions.
Subsequent chest x-ray was improved.
On postoperative day #11, the patient underwent a psychiatry
consultation. As the patient has a history of anxiety, it
was thought that the patient has a combination of delirium
and dementia complicated by encephalopathy and it was
recommended to continue the present management. The patient
underwent repeat bronchoscopy on postoperative day #11 which
showed relatively clear airways, clear secretions, no plugs
in the left upper lobe.
On postoperative day #12, the patient was tracking with her
eyes, inconsistently following commands, non purposeful upper
body movement. The patient remained hemodynamically stable
and weaning on the ventilator. On postoperative day #12,
neurology evaluated the patient and felt that she would
continue to improve over the next several weeks and
recommended once the patient was in a rehabilitation facility
she could benefit from a dopamine agonist such as
bromocriptine 2.5 mg q day and slowly titrate over several
weeks to about 20 mg per day. The patient's ventilator had
been weaned down to pressure support ventilation which she
has tolerated well.
On [**5-16**], postoperative day #17, the patient was accepted at a
rehabilitation facility and was clear for discharge to
rehabilitation facility.
DISCHARGE CONDITION: T-max 99.3??????, pulse 84 in sinus rhythm,
blood pressure 139/83, respiratory rate 23, oxygen saturation
95%. The patient is on the ventilator via tracheostomy.
Pressure support ventilation 50% FIO2, PEEP of 5, pressure
support of 12. Tidal volumes about 400. Neurologically, the
patient opens eyes to voice, tracks visual stimuli,
occasionally will follow commands by sticking out tongue,
although inconsistently. The patient has non purposeful
movements of her upper extremities and will withdraw her
lower extremities to pain. Cardiovascular regular rate and
rhythm without rub or murmur. Lungs - breath sounds are
coarse with scattered wheezes and rhonchi throughout. The
patient is being intermittently suctioned for small amounts
of yellow secretions. The patient's last sputum culture from
[**5-6**] showed sparse growth of Pseudomonas. Abdomen is obese,
positive bowel sounds, nondistended. PEG tube is in place
without erythema or drainage. The patient is tolerating tube
feeds ProMod with fiber at 55 cc an hour.
LABORATORY DATA FROM [**2157-5-16**]: White blood cell count 8.8,
hematocrit 32.6, platelet count 356. Sodium 138, potassium
4.4, chloride 102, bicarbonate 25, BUN 23, creatinine 0.6,
glucose 138. The patient's sternal incision is clean and dry
without erythema. Sternum is stable. The patient's vein
harvest site is clean and dry without erythema or drainage.
DISCHARGE MEDICATIONS:
1. Norvasc 5 mg per PEG qd
2. Celexa 20 mg quit
3. Combivent metered dose inhaler 2 puffs qid
4. Isordil 15 mg qd
5. Colace 100 mg qd
6. Prevacid 30 mg qd
7. Plavix 75 mg qd
8. Lopressor 50 mg tid
9. Levofloxacin 500 mg q 24 hours x5 days
10. Heparin 5000 units subcutaneous q 12 hours
11. Aspirin 325 mg qd
12. Ceftazidime 1 gm intravenous q8h x5 days
13. Nystatin swish and swallow 5 cc to mouth qid
14. Regular insulin sliding scale for blood sugar 150 to 200
give 3 units subcutaneous, for blood sugar 201 to 250 give 6
units subcutaneous, for blood sugar 251 to 300 give 9 units
subcutaneous, for blood sugar 301 to 350 give 12 units
subcutaneous.
VENTILATOR SETTINGS: CPAP FIO2 50%, PEEP 5, pressure support
12.
Th[**Last Name (STitle) 1050**] is to receive all medications via PEG tube. The
patient is to receive tube feeds ProMod with fiber at 55 cc
an hour via PEG tube. The patient is to follow up upon
discharge from rehabilitation with Dr. [**Last Name (Prefixes) **], as well
as her cardiologist. The patient is to be discharged to
rehabilitation in stable condition.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 3870**]
MEDQUIST36
D: [**2157-5-16**] 10:57
T: [**2157-5-16**] 11:03
JOB#: [**Job Number 42284**]
ICD9 Codes: 2762, 5185, 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1233
} | Medical Text: Admission Date: [**2159-6-25**] Discharge Date: [**2159-7-12**]
Date of Birth: [**2105-5-2**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
Ventricular fibrillation and cardiac arrest.
Major Surgical or Invasive Procedure:
Endotracheal intubation at outside hospital.
History of Present Illness:
Mr. [**Known firstname **] [**Known lastname **] is a 54 year-old gentleman with prior history
of mitral prolapse with myxomatous changes, dyslipidemia who
underwent a possible seizure and then a cardiac arrest with a
tachycardia who now is transfered to [**Hospital1 18**] for further care. Pt
was in his prior state of health and had a normal echocardiogram
and stress test 2 weeks ago (per Dr. [**Last Name (STitle) **] and Family) until
[**2159-6-23**] when he was about to interview for a new job. Patient
he was not having any abnormal movements and he did not loose
sphincter control. He did not have a pulse and was not
responsive. Vomit was found in his mouth. CPR was initiated.
When EMS arrived his HR was ~220s in AFib (per report) and
patient was shocked x2 without response. Pt received epinephrine
and atropine. Then he received lidocaine. Then he went into VFib
and was successfully shocked out of it. He was transferred to
the ER of [**Hospital 6136**] Hospital Group, his SpO2 was always >95%
per report. In the ER, his ECG showed sinus tachycardia with
RBBB, ST depression in lateral leads (V2-V6), QS in D3, AVF, D2.
His cardiac enzymes were negative, glucose was 330. Temp 39.4 C.
WBC 7.1, HGB 13.1, HCT 39.5, Trop 0.02. Na 141, K 2.8, Cl 107,
HCO3 12, Gap 22, Glucose 381, BUN 18, creatinine 1.2, calcium
8.1, albumin 3.6, alk phos 53, AST 248, ALT 259, CK 80, PT 12.6,
INR 1. CT scan did not show clearly C3-C4, so patient was kept
in collar. His tox-screen was positive for opioids and
canabinoids. Cool-down protocol was initiated and patient was
admitted to the ICU and kept on it for 24 hours.
He was minimally reponsive afterwards. Pt had serial ECGs that
showed multiple PVCs, changes in axis and AFib. His Trop I
peaked at 2.24 and CK at 5572 with MB of 36.2 and MBI 0.6%.
Patient underwent echocardiogram that shwoed EF 55%, LV mildly
dilated, no wall-motion abnormality, no intra-cardiac thrombus,
LA normal, bicuspid aortic valve, MR [**First Name (Titles) 151**] [**Last Name (Titles) 82966**] changes.
His LFTs were elevated to 300 range and 1:1 ratio, bilirubin of
2.0, albumin of 3.3 normal INR, that were thought to be
secondarely to shock liver. Pt had one episode of hematuria with
aspirin and lovenox, that was thought to be traumatic.
Pt was febrile up to [**Age over 90 **] yesterday and with WBC of 14,000.
Therefore, there was concerned for VAP and he was started on
Zosyn.
Past Medical History:
PAST CARDIOVASCULAR HISTORY:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
-CABG: None.
-PERCUTANEOUS CORONARY INTERVENTIONS: None.
-PACING/ICD:
PAST MEDICAL HISTORY:
Leaky valve disease since childhood? Reported MR [**First Name (Titles) 151**] [**Last Name (Titles) 82966**]
changes on OSH echocardiogram
Dyslipidemia
Social History:
Patient lives with his wife and 2 kids. He is currently
unemployed. He denies any current or past history of smoking. He
drinks alcohol (last drink [**2159-6-22**]) [**3-12**] drinks daily. Denies
any illegal drug use. No recent travel.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; Granfather and father with MI in 60s,
mother with [**Name2 (NI) 499**] cancer in 40s and brother with metastatic
melanoma.
Physical Exam:
On Admission:
VITAL SIGNS - Temp 97.8 F, BP 140/80 mmHg, HR 75 BPM, RR 16 X',
O2-sat 100% 35% intubated.
GENERAL - well-appearing man, sedated, comfortable, Mood.
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - bibasilary crackles and wheezes.
HEART - PMI located in 5th intercostal space, midclavicular
line. RRR, normal S1, S2. Systolic murmur [**1-12**] apex. No thrills,
lifts. No S3 or S4.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding. Abd aorta not enlarged by palpation. No
abdominial bruits.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), No c/c/e. No femoral bruits.
SKIN - no rashes or lesions. No stasis dermatitis, ulcers,
scars, or xanthomas.
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - responding to severe pain, not following commands,
sedated. Corneal reflex present, no gag reflex, constricted
pupils.
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:
[**2159-6-25**] 09:34PM WBC-11.3* RBC-4.14* HGB-12.5* HCT-37.1*
MCV-90 MCH-30.2 MCHC-33.7 RDW-13.7
[**2159-6-25**] 09:34PM NEUTS-90.2* LYMPHS-6.0* MONOS-3.1 EOS-0.6
BASOS-0.2
[**2159-6-25**] 09:34PM PLT COUNT-226
[**2159-6-25**] 09:34PM GLUCOSE-124* UREA N-12 CREAT-0.8 SODIUM-139
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14
[**2159-6-25**] 09:34PM GLUCOSE-124* UREA N-12 CREAT-0.8 SODIUM-139
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-23 ANION GAP-14
[**2159-6-25**] 09:34PM ALT(SGPT)-129* AST(SGOT)-116* LD(LDH)-506*
CK(CPK)-2909* ALK PHOS-69 TOT BILI-1.8* DIR BILI-0.5* INDIR
BIL-1.3
[**2159-6-25**] 09:34PM ALBUMIN-3.3* CALCIUM-8.1* PHOSPHATE-2.0*
MAGNESIUM-2.5 CHOLEST-178
[**2159-6-25**] 09:34PM LIPASE-19
[**2159-6-25**] 09:34PM CK-MB-6 cTropnT-0.04*
[**2159-6-25**] 09:34PM TRIGLYCER-242* HDL CHOL-39 CHOL/HDL-4.6
LDL(CALC)-91
[**2159-6-25**] 09:24PM TYPE-ART PO2-95 PCO2-36 PH-7.45 TOTAL CO2-26
BASE XS-1
CXR ([**2159-6-25**]): The heart size appears to be enlarged, which
might be exaggerated by the low lung volumes. There is left
retrocardiac opacity containing air bronchogram that might
represent infection, aspiration or combination of both as well
as atelectasis. The left hilus appears to be enlarged, which
might be due to low lung volumes and summation of shadows,
although left hilar abnormality cannot be excluded. The right
lung is grossly unremarkable. There is most likely present small
amount of pleural effusion. There is no pneumothorax, at least
within the limitations of this radiograph. Followup with chest
radiograph with better lung volumes is recommended or preferably
PA and lateral whenever patient conditions allow.
CXR ([**2159-7-2**]): Improved lung aeration without new acute
cardiopulmonary process.
Cardiac Cath ([**2159-6-26**]): 1. Coronary angiography in this right
dominantsystem demonstrated no flow obstructing lesions on
angiography. The LMCa had minimal luminal irregularities. The
LAD had mild luminal irregularities on angiography. The Cx had
no angiographically apparent disease. The RCA had a spasm in the
mid vessel that resolved during the catheterization and had no
angiographically apparent disease afterwards.
2. Resting hemodynamics revealed right sided filling pressures.
RVEDP
was 20mmHg. PCWP was slightly elevated at 17mmHg. There was mild
pulmonary artery hypertension with a systolic pressure of 49
mmHg.
3. Oxygen saturation revealed a step off between the SVC and all
[**Doctor Last Name 1754**] of the heart. However Qp/Qs ratio was 0.90 so no
intracardiac
shunt was calculated. FINAL DIAGNOSIS: 1. Coronary arteries are
normal. 2. Mild pulmary hypetension with PASP of 49mmHg 3.
Arterial shunt with step off from aorta to RA
ECHO ([**2159-6-26**]): The left atrium is normal in size. The
interatrial septum is aneurysmal. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated.
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
aortic root is moderately dilated at the sinus level. The
ascending aorta is mildly dilated. The aortic valve is bicuspid.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened and are
myxomatous. There is probable mild mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion. IMPRESSION: Suboptimal image quality. Moderately
dilated left ventricular cavity. Normal global and regional
biventricular systolic function. Aneurysmal interatrial septum
without evidence of intracardiac shunting by color Doppler or
saline administration (at rest). Probable mild mitral valve
prolapse with mild mitral regurgitation.
CT Head/Neck ([**2159-6-26**]): Diffuse loss of [**Doctor Last Name 352**]-white
differentiation with effacement of the sulci and ventricles.
Given clinical history, this is likely to reflect edema
secondary to anoxic brain injury. MRI is recommended for further
characterization as clinically indicated. NECK: 1. No evidence
for fracture or acute malalignment involving the cervical spine.
2. Mild-to- moderate cervical spondylosis causing mild spinal
canal stenosis.
CT Head ([**6-28**]): No significant interval change from previous
study.
CT Orbit ([**6-28**]): 1. Medialization of the right stapes prosthesis
2. Right otospongiosis. 3. Nonspecific inflammatory changes of
the right middle ear cavity and mastoid air cells. 4. Partial
opacification of the left mastoid air cells.
EEG ([**2159-7-1**]): Frequent ventricular ectopy is noted with an
otherwise
regular rhythm with an average rate of 72 beats per minute.
IMPRESSION: This is an abnormal routine EEG due to the slow
bifrontal
centrally predominant background which is suppressed more
posteriorly.
Compared to telemetry obtained on [**2159-6-29**], there are spike slow
wave
discharges followed by background suppression. These findings
suggest
either anoxic brain injury or potential for electrographic
seizures. No
electrographic seizures were seen in this recording.
EEG ([**2159-7-4**]): This is an abnormal video EEG study due to slow
bifrontal
centrally predominant background which is suppressed posteriorly
with
suppressive bursts and spike and slow wave discharges. Compared
to
routine EEG obtained on [**2159-7-1**], the study is of lower voltage
and
duration of suppressive bursts are increased. These findings
suggest
either anoxic brain injury or potential for electrographic
seizures. No
electrographic seizure was seen in this recording.
EEG ([**2159-7-5**]): This is an abnormal video EEG study due to slow
bifrontal
centrally predominant background which is suppressive with
bursts and
spike and slow wave discharges. Compared to telemetry obtained
on
[**2079-7-2**], the study is unchanged. These findings are suggestive
of
anoxic brain injury. No electrographic seizures were seen in
this
recording.
Brief Hospital Course:
Mr. [**Known firstname **] [**Known lastname **] is a 54 YO M wtih history of MVP and bicuspid
aortic valve s/p possible seizure and cardiac arrest with
subsequent elevation in cardiac enzymes and LFTs. No meaningful
change in neurologic status since admission (off all sedation).
.
#Anoxic Brain Injury: On admission patient was sedated after
cardiac arrest and subsequent intubation. In the CCU sedatives
were stopped yet the patient did not regain any meaninful
neurologic function. CT scan of the head was performed initially
and showed cerebral edema consistent with anoxic brain injury,
no bleed, herniation, or mass shift. Further, neurology was
consulted to help further evaluate the patient and give some
insight into prognosis. Neurology recommended MRI of the brain,
however this was not able to be performed secondary to stapedial
implant. Multiple video EEGs were performed and ruled out any
seizure activity. After this evaluation and 10 days without
sedation it was determined that the patient would never regain
any meaningful neurologic function. During family meetings
throughout this time the wife made it clear that her husband
would not want to be kept alive under these conditions. On [**7-6**]
the decision was made by the family to make the patient DNR/DNI,
extubate, and provide comfort measures only. Patient's
respiratory rate increased multiple times and patient then
presented [**Last Name (un) 6055**]-[**Doctor Last Name **] breathing. He was made comfrotable with
oral concentrated morphine. Palliative care / Hospice and social
work service were consulted and helped with morphine and comfort
measure management and other social issues. Patient expired on
[**2159-7-12**] at 2:35 AM peacefully and with his wife at the side.
PCP was informed.
.
#. Cardiac arrest - On admission the etiology of cardiac arrest
was unclear. On review of ECGs it appears that patient was
having wide-complex tachycardia at 220 BPM. Pt had BBB (left and
right varying from ECGs), which made ischemic changes difficult
to assess, but his cardiac enzymes did not suggest MI given the
pattern with Trop I of 2.24 and CK ~5500 with negative MBI.
Cardiac cath confirmed that patient was without coronary artery
disease. The etiology of arrest, remains somewhat unclear, but
there was report of atrial fibrillation per EMS report that may
have led to ventricular fibrillation. It is unclear if patient
had ventricular tachcyardia, atrial fibrillaiton with abnormal
ventricular conduction or bypass tract. Electrophysiology
service saw patient and recommended EP study and possible
ablation and ICD placement if patient's neurologic prognosis was
adequate. They also recommended that the patient be started on
beta blockers to control increased amount of ectopy with
frequent PVCs. Patient was monitored on telemetry and besides
frequent PVCs which improved with beta blockade there was no
arrhythmia noted.
.
#. CAD - On admission there was some question as to the etiology
of the patient's cardiac arrest. Patient had a normal stress
test 2 weeks prior to admission, with multiple ECG changes
including right and left bundle. On admission to outside
hospital had Trop I of 2.24 and CK of ~5500 with negative MBI.
At [**Hospital1 18**] patient went for cardiac catheterization which showed
no significant coronary artery disease. Patient was monitored on
telemetry and recieved serial ECGs. Cardiac Enzymes were trended
and continued to decrease sp arrest. Patient was initially
continued on ASA 325 mg but this was discontinued given
possibility of Trach/Peg placement. Patient's elevation in
cardiac enzymes was thought to be secondary to cardiac arrest.
.
#. Rhythm - On admission patient was in sinus rhythm with LBBB
morphology, but RBBB in multiple ECGs at other hospital. On
telemetry patient had frequent PVCs. Throughout the patients
admission electrolytes were followed closely and repleted
aggressively. Initially Metoprolol 25mg TID was started for this
increased ectopy and increased to 100mg TID. ECGs were monitored
daily for interval change. ECHO was performed which confirmed
the findings noted below. Electrophysiology was consulted and
recommended increased the beta blocker dose. EP would further
intervene if neurologic status improved.
#. Pump/Valvular disease - No signs of heart failure at this
time. Preserved EF. Dilated heart in echocardiogram in pt with
preserved EF, bicuspid AS and [**Hospital1 82966**] degeneration of mitral
valve. Given neurologic status valvular disease was not
addressed.
.
#. Fever - Status post cooling protocol WBC was high up to
14,000. No signs of infection on CXR and UA clean at OSH.
Concern for aspiration PNA vs. aspiration pneumonitis. Patient
was started on Vancomycin and Levofloxacin. Vancomycin was DC'd.
.
#. Alcohol abuse - Last drink on admission was 3 days prior.
Patient was placed on CIWA protocol. At no time during the
admission did it appear patient was going through withdrawals.
He did not require any benzodiacepine.
.
#. Abnormal LFTs - On admission patient had elevated liver
enzymes. Given history of cardiac arrest this elevation was
thought to be secondary to shock liver. Enzymes were trended and
returned to [**Location 213**].
.
#. Hematuria - On admission patient had report of hematuria.
This resolved without intervention. Most likely traumatic after
Foley placement.
Medications on Admission:
Multivitamin daily
Discharge Medications:
Expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Anoxic brain injury after cardiac arrest and possible
ventricular fibrillation.
Discharge Condition:
Expired.
Discharge Instructions:
Expired.
Followup Instructions:
Expired.
ICD9 Codes: 486, 5070, 4271, 4275, 4240, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1234
} | Medical Text: Admission Date: [**2129-1-24**] Discharge Date: [**2129-2-2**]
Date of Birth: [**2046-10-11**] Sex: M
Service: SURGERY
Allergies:
Percocet / Magnesium Citrate
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Left lower extremity claudication, thoracic aneurysm.
Major Surgical or Invasive Procedure:
PROCEDURES:
1. Endovascular repair of descending thoracic aortic
aneurysm with extension .46-46/ 46-42- Talent thoracic
2. Right-to-left femoral-femoral crossover graft with 8-mm
PTFE, right superficial femoral artery embolectomy with
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] catheter.
History of Present Illness:
The patient is an 82-year-old male who has a complicated
vascular history which started with a ruptured infrarenal
abdominal aortic aneurysm. This was repaired
initially with a Zenith Endograft. This graft then later
required explantation and aortobi-iliac graft operative repair.
He recovered well from this but suffered a left graft limb
occlusion which did not cause limb threat but has
created lifestyle-limiting left lower extremity claudication. He
presents at this time for endovascular repair of his remaining
thoracic aneurysm and femoral-femoral bypass graft.
Past Medical History:
1. CAD, s/p CABG ([**2117**]) with an LIMA to LAD and vein graft to
the first diagonal, obtuse marginal, and right coronary
arteries.
2. AAA, s/p repair as follows:
[**2127-10-8**] - Endovascular aneurysm repair. Bilateral femoral artery
exposures.
[**2127-10-16**] - Exposure of left common femoral artery and primary
repair; Balloon angioplasty of proximal extension cuff of
endograft(aorta) and left CIA and EIA
[**2127-10-30**] - Contained rupture of aortic aneurysm, status post
endovascular stent graft including suprarenal fixation, Palmaz
stent and cuff followed by conversion of endovascular aneurysm
repair to open aneurysm repair with infrarenal tube bifurcated
graft.
3. PVD, s/p bilateral carotid endarterectomies ([**2123**], [**2127**]).
4. COPD
5. Hyperlipidemia
6. Hypertension
7. ?Mild Congestive heart failure, per OMR, but pt denies pedal
edema or ever being told he had HF, EF > 55% 10/08
8. Anxiety
9. Left rotator cuff tear, s/p repair
10. Obstructive sleep apnea, on CPAP
11. Atrophic right kidney
12. s/p right knee replacement
Social History:
Smoker x 40 years (~2 ppd), quit 21 years ago. Drinks 2 glasses
of wine [**2-23**] nights per week. Drinks egg nog with rum during the
holiday season.
Family History:
Mother died of breast cancer. One sister had a "liver
condition". Patient is unsure whether there is any family
history of CAD.
Physical Exam:
PHYSICAL EXAMINATION
Vitals: T: 99.4 degrees Fahrenheit, BP: 94/49 mmHg supine, HR
102
bpm(100-110), RR 18, O2: 95 % on 3L.
Gen: Pleasant, well appearing...
Eyes: No conjunctival pallor. No icterus.
ENT: MMM. OP clear.
CV: JVP low. Normal carotid upstroke without bruits. PMI in 5th
intercostal space, mid clavicular line. Irregular. nl S1, S2. No
murmurs, rubs, clicks, or gallops. Full distal pulses
bilaterally.
LUNGS: CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, mild tenderness in the scar area, ND. No HSM.
Abdominal aorta was not enlarged by palpation. No abdominal
bruits.
Heme/Lypmh/Immune: No CCE, no cervical lymphadenopathy.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. CN 2-12 grossly intact. Preserved sensation
throughout. 5/5 strength throughout. [**1-22**]+ reflexes, equal BL.
Normal coordination. Gait assessment deferred
PSYCH: Mood and affect were appropriate
Pertinent Results:
[**2129-2-1**] 05:45AM BLOOD
WBC-7.9 RBC-3.49* Hgb-10.7* Hct-33.3* MCV-95 MCH-30.7 MCHC-32.2
RDW-15.0 Plt Ct-278
[**2129-2-1**] 05:45AM BLOOD
PT-25.3* PTT-34.8 INR(PT)-2.4*
[**2129-2-1**] 05:45AM BLOOD
Glucose-99 UreaN-12 Creat-1.1 Na-140 K-4.0 Cl-104 HCO3-26
AnGap-14
[**2129-2-1**] 05:45AM BLOOD
Calcium-8.3* Phos-3.3 Mg-1.7
[**2129-1-24**] 4:06 pm MRSA SCREEN Source: Nasal swab.
MRSA SCREEN (Final [**2129-1-27**]): No MRSA isolated.
CTA:
INDICATION: 81-year-old male status post PTFE/EVAR with
hematocrit drop.
Evaluate for hemorrhage.
CT CHEST WITHOUT CONTRAST: There are no pathologically enlarged
axillary
lymph nodes. Scattered mediastinal lymph nodes measure up to 7
mm in short
axis, not meeting CT criteria for pathologic enlargement and
unchanged.
Atherosclerotic calcifications involve the thoracic aorta and
coronary
arteries. The patient is status post endovascular stent repair
of a
descending thoracic aorta aneurysm, however evaluation of the
stent itself is limited without contrast. There is no
pericardial or pleural effusion.
Lung windows reveal diffuse centrilobular and paraseptal
emphysema. Multiple bilateral pulmonary nodules are not
significantly changed compared to [**1-10**], including a 7-mm
nodule at the left lung base (2:51). Left greater than right
bibasilar atelectasis is present. A small amount of secretions
are present in the right mainstem bronchus. Otherwise, the
airways are patent to the subsegmental level bilaterally.
CT ABDOMEN WITH CONTRAST: Non-contrast evaluation of the liver,
spleen,
pancreas, adrenal glands and kidneys are unremarkable.
Intra-abdominal loops of large and small bowel are of normal
caliber and there is no
pneumoperitoneum or free fluid. Scattered small mesenteric and
retroperitoneal lymph nodes do not meet CT criteria for
pathologic
enlargement. The patent is status post stenting of an abdominal
aortic
aneurysm, however, evaluation of both it and the known chronic
occlusion of the left common iliac and internal and external
iliac arteries is limited without contrast. Atherosclerotic
calcifications again involve the abdominal aorta and its
branches.
CT PELVIS WITHOUT CONTRAST: The rectum, sigmoid and prostate are
unremarkable. Scattered diverticula of the descending colon are
not associated with acute inflammation. The bladder contains a
Foley and non- dependent air. There is no free pelvic fluid or
pathologically enlarged pelvic or inguinal lymph nodes.
Post-surgical changes are noted in the inguinal regions
bilaterally with small hyperdense collections along the anterior
aspect of the common femoral vessels, left greater than right,
likely representing small hematomas, not large enough to cause a
hematocrit drop. A fem-fem bypass is new since [**1-10**].
Bone windows reveal no worrisome lytic or sclerotic lesions.
IMPRESSION:
1. No significant hemorrhage noted in the chest, abdomen or
pelvis. Small
foci of hemorrhage along the anterior aspects of the common
femoral vessels bilaterally secondary to recent procedure are
not enough to explain hematocrit drop.
2. Extensive atherosclerotic disease status post stenting of
descending
thoracic and abdominal aortic aneurysms, though evaluation is
limited without contrast.
3. Scattered descending colonic diverticula without evidence of
acute
diverticulitis.
4. Emphysema with unchanged bilateral small pulmonary nodules.
Brief Hospital Course:
Mr. [**Known lastname **],[**Known firstname 1730**] M was admitted on [**1-24**] with Thoracic aortic
aneurysm and left
leg ischemia with left iliac occlusion. He agreed to have an
elective surgery. Pre-operatively, he was consented. A CXR, EKG,
UA, CBC, Electrolytes, T/S - were obtained, all other
preperations were made.
It was decided that she would undergo a:
Right to left femoral-femoral bypass graft done after
endovascular repair of descending thoracic aneurysm.
He was prepped, and brought down to the operating room for
surgery. Intra-operatively, he was closely monitored and
remained hemodynamically stable. He tolerated the procedure well
without any difficulty or complication.
Post-operatively, he was extubated and transferred to the PACU
for further stabilization and monitoring.
Had intra-op TTE. Preserved EF of 55%, diagnosis of Diastolic,
chronic CHF.
He was then transferred to the CVICU for further recovery. While
in the VICU he recieved monitered care. When stable he was
delined. His diet was advanced. A PT consult was obtained.
While in the CVICU he did have atrial fibrillation. Cardiology
consulted. Started on Amio. Remained in Afib. Po diltiazem
started, other medications adjusted. Pt sill in afib, but with
rate control. Started on Coumadin with INR goal. of [**2-23**].
During his bouts of afib, he did have low BP, resusitated with
PRBC. HCT stable on DC.
When he was stabalized from the acute setting of post operative
care, he was transfered to floor status.
On the floor, he remained hemodynamically stable with his pain
controlled. He progressed with physical therapy to improve her
strength and mobility. He continues to make steady progress
without any incidents. He was discharged to a rehabilitation
facility in stable condition.
Pt did fail voiding trial. Replaced foley. Started on flomax. Pt
to have foley removed by Rehab in [**2-23**] days.
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. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO HS (at bedtime) as needed for indigestion.
3. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM: INR goal is [**2-23**].
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): x 7 days, then 200 [**Hospital1 **] x 7 days, Then 200 mg po qd. Then
have patient f/u with PCP to DC.
9. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain .
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
14. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day): Please swith to long acting at time of DC at
rehab.
15. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 11496**] - [**Location (un) **]
Discharge Diagnosis:
Thoracic aortic aneurysm and left leg ischemia with left iliac
occlusion.
AFIB
Urinary Retention
PVD
COPD
Hyperlipidemia
Hypertension
Mild Congestive heart failure, per OMR, but pt denies pedal
edema or ever being told he had HF, EF > 55% 10/08
Anxiety
Obstructive sleep apnea, on CPAP
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Endovascular Aortic Aneurysm Discharge Instructions
Medications:
?????? If instructed, take Aspirin 325mg (enteric coated) once daily
?????? If taking Aspirin, Do not stop Aspirin unless your Vascular
Surgeon instructs you to do so.
?????? 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 to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**2-23**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
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 [**Month/Day (3) **] 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
?????? Call and schedule an appointment to be seen in [**4-26**] weeks for
post procedure check and CTA
What to report to office:
?????? 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 or
incision)
?????? 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:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2129-5-3**] 1:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2129-5-3**] 2:00
Completed by:[**2129-2-2**]
ICD9 Codes: 4589, 4280, 496, 9971, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1235
} | Medical Text: Admission Date: [**2119-8-21**] Discharge Date: [**2119-8-24**]
Service: MEDICINE
Allergies:
Tylenol
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Balloon Aortic Valvuloplasty [**2119-8-22**] -- Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
History of Present Illness:
Ms. [**Known lastname **] is an 88yoF with a h/o severe AS, Afib on coumadin,
HTN, HLD who was transferred from OSH with acute pulmonary edema
requiring intubation and hypotension requiring pressors.
Patient is unable to provide a history at this time so details
obtained by family and note by Dr. [**Last Name (STitle) **] in OMR. Pt recently
saw Dr. [**Last Name (STitle) **] in clinic on [**2119-8-16**] for evaluation for AVR. Per
his note, she had a syncopal episode approximately 5 mos ago.
She also c/o occasional SOB but this had recently improved. Her
most recent echocardiogram of [**2119-7-19**] showed severe AS ([**Location (un) 109**]
0.47cm2, mn 37) with normal systolic function (LVEF 60%). She
was scheduled for elective AVR on [**2119-9-21**] with anticipated
pre-admission for IV heparin and routine PATs.
.
Per the family, on the day of admission she developed acute SOB
at home and called her neighbor, who is a nurse. Her daughter
had visited her only 30 minutes prior, and states that she did
not appear SOB at that time. Her neighbor called EMS and the pt
was brought to [**Hospital6 33**]. There she was intubated for
poor responsiveness and started on dopamine gtt for BP 70/40.
She was transferred to [**Hospital1 18**] for further management.
.
On transfer to ED, she was intubated and on dopamine gtt.
Vitals afebrile with HR 140, BP 97/64, RR 22 O2sat 95%. BP
decreased to 71/57, started on levophed and neosynephrine gtt
and BP stabilized 90s/60s. Received IV lasix 40mg x1. Dopamine
gtt was d/c'd. EKG showed Afibb with RVR. LIJ and arterial line
placed. (RIJ attempted but c/b blood clot.) DCCV attempted but
she remained in afib. She was admitted to CCU for respiratory
and pressure support.
.
ROS: Unable to obtain
Past Medical History:
1. CARDIAC RISK FACTORS: +Hypertension +Hyperlipidemia
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
- Severe Aortic stenosis: [**Location (un) 109**] 0.47cm2, mn 37
- Atrial fibrillation (per family, diagnosed [**5-19**] mos ago;
cardioversion discussed but not attempted, now on coumadin)
3. OTHER PAST MEDICAL/SURGICAL HISTORY:
- S/p Bilateral Total Knee Replacements
- S/p Right Thumb surgery
- S/p Appendectomy
- Left Cataract
Social History:
Lives alone in [**Location (un) 3493**], several adult children who live nearby.
Per family, she is still extremely active and independent in
all ADLs. She continues to drive and works part time in her
son's restaurant. Never smoked, rare ETOH.
Family History:
NC
Physical Exam:
Admission Exam
Vitals: T 96 HR 102 BP 85/54 RR 16 O2 96% on vent
GENERAL: Sedated, intubated
HEENT: NCAT. Sclera anicteric. PERRL.
NECK: Supple, JVP flat.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Tachy, Irregularly irregular rhythm, normal S1, S2. IV/VI
systolic murmur, loudest at RUS border, radiating to carotids.
No S3 or S4.
LUNGS: Intubated, bibasilar crackles, no wheezes/rhonchi.
ABDOMEN: Soft, ND. No HSM. 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 1+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 1+ DP 1+ PT 1+
Pertinent Results:
CBC:
[**2119-8-21**] 10:05PM WBC-15.6* RBC-5.28 HGB-15.9 HCT-49.3* MCV-93
MCH-30.1 MCHC-32.2 RDW-14.8
[**2119-8-21**] 10:05PM NEUTS-79.1* LYMPHS-17.7* MONOS-2.2 EOS-0.2
BASOS-0.9
[**2119-8-21**] 10:05PM PLT COUNT-328
BMP:
[**2119-8-21**] 10:05PM GLUCOSE-287* UREA N-28* CREAT-1.5* SODIUM-139
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-20* ANION GAP-19
[**2119-8-23**] 02:24PM BLOOD Glucose-143* UreaN-61* Creat-4.2* Na-134
K-5.8* Cl-103 HCO3-15* AnGap-22*
LFTs:
[**2119-8-21**] 10:05PM ALT(SGPT)-14 AST(SGOT)-26 CK(CPK)-103 ALK
PHOS-90 TOT BILI-0.9
Cardiac Enzymes:
[**2119-8-21**] 10:05PM CK-MB-8
[**2119-8-21**] 10:05PM cTropnT-0.08*
[**2119-8-23**] 04:06AM BLOOD CK-MB-14* MB Indx-5.3
ABG:
[**2119-8-21**] 10:50PM TYPE-ART O2-100 PO2-93 PCO2-50* PH-7.21*
TOTAL CO2-21 BASE XS--8 AADO2-575 REQ O2-94 -ASSIST/CON
INTUBATED-INTUBATED COMMENTS-GREEN TOP
[**2119-8-23**] 07:25PM BLOOD Type-ART pO2-64* pCO2-29* pH-7.30*
calTCO2-15* Base XS--10
UA:
[**2119-8-22**] 10:57AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
[**2119-8-22**] 10:57AM URINE RBC->182* WBC-90* Bacteri-MOD Yeast-MANY
Epi-0
[**2119-8-22**] 10:57AM URINE CastHy-19*
Microbiology:
[**2119-8-22**] 10:52 am BLOOD CULTURE Source: Line-aline.
Blood Culture, Routine (Preliminary):
GRAM POSITIVE COCCUS(COCCI). IN CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2119-8-23**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2119-8-23**] 2:45PM.
Imaging:
CXR [**2119-8-21**]: New left internal jugular line terminates in the
proximal
SVC. Endotracheal tube has been retracted, and now terminates 3
cm above the carina. Nasogastric tube has also been retracted,
with side port just beyond the gastroesophageal junction, and
tip in the stomach. There is no
pneumothorax. Severe cardiomegaly and/or pericardial effusion is
unchanged, vascular congestion and moderated pulmonary edema are
worse.
CXR [**2119-8-23**]:
1. Progressive asymmetric focal opacification in the right lower
lobe raises concern for infection.
2. Endotracheal tube 1.8 cm above the carina.
[**2119-8-21**] TTE: The left atrium is elongated. The estimated right
atrial pressure is 5-10 mmHg. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional wall motion is normal. [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.] Left ventricular systolic
function is hyperdynamic (EF>75%). Right ventricular chamber
size is normal. with mild global free wall hypokinesis. The
ascending aorta is mildly dilated. The aortic valve leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis (valve area 0.8-1.0cm2). No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
partial posterior mitral leaflet flail. Moderate to severe (3+)
mitral regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a small pericardial effusion.
The effusion appears circumferential. There are no
echocardiographic signs of tamponade. Echocardiographic signs of
tamponade may be absent in the presence of elevated right sided
pressures.
[**2119-8-23**] TTE: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global left ventricular
hypokinesis. Severe aortic stenosis. Moderate, eccentric mitral
regurgitation. Small posterior pericardial effusion. Compared
with the prior study (images reviewed) of [**2119-8-22**], aortic valve
gradient is lower. The severity of mitral regurgitation is
reduced, although image quality is technically limited. The
heart rate is slower. The severity of tricuspid regurgitation is
reduced. The estimated pulmonary artery pressures are lower.
[**2119-8-22**] Cardiac Catheterization:
Patient was brought to the cath lab on ventilator and
inotropic support. Vascular access was secured through the right
femoral
artery and vein. Selective coronary angiography was performed
using 4 Fr
JL 4 and JR 4 diagnostic catheters. A 5 Fr Pigtail catheter on a
straight 0.035 wire was used to cross the aortic valve.
Hemodynamic
parameters were measured and an Amplatz 260 cm Extra stiff wire
with
floppy 7 cm tip shaped like a pigtail to avoid injuring the
ventricle
was delivered to the left ventricle through the pigtail
catheter. The
pigtail was withdrawn. A temporary pacing catheter was advanced
in
to the RV apex and tested for capture. Then a Tyshak 20 mm x 6
cm
valvuloplasty balloon was railed in over the amplatz wire and
situated
across the aortic valve. The balloon was rapidly inflated and
deflated 2
times for valvuloplasty while patient was underwent rapid RV
pacing with
drop in SBP<60-70 mm Hg. FOllowing valvuloplasty right heart
catheterization was performed using a Swan-Ganz catheter which
was
left in place and covered with sterile sheath. The arterial
puncture
site was closed with an 8Fr Angioseal device. Of note, in she
was
electrically cardioverted after loading with amiodarone IV.
FINAL DIAGNOSIS:
1. Non-obstructive CAD
2. Severe aortic stenosis status post palliative balloon aortic
valvuloplasty
3. Severe acute MR due to a flail posterior leaflet.
Brief Hospital Course:
Primary Reason for Hospitalization:
88yoF with h/o severe AS, afib on coumadin, HTN, HLD who is
transferred from [**Hospital6 33**] for acute pulmonary edema
and hypotension requiring intubation and pressors.
Brief Hospital Course:
On admission pt required levophedrine and phenylephrine pressors
to maintain blood pressure with MAP > 60. On HD#2 TTE showed
severe mitral regurgitation with flail valve, and severe aortic
stenosis. She was cardioverted and started on amiodarone drip,
and reverted to sinus rhythm. She had an aortic balloon
valvuloplasty in hopes of improving flow through the stenotic
valve. Unfortunately her blood pressure continued to decrease
and she developed renal failure and anuria. She also developed
fever with leukocytosis (WBC 21), and CXR showed e/o RLL
pneumonia. She was started on vanc/cefepime for broad coverage.
Swann-Ganz catheter showed cardiac output of 3.1L/min and
cardiac index of 1.9. On [**2119-8-23**] renal service was consulted
and a trial of CVVH was started in hopes of correcting her
electrolyte abnormalities. Unfortunately her blood pressure
continued to decrease to 70s/40s despite pressors. A family
meeting was held, and the family decided to change goals of care
to comfort measures only. CVVH and pressors were stopped. At
00:45 on [**2119-8-24**] she passed away with family at bedside. Family
declined autopsy. Primary care physician and attending
notified.
Medications on Admission:
Medications - Prescription
DILTIAZEM HCL [CARTIA XT] - (Prescribed by Other Provider) -
240
mg Capsule, Ext Release 24 hr - 1 Capsule(s) by mouth once a day
SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
WARFARIN - (Prescribed by Other Provider) - 2 mg Tablet - 1
Tablet(s) by mouth
.
Medications - OTC
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D] - (Prescribed by Other
Provider) - 1,000 unit Capsule - 1 Capsule(s) by mouth once a
day
NIACIN - (Prescribed by Other Provider) - 500 mg Capsule,
Extended Release - 1 Capsule(s) by mouth once a day
Discharge Disposition:
Expired
Discharge Diagnosis:
Mitral valve regurgitation
Aortic valve stenosis
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
ICD9 Codes: 4241, 486, 5849, 4271, 2767, 4240, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1236
} | Medical Text: Admission Date: [**2126-2-28**] Discharge Date: [**2126-3-22**]
Date of Birth: [**2070-7-15**] Sex: M
Service: CARDIAC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 55 year-old
male with a history of peripheral vascular disease who
presented to the Medical Service with a chief complaint of
claudication times one year. The patient was admitted for
prehydration prior to cardiac catheterization. Previous ABIs
on [**2126-2-15**] revealed significant bilateral superficial and
femoral artery occlusion and tibial artery disease. The
patient also reported some pain with walking consistent with
claudication left greater then right reporting symptoms for
approximately one year. The patient also noted some chest
pressure with short distance walking or walking up a flight
of stairs. Reports four pillow orthopnea and a history of
lower extremity edema. The patient has a significant family
history of coronary artery disease and a 20 pack year history
of smoking. The patient denies cough, current chest
discomfort, fevers or chills, nausea, vomiting, diarrhea,
difficulty urinating, blood in the stool or urine.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypercholesterolemia.
3. Insulin dependent diabetes.
4. Congestive heart failure.
5. Chronic renal insufficiency.
PAST SURGICAL HISTORY: Unremarkable.
MEDICATIONS ON ADMISSION:
1. Lantus 40 units q.a.m.
2. Lasix 100 mg po b.i.d.
3. Elavil 25 mg po q.d.
4. Pletal 100 mg po b.i.d.
5. Lipitor 20 mg po q day.
6. Lisinopril 40 mg po q day.
7. _________ 15 mg po q day.
8. Toprol XL 25 mg po q day.
9. Aspirin 81 mg po q day.
ALLERGIES: Cefepime with diaphoresis and tachycardia.
SOCIAL HISTORY: The patient has a 20 pack year smoking
history. No alcohol and no drugs.
FAMILY HISTORY: Father with coronary artery disease.
PHYSICAL EXAMINATION: The patient was afebrile and vital
signs stable and in no acute distress. Alert and oriented
times three. Head was normocephalic, atraumatic. No scleral
icterus noted. Neck was soft and supple. No masses noted.
No JVD. The patient had some carotid bruits bilaterally
right greater then left. Heart was regular rate and rhythm.
No murmurs. Chest was clear to auscultation bilaterally. No
rhonchi or rales. Abdomen was soft, nontender, nondistended.
Positive bowel sounds. Extremities was not significant for
any edema. Dorsalis pedis pulses were absent and posterior
tibial pulses were 2+ bilaterally. The patient was
neurologically intact.
HOSPITAL COURSE: The patient was admitted to the Medical
Service. The patient was a 55 year-old male who was admitted
to the Medical Service for prehydration prior to angio for
claudication. The patient went for cardiac catheterization
on [**2126-3-1**]. Dr. [**First Name (STitle) **] attending and the patient was noted to
have three vessel disease. For more details please see
procedure note. Cardiac Surgery was consulted on [**2126-3-2**].
The patient was evaluated by Dr. [**Last Name (STitle) 1537**] and deemed appropriate
for coronary artery bypass surgery. After undergoing the
appropriate preoperative workup the patient went to the
Operating Room on [**2126-3-6**] for coronary artery bypass graft
times four, left internal mammary coronary artery to left
anterior descending coronary artery, saphenous vein graft to
right coronary artery to the posterior descending coronary
artery, saphenous vein graft to the obtuse marginal. For
more detailed account please see operative report. The
patient was transferred to the CSRU on a Dobutamine and Neo
IV. Chest x-ray postoperatively was notable for a left lower
lobe collapse. The patient was extubated early on
postoperative day number one. In addition, on postoperative
day number one the patient required one unit of packed red
blood cells. Of note on postoperative day number two the
patient had a creatinine of 2.8, which rose from 2.0. The
Renal Service was consulted and they recommended holding
diuresis with Lasix, transfusing to a hematocrit above 30 and
avoiding other nephrotoxic agents. In addition they
recommended keeping systolic blood pressure over 130.
On [**2126-3-7**] the patient remained on pressors with
neo-synephrine intravenously. Insulin drip was also
restarted at this time. On [**2126-3-10**] the patient was
transfused 2 units of packed red blood cells for a low urine
output. The patient's renal status was worsening at this
time with creatinine of 2.5 to 3 range. In addition, on this
day the mediastinal chest tube was discontinued. The patient
continued to have left persistent left lower collapse. On
[**2126-3-12**] the patient was transfused 1 unit of packed red blood
cells. The patient was off pressors. On [**2126-3-14**] the patient
had a bronchoscopy, which revealed a mild tracheal malacia
otherwise within normal limits. The patient also at this
time was noted to have a rise in white blood cell count, so
was placed on Levofloxacin. White blood cell count rose to
24. On [**2126-3-15**] the patient was found to have an alkaline
phosphatase of greater then 1000. Right upper quadrant
ultrasound was done, which showed some dilation. General
Surgery Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] was consulted and the patient was
monitored with expectant management. The patient was
eventually transferred to the floor on [**2126-3-15**]. The patient
continued to have left lower lobe collapse on chest x-ray.
Creatinine was stable in the 2 to 2.5 range. White blood
cell count was persistently high between 20 and 25,000.
Liver function tests were steady decreasing and the patient's
abdominal examination was benign. The patient was also noted
to have some erythema at the superior pole of the sternotomy
wound with minimal drainage, which improved over the course
of his floor stay.
On [**2126-3-18**] Infectious Disease was consulted and they
recommended placing the patient on Vancomycin. He was placed
on 1 gram q 24 hours. Over the next several days the
patient's white blood cell count steadily decreased to the
current discharge white blood cell count of 11. In addition,
the patient was intermittently diuresed. In addition, the
patient received intermittent doses of Kayexalate for a
potassium level between 5 and 6. The patient continued to
improve clinically on the Vancomycin. Infectious Disease
recommended discharge with PICC line and intravenous
Vancomycin for three weeks. On the day of discharge the
patient's white blood cell count was stable at 11. The
patient's creatinine had decreased to 1.8. The patient was
replaced on po Lasix, however, on only 40 mg b.i.d. instead
of his usual home dose of 100. The patient's ace inhibitor
and [**Last Name (un) **] continued to be held to be started at the discretion
of his primary care physician. [**Name10 (NameIs) **] patient continued to have
left lower lobe collapse, however, pulmonary is recommending
no intervention at this time. The patient is clinically
stable.
DISCHARGE STATUS: To home with services.
DISCHARGE DIAGNOSES:
1. Three vessel coronary artery disease.
2. Hypertension.
3. Hypercholesterolemia.
4. Insulin dependent diabetes mellitus.
5. Chronic renal insufficiency.
6. Congestive heart failure.
MEDICATIONS ON DISCHARGE:
1. Amitriptyline 25 mg po q.h.s.
2. Lipitor 20 mg po q.d.
3. Colace 100 mg po b.i.d.
4. Aspirin 325 mg po q day.
5. Dilaudid 2 mg one to two tabs po q 6 hours for pain.
6. Glargine insulin 20 units subq q breakfast.
7. Regular insulin sliding scale as directed.
8. Metoprolol 75 mg po b.i.d.
9. Protonix 40 mg po q day.
10. Pletal 100 mg po b.i.d.
11. Vancomycin 1 gram intravenously q day times three weeks.
12. Lasix 20 mg po b.i.d.
FOLLOW UP:
1. The patient is to follow up with the Wound Care Clinic in
one week.
2. Follow up with primary care physician in two to three
weeks for management of intravenous antibiotics.
3. Dr. [**First Name (STitle) **] from cardiology in two to three weeks.
4. Infectious disease please fax weekly laboratory results
and follow up prn.
5. Dr. [**Last Name (STitle) 1537**] in four weeks.
6. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from General Surgery in two weeks.
Please call for an appointment.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Name8 (MD) 7190**]
MEDQUIST36
D: [**2126-3-22**] 09:27
T: [**2126-3-22**] 09:36
JOB#: [**Job Number 7191**]
ICD9 Codes: 4280, 5845 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1237
} | Medical Text: Admission Date: [**2107-2-3**] Discharge Date: [**2107-2-15**]
Date of Birth: [**2045-12-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
"Some ADHD medicine"
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2107-2-3**] Cardiac cath
[**2107-2-7**] Urgent off-pump coronary artery bypass graft x3 -- left
internal mammary artery to left anterior descending artery and
saphenous vein grafts to obtuse marginal and diagonal arteries
History of Present Illness:
61 year old male with a history of asthma and mild sleep apnea
describes many years of chest discomfort that have progressed in
frequency and duration. Currently he has daily episodes of
exertional chest discomfort. He reports that the discomfort
begins in the neck and spreads down to the chest. It typically
will resolve with rest but there was one time that he required
SL nitroglycerin to get relief of his discomfort. He has
undergone stress testing through the years. A myoview study was
negative in [**2101**]. Non imaging ETT in [**2106-5-26**] was positive for
chest pain but negative for ischemic EKG changes. He was
referred for cardiac catheterization to further evaluate. He was
found to have coronary artery disease and is now being referred
to cardiac surgery for revascularization.
Past Medical History:
Asthma
ADHD
Mild sleep apnea (CPAP)
GERD
Hx of vasovagal syncope (after coughing or vomiting)
Paratracheal cyst noted on CT s/p mediastinal thorascopy:
benign,
? recurrence
Anemia
Vitamin D deficiency
Psoriasis
Hard of hearing
Hypothyroidism (not on any meds)
ADHD
Mini strokes (per pt not TIAs)
Tonsillectomy
Appendectomy
Jaw abscess s/p I&D
Varicocelectomy
s/p mediastinal thorascopy: benign, ? recurrence
Social History:
Race:Caucasian
Last Dental Exam: <1 year ago
Lives with:Wife
Contact: [**Name (NI) 83013**] [**Name (NI) 83014**] (wife) Phone# [**Telephone/Fax (1) 83015**]
Occupation:Self employed artist
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**2-1**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Both parents died at young ages from cancer. No family history
of premature CAD.
Physical Exam:
Admission:
Pulse:64 Resp:16 O2 sat:100/RA
B/P Right:126/76 Left:125/76
Height:5'[**05**]" Weight:220 lbs
General:
Skin: Dry [x] intact [x] Psoriasis bilateral knees, elbows, feet
HEENT: PERRLA [x] EOMI [x] Glasses
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] Obese, umbilical hernia, well healed appy incision
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: Left calf
Neuro: Grossly intact [x]
Pulses:
Femoral Right:cath site Left: 2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right:none Left:none
Discharge:
VS 98.3 90 110/68 18 98%-2LNP
Gen- NAD
Neuro- A&O x3, nonfocal
CV- RRR, no Murmur. Sternum stable- incision CDI
Pulm- CTA-bilat
Abdm- soft, NT/ND/+BS
Ext- warm, well perfused 1+ bilat edema
Pertinent Results:
[**2107-2-3**] Cardiac cath: 1. Selective coronary angiography of this
right dominant system demonstrated left main and three vessel
disease. The LMCA had an eccentric 80% lesion distally near the
bifurcation. The LAD had a 90% stenosis both before and after
D1. The proximal aspect of D1 itself also had a 90% lesion. The
LCx had an ostial 90% lesion. The RCA was notable for an 80%
stenosis in the mid-PDA. 2. Limited resting hemodynamics
revealed normal systemic systolic arterial pressures, with a
central aortic pressure of 137/77, mean 93 mmHg.
.
[**2107-2-4**] Carotid U/S: Right ICA no stenosis. Left ICA <40%
stenosis.
.
[**2107-2-7**] Echo: 1. The left atrium is normal in size. 2. Regional
left ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). 3. Right ventricular
chamber size and free wall motion are normal. 4. There are
simple atheroma in the aortic root. There are simple atheroma in
the ascending aorta. There are simple atheroma in the aortic
arch. There are simple atheroma in the descending thoracic
aorta. 5. The aortic valve leaflets (3) appear
structurallynormal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. 6. The mitral valve appears
structurally normal with trivial mitral regurgitation. 7. There
is a small pericardial effusion.
Post myocardial revascularization: The patient is on no
inotropes. The patient is atrially paced. Biventricular function
is unchanged. Mitral regurgitation is unchanged. The aorta is
intact after partial cross-clamping.
.
[**2107-2-10**] Chest X-ray: The patient was extubated with removal of
supporting tubes and lines. Bibasilar atelectasis and small
amount of pleural effusion is seen. Small left apical
pneumothorax is present. No right pneumothorax is seen.
.
[**2107-2-12**] Hct-25.8*
[**2107-2-11**] WBC-7.3 RBC-2.84* Hgb-8.6* Hct-25.8* Plt Ct-158
[**2107-2-3**] WBC-5.1 RBC-4.17* Hgb-12.2* Hct-36.4 Plt Ct-142*
[**2107-2-12**] UreaN-35* Creat-1.4* Na-138 K-4.6 Cl-100
[**2107-2-11**] Glucose-108* UreaN-28* Creat-1.1 Na-137 K-4.3 Cl-101
HCO3-25
[**2107-2-3**] Glucose-98 UreaN-27* Creat-1.2 Na-139 K-4.3 Cl-105
HCO3-28
[**2107-2-12**] Mg-2.2
[**2107-2-3**] %HbA1c-5.8 eAG-120
[**2107-2-15**] 05:50AM BLOOD Hct-29.7*
[**2107-2-15**] 05:50AM BLOOD PT-17.2* INR(PT)-1.6*
[**2107-2-15**] 05:50AM BLOOD Glucose-105* UreaN-26* Creat-1.3* Na-137
K-4.5 Cl-98 HCO3-31 AnGap-13
Brief Hospital Course:
Mr [**Known lastname 83016**] was admitted to the cardiology service with angina on
exertion for planned cardiac catheterization. On [**2-3**] he was
brought to the cath lab, it revealed left main and 3 vessel
disease. The patient was then referred to cardiac surgery for
surgical revascularization. He had the usual pre-op screen
including vein mapping, carotid ultrasound, labs, CXR, and MSSA
screen.
He was brought to the operating room by Dr [**Last Name (STitle) 7772**] on [**2-7**]
for coronary artery bypass grafting. Please see the operative
report for details. In summary he had:
1. Urgent off-pump coronary artery bypass graft x3 -left
internal mammary artery to left anterior descending artery and
saphenous vein grafts to obtuse marginal and
diagonal arteries. 2. Endoscopic harvesting of the long
saphenous vein.
He tolerated the operation well and post operatively was
transferred tot he cardiac surgery ICU in stable condition. In
the immediate post-op period he was stable, woke neurologically
intact and extubated. On [**2-8**] he transferred to the stepdown
floor.
Respiratory: aggressive pulmonary toilet nebs and ambulation he
titrated off oxygen with saturations of 97%. Inhalers, singular
and home CPAP were continued.
Cardiac: low-dose beta-blockers were started. On postoperative
day 3 had intermittent atrial fibrillation 70-90's. Amiodarone
PO was started and he converted to sinus rhythm 60-70's. A 3
months course of Plavix was started immediately postoperative
for off-Pump CABG. His heart rate became bradycardic into the
30s. Electrophysiology was consulted. Amio was discontinued. He
remains on beta-blocker with a stable HR in the 80s. Paroxysmal
AF continued and he was started on anticoagulation with
Coumadin. He remained hemodynamically stable 110-130's. Low
dose aspirin and statin were continued.
GI: benign. Tolerated a regular diet
Renal: He was gently diuresed toward his preop weight of 100 kg.
Renal function CRE peaked to 1.4 base 0.9-1.2. His diuretic was
decreased. He continued to have good urine output. Electrolytes
were closely monitored and repleted as needed. Foley reinserted
for failure to void. Flomax was restarted and voiding trial with
good results.
Endocrine: well controlled with insulin sliding scale.
Disposition: he was seen by physical therapy who recommended
rehab. He was discharged on POD# 8 to [**Hospital 83017**] Nursing and Rehab
in [**Location (un) 1456**]. All follow up appointments were advised.
Medications on Admission:
ALBUTEROL SULFATE 90 mcg HFA Aerosol Inhaler - PRN
SYMBICORT 160 mcg-4.5 mcg/actuation HFA Aerosol - 2 puffs [**Hospital1 **]
WELLBUTRIN XL 300 mg Daily
CYCLOBENZAPRINE 10 mg PRN
FLUTICASONE 50 mcg- 2 sprays each nostril daily
METOPROLOL TARTRATE 25 mg [**Hospital1 **]
SINGULAIR 10 mg Daily
NITROGLYCERIN 0.4 mg [**Hospital1 8426**], Sublingual - 1 [**Hospital1 8426**] sublingually
every five minutes for chest discomfort. Call 911 if pain
persists longer than 15 minutes
OMEPRAZOLE 20 mg Daily
ASPIRIN 325 mg Daily
CALCIUM CARBONATE Dosage uncertain
VITAMIN D3 1,000 unit Daily
CLARITIN Dosage uncertain
VITAMIN B COMPLEX Dosage uncertain
Discharge Medications:
1. aspirin 81 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One (1)
[**Hospital1 8426**], Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 [**Hospital1 8426**], Delayed Release (E.C.)(s)* Refills:*2*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. pantoprazole 40 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One
(1) [**Hospital1 8426**], Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 [**Hospital1 8426**], Delayed Release (E.C.)(s)* Refills:*2*
4. oxycodone-acetaminophen 5-325 mg [**Hospital1 8426**] Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 [**Hospital1 8426**](s)* Refills:*0*
5. bupropion HCl 150 mg [**Hospital1 8426**] Extended Release Sig: Two (2)
[**Hospital1 8426**] Extended Release PO QAM (once a day (in the morning)).
Disp:*60 [**Hospital1 8426**] Extended Release(s)* Refills:*2*
6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
7. atorvastatin 10 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY
(Daily).
Disp:*30 [**Hospital1 8426**](s)* Refills:*2*
8. metoprolol tartrate 25 mg [**Hospital1 8426**] Sig: 0.5 [**Hospital1 8426**] PO BID (2
times a day).
Disp:*60 [**Hospital1 8426**](s)* Refills:*2*
9. clopidogrel 75 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY (Daily)
for 6 months.
Disp:*30 [**Hospital1 8426**](s)* Refills:*0*
10. cholecalciferol (vitamin D3) 1,000 unit [**Hospital1 8426**] Sig: One (1)
[**Hospital1 8426**] PO DAILY (Daily).
Disp:*30 [**Hospital1 8426**](s)* Refills:*2*
11. montelukast 10 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO DAILY
(Daily).
Disp:*30 [**Hospital1 8426**](s)* Refills:*2*
12. furosemide 20 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2 times
a day).
Disp:*60 [**Hospital1 8426**](s)* Refills:*2*
13. potassium chloride 10 mEq [**Hospital1 8426**] Extended Release Sig: Two
(2) [**Hospital1 8426**] Extended Release PO BID (2 times a day).
Disp:*120 [**Hospital1 8426**] Extended Release(s)* Refills:*2*
14. warfarin 1 mg [**Hospital1 8426**] Sig: Three (3) [**Hospital1 8426**] PO ONCE (Once)
for 1 doses.
Disp:*1 [**Hospital1 8426**](s)* Refills:*0*
15. warfarin 1 mg [**Hospital1 8426**] Sig: [**Name6 (MD) **] [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] once a day.
Disp:*qs [**Last Name (Titles) 8426**](s)* Refills:*2*
16. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
Disp:*qs * Refills:*2*
17. acetaminophen 325 mg [**Last Name (Titles) 8426**] Sig: Two (2) [**Last Name (Titles) 8426**] PO Q4H
(every 4 hours) as needed for fever/pain.
Disp:*60 [**Last Name (Titles) 8426**](s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation & Skilled Nursing Center - [**Location (un) 1456**]
Discharge Diagnosis:
Coronary artery disease s/p Coronary artery bypass graft x 3
Past medical history:
Asthma
ADHD
Mild sleep apnea (CPAP)
GERD
Hx of vasovagal syncope (after coughing or vomiting)
Paratracheal cyst noted on CT s/p mediastinal thorascopy:
benign,
? recurrence
Anemia
Vitamin D deficiency
Psoriasis
Hard of hearing
Hypothyroidism (not on any meds)
ADHD
Mini strokes (per pt not TIAs)
Tonsillectomy
Appendectomy
Jaw abscess s/p I&D
Varicocelectomy
s/p mediastinal thorascopy: benign, ? recurrence
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema 1+ bilaterally
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 one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
WOUND CARE CLINIC: Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2107-2-22**] 11:00
Surgeon:Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2107-3-15**] 1:15
Cardiologist: Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] X. [**Telephone/Fax (1) 45578**]: [**2107-3-2**] at
9:00a (inform patient appt for [**2107-2-16**] is canceled)
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 79695**] in [**3-31**] 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**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2107-2-15**]
ICD9 Codes: 9971 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1238
} | Medical Text: Admission Date: [**2156-5-27**] Discharge Date: [**2156-6-3**]
Date of Birth: [**2090-3-24**] Sex: F
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: This 66-year-old white female
has a history of known coronary artery disease and is status
post a remote MI many years ago, with a history of chronic
stable angina since that time. She was recently admitted at
the beginning of [**Month (only) 547**] with chest pain, and had slightly
elevated troponins. At that point, a cardiac catheterization
was recommended, but the patient refused. She went home from
[**Hospital3 417**] Hospital and returned the following day with
severe discomfort in the chest, and agreed to a cardiac cath.
She was then transferred to [**Hospital1 **]-[**Hospital1 **] for cardiac cath, as
Dr. [**Last Name (STitle) **] is her doctor.
PAST MEDICAL HISTORY:
1. History of coronary artery disease, status post MI in the
past.
2. History of hyperlipidemia.
3. History of insulin dependent diabetes.
4. History of hypertension.
5. History of severe right MCA stenosis, status post old
small left cerebral infarct.
6. History of Congestive heart failure
7. History of TIAs.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg po qd.
2. Plavix 75 mg po qd.
3. Lopressor 50 mg po qid.
4. Zocor 20 mg po qd.
5. Colace 100 mg po bid.
6. Zestril 5 mg po qd.
7. Potassium.
8. Sublingual Nitro.
9. Digoxin 0.125 mg po qd.
10.Lasix 120 mg po qd.
11.Humalog insulin sliding scale and Lente, dose unknown.
ALLERGIES: No known allergies.
REVIEW OF SYSTEMS: Significant for generalized fatigue.
PHYSICAL EXAM: She is a well-developed, well-nourished white
female in no apparent distress.
VITAL SIGNS: Stable. Afebrile.
HEENT EXAM: Normocephalic, atraumatic. Extraocular
movements intact. Oropharynx benign.
NECK: Supple. Full range of motion. No lymphadenopathy or
thyromegaly. Carotids 1+ and equal bilaterally without
bruits.
LUNGS: Clear to auscultation and percussion.
CARDIOVASCULAR EXAM: Regular rate and rhythm. Normal S1,
S2, with no rubs, murmurs or gallops.
ABDOMEN: Soft, nontender with positive bowel sounds. No
masses or hepatosplenomegaly.
EXTREMITIES: Without clubbing, cyanosis or edema. Pulses
were 1+ and equal bilaterally with the exception of the DPs
which were trace bilaterally.
NEURO EXAM: Nonfocal.
STUDIES: She also had an echocardiogram on [**2156-5-18**] which
revealed mild left ventricular enlargement with moderate to
severe impairment of the left ventricular systolic function,
and an estimated LVEF of 25-30%. There was akinesis of the
mid and apical portion of the septum. There was mild
thickening of the mitral valve leaflets and annulus, with
moderate to severe MR, and mild tricuspid insufficiency.
HOSPITAL COURSE: So, she was transferred to the [**Hospital1 **] where she underwent an emergency cath which
revealed that the left main had a small filling defect. The
LAD had ostial proximal subtotal stenosis with decreased
flow, and they felt there was a clot in the left main
coronary artery. The left circumflex had diffuse moderate
disease. The RCA was proximally occluded with distal vessels
filled by LCA collaterals, and aortography showed diffuse
atheromatous disease of the aorta and significant disease in
the left iliac.
Dr. [**Last Name (STitle) 70**] was consulted and took the patient for an
emergency CABG x 2 with LIMA to the LAD and reversed
saphenous vein graft to the OM, and a mitral valve
annuloplasty with a #26 [**Doctor Last Name 405**] band. The patient tolerated
the procedure well and was transferred to the CSRU on
milrinone and epinephrine. She remained intubated overnight
and was extubated the following day. She remained
hemodynamically stable, and her epi was weaned off on the
first day. Postop day #2, her milrinone was weaned and then
DC'd on postop day #3. On postop day #3, her chest tubes
were DC'd.
She continued to slowly progress, and on postop day #4 she
was transferred to the floor in stable condition. She had
her wires DC'd on postop day #5 and was very slow with
ambulation, and slow to progress. She was followed as well
by [**Last Name (un) **] and had her insulin changed to Lantus with still
Humalog sliding scale. She also had a white count of
13-16,000, and had an echo on postop day #7 which showed no
vegetations. All of her cultures were negative, and she was
discharged to rehab in stable condition.
LABS ON DISCHARGE: White count 14,700, hematocrit 30.7,
platelets 376,000, sodium 138, potassium 4.3, chloride
98-232, BUN 18, creatinine 0.9, blood sugar 143.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg po bid for 7 days.
2. KCL 10 mEq po qd for 7 days.
3. Colace 100 mg po bid.
4. Aspirin 325 qd.
5. Plavix 75 mg po qd.
6. Zocor 20 mg po qd.
7. Dilaudid 2 mg q 4-6 h prn pain.
8. Lopressor 50 mg po bid.
9. Glargine 24 U subcu q hs.
10.Humalog sliding scale.
FOLLOW-UP: She will be followed by Dr. [**Last Name (STitle) 9006**] in [**1-30**] weeks,
Dr. [**First Name (STitle) 1557**] in [**4-1**] weeks, Dr. [**Last Name (STitle) 70**] in 6 weeks, and Dr.
[**Last Name (STitle) **] in 1 month.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Mitral valve regurgitation.
3. Insulin dependent diabetes.
4. Hypertension.
5. Hypercholesterolemia.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 11726**]
MEDQUIST36
D: [**2156-6-3**] 12:30
T: [**2156-6-3**] 12:30
JOB#: [**Job Number 95512**]
ICD9 Codes: 4240, 4280, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1239
} | Medical Text: Admission Date: [**2188-10-24**] Discharge Date: [**2188-10-30**]
Date of Birth: [**2109-3-11**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Oxycontin / Penicillins / Prednisone / Codeine /
Advair Diskus
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
pulmonary embolism
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a 79 yo woman with hx of non-small cell lung
cancer who was transfered from OSH with bilateral PEs. For full
HPI please see admission note. Briefly, she had last received
taxol, carboplatin, on [**2188-10-20**].She had rcvd avastin as well on
prior cycles but held due to poorly controlled BP. The patient
was at home when she noted acute worsening of chronic dyspnea
and came to [**Hospital1 18**] [**Location (un) 620**] where she was diagnosed with bilateral
PEs. She was started on heparin gtt and bedside ECHO showed RV
strain, but patient remained hemodynamically stable while in
ICU. She was transitioned to lovenox and called out to the
floor.
Past Medical History:
PAST ONCOLOGIC HISTORY:
======================
Adapted from Dr.[**Name (NI) 3279**] notes:
This patient is a former heavy smoker, although quit over 20
years ago. Developed left arm pain down in [**State 108**] late in the
spring of [**2186**]. She was evaluated for this, which included a CT
scan of the chest, which indicated a right middle lobe lung
lesion. She came back to [**Location (un) 86**] and underwent a right middle
lobectomy at [**Hospital6 **] by Dr. [**First Name (STitle) **].
She had a stage I T1 N0 2.6-cm moderately differentiated
adenocarcinoma resected by right middle lobectomy at [**Hospital 2082**] [**2186-7-11**] by Dr. [**First Name (STitle) **]. There was no vascular
lymphatic invasion. Margins were negative. Multiple lymph nodes
were sampled and were negative. She also had a mediastinoscopy
preoperatively with multiple N2 and N3 lymph nodes that were
negative. Over the next year, she had an increasing right lower
lung nodule. She underwent a CT-guided needle biopsy on [**2187-7-31**].
This was a 1.2-cm right lower lobe nodule. The report was
positive for malignancy changes consistent with non-small cell
carcinoma, favor adenocarcinoma. Finally, she did have an MRI of
her brain done at [**Hospital6 **] on [**2188-6-26**]. This
showed some mild chronic
microvascular changes but no evidence of tumor.
PAST MEDICAL HISTORY:
====================
- Non- small cell Lung cancer, adenocarcinoma as above.
- Allergic rhinitis.
- Hypertension.
- Hyperlipidemia.
- Gastroesophaeal reflux disease.
- Esophageal stricture, status post-dilation.
- Status post-total hip replacements and one knee replacement
for osteoarthritis.
Social History:
Per Dr.[**Name (NI) 79529**] note:
She is married and lives with her husband. They winter in
[**State 108**] and they live up here the rest of the time. She does not
work anymore, but used to work as an assistant to a thoracic
surgeon at the [**Location 1268**] VA. She does not drink any alcohol.
She smoked one pack a day for 30-years, but quit in [**2162**].
Family History:
There is no family history of any lung disease. Her brother had
some type of cancer, which was either a thyroid cancer or throat
cancer, the patient is not sure.
Physical Exam:
Vitals - T: 96.3 BP: 126/83 HR: 83 RR: 16 02 sat: 100% on 1L
GENERAL: NAD
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, Pale conjunctiva,
patent nares, MMM, dentures,
NECK: no LAD, no JVD
CARDIAC: RRR, S1/S2, Soft 1/6 SEM and LUSB
LUNG: Decreased breath sounds throughout, but no
Wheezes/Rales/Rhonchi.
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Pertinent Results:
[**2188-10-24**] WBC-2.3*# Hgb-10.8* Hct-31.8* Plt Ct-131*#
[**2188-10-25**] WBC-2.0* Hgb-9.7* Hct-27.8* Plt Ct-111*
[**2188-10-25**] WBC-2.0* Hgb-9.6* Hct-27.3* Plt Ct-109*
[**2188-10-26**] WBC-1.7* Hgb-9.5* Hct-27.6* Plt Ct-103*
[**2188-10-27**] WBC-1.6* Hgb-8.3* Hct-23.7* Plt Ct-74*
[**2188-10-28**] WBC-1.3* Hgb-8.1* Hct-23.6* Plt Ct-81*
[**2188-10-29**] WBC-1.4* Hgb-10.6*# Hct-30.8*# Plt Ct-109*
[**2188-10-30**] WBC-2.4*# Hgb-10.4* Hct-30.9* Plt Ct-96*
.
[**2188-10-24**] Neuts-74.5*
[**2188-10-28**] Neuts-28*
[**2188-10-29**] Neuts-9*
[**2188-10-30**] Neuts-7*
.
[**2188-10-24**] UreaN-20 Creat-1.0 Na-129* K-3.4 Cl-90* HCO3-27
AnGap-15
[**2188-10-25**] UreaN-19 Creat-0.9 Na-130* K-2.9* Cl-92* HCO3-28
AnGap-13
[**2188-10-25**] UreaN-20 Creat-1.0 Na-130* K-3.8 Cl-95* HCO3-25
AnGap-14
[**2188-10-26**] UreaN-27* Creat-1.2* Na-131* K-3.7 Cl-95* HCO3-24
AnGap-16
[**2188-10-27**] UreaN-23* Creat-1.1 Na-134 K-4.2 Cl-100 HCO3-29
AnGap-9
[**2188-10-28**] UreaN-16 Creat-0.9 Na-134 K-4.2 Cl-102 HCO3-27
AnGap-9
[**2188-10-29**] UreaN-12 Creat-1.0 Na-136 K-4.5 Cl-102 HCO3-26
AnGap-13
[**2188-10-30**] UreaN-12 Creat-1.0 Na-136 K-4.6 Cl-100 HCO3-28
AnGap-13
.
[**2188-10-25**] 12:00AM BLOOD CK-MB-6 cTropnT-0.31*
[**2188-10-25**] 10:49AM BLOOD CK-MB-4 cTropnT-0.18*
[**2188-10-25**] BLOOD Type-ART Temp-36.1 pO2-112* pCO2-37 pH-7.48*
calTCO2-28 Base XS-4
.
Images:
[**10-24**] TTE: The left atrium is normal in size. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). The right ventricular cavity is
moderately dilated with moderate global free wall hypokinesis.
There is abnormal systolic septal motion/position consistent
with right ventricular pressure overload. The aortic valve is
not well seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal left ventricular systolic function.
Moderately dilated right ventricle with moderate to severe right
ventricular dysfunction. Moderate pulmonary hypertension is
noted.
.
CT chest ([**10-24**]):
1) EXTENSIVE BILATERAL PULMONARY EMBOLISM.
2) UNCHANGED MODERATE RIGHT PLEURAL EFFUSION WITH A POSTERIORLY
LOCULATED COMPONENT.
3) QUESTIONABLE SLIGHT DECREASE IN THE RIGHT APICAL
PLEURAL-BASED
LESION AND IN THE LEFT ANTERIOR UPPER LOBE LESION. OTHER
PULMONARY
LESIONS ARE UNCHANGED.
4) UNCHANGED MEDIASTINAL AND RIGHT HILAR LYMPH NODES, UP TO 1
CM.
Brief Hospital Course:
79 yo woman with hx of non-small cell lung cancer who was
transfered from OSH with bilateral PEs.
.
# Pulmonary emboli: Patient with dyspnea much improved
throughout hospitalization. Discharged on lovenox. .
# Hypertension: patient was intermittinely hypotensive in ICU
but assymptomatic. Recieved fluid boluses with response. Home
medications were held initially. They were restarted gradually
as patient returned to baseline blood pressure. She was
discharge on a decreased dose of atenolol and no chlorthalidone
with instructions to follow with her PCP.
.
# NSCLCa with liver mets: S/p 4 weeks of chemo with taxol,
carboplatin, Avastin, on [**2188-10-20**]. Plan per primary oncologist.
.
# Pancytopenia: Secondary to chemo. Stabilized prior to
discharge and patient remained afebrile.
.
# H/o Intermittent Atrial Tachycardia: On atenolol 75mg twice
daily at home. Discharged on 50mg twice daily.
Medications on Admission:
Atenolol 75 mg [**Hospital1 **]
Atorvastatin 20 mg daily
Irbesartan-HCTZ 150/12.5 mg daily
Rabeprazole 20 mg daily
Tiotroprium 1 Cap daily
Discharge Medications:
1. Enoxaparin 100 mg/mL Syringe Sig: Ninety (90) mg Subcutaneous
every twelve (12) hours.
Disp:*3 syringes* Refills:*0*
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Aciphex 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO every other day.
6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. Irbesartan-Hydrochlorothiazide 150-12.5 mg Tablet Sig: one
half Tablet PO once a day.
8. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for itching.
9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
TID (3 times a day) as needed for oral sores: before meals if
needed.
Disp:*100 ML(s)* Refills:*2*
11. Formoterol Fumarate 20 mcg/2 mL Solution for Nebulization
Sig: One (1) solution Inhalation twice a day as needed for
shortness of breath or wheezing.
Disp:*60 solutions* Refills:*3*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: pulmonary embolism
Secondary: lung cancer, hypertension
Discharge Condition:
Good
Discharge Instructions:
Dear Ms. [**Known lastname **],
You were admitted because you had a blood clot that traveled to
your lungs. We started you on medication to prevent clot
formation called Lovenox.
The following changes were made to your medications:
START Lovenox 90mg (0.9cc) inject subcutaneously twice daily
START Perforomist nebulizer twice daily
STOP Chlorthalidone
Please continue all other medications as prescribed.
You should see Dr. [**Last Name (STitle) 3274**] in the next two weeks in his office
in [**Location (un) 620**].
Please call your doctor or 911 if you have chest pain, worsened
shortness of breath or for any other concern.
Followup Instructions:
Please call to make an appointment with Dr. [**Last Name (STitle) 3274**] within two
weeks.
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2188-11-27**] 3:40
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2188-11-27**] 4:00
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 1112**]/DR. [**Last Name (STitle) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2188-11-27**] 4:00
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
ICD9 Codes: 2761, 4019, 496, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1240
} | Medical Text: Admission Date: [**2118-12-11**] Discharge Date: [**2118-12-20**]
Date of Birth: [**2053-11-10**] Sex: F
Service: MEDICINE
Allergies:
Zosyn / ceftriaxone
Attending:[**First Name3 (LF) 2782**]
Chief Complaint:
Unresponsiveness, altered, intubated for airway protection found
to have urosepsis
Major Surgical or Invasive Procedure:
intubated, mechanical ventilation
History of Present Illness:
65 yo female with MS [**First Name (Titles) **] [**Last Name (Titles) 84078**] for questionable hx TMJ who was
sent in from her NSH after being found covered in vomit with
agonal breathing. NSH notes reports "symptoms of seizure
activity" with patient subsequently unresponsive and found to be
hypoxic with sats <83% on 2L. Per EMS, she was unresponsive en
route, still breathing but not withdrawing to pain.
.
In the ED, initial vitals were: no temp recorded, 118 135/71 34
100% on NRB. She was easily intubated for airway protection
with a grade 1 view. Head CT was unremarkable for bleed. Neuro
was consulted and felt this was likely toxic metabolic if
seizure activity, but will continue to follow. She has had
multiple episodes of UTI in the past. Blood and urine cultures
were sent and she was given vanco/zosyn. Foley was changed.
Per the ED resident, they were not aware of her potential
allergy but she did not have a rash prior to transfer to the
MICU. When the patient was signed out she was currently doing
well on vent with most recent vitals prior to transfer being
afeb, 92, 103/60 with sats 100% on 400x18, 5x50%. She dropped
her pressures prior to transfer to 67/41 with HR 94. She was
given 2L of IVF and started on levophed. Sedation was held.
.
Of note, per Dr.[**Name (NI) 84079**] note to her PCP, [**Name10 (NameIs) **] last admission was
for urinary tract infection, E. coli bacteremia, and sepsis, and
initially required admission to the ICU for vasopressor support.
She was also found to have an obstructing left renal stone and
had a percutaneous nephrostomy tube placed with improvement in
her infection. She was able to be taken of vasopressor agents
and was discharged to complete a 14 day total course of
antibiotics. At that time, urology recommended to leave the
nephrostomy tube in the left renal system indefinitely with tube
changes every 3 months as she was high risk for both
nephrolithotomy and extracorporeal shock wave lithotripsy. Her
hospital course was also notable for hypoxia with a 4L oxygen
requirement which was felt to be due to a combination of mild
volume overload, respiratory muscle weakness in the setting of
multiple sclerosis and infection, and intermittent aspiration.
Her oxygen requirement was stable and she was discharged to
rehab to have gentle diuresis as tolerated and tocontinue her
usual dysphagia diet. She has been on 2L at her NSH with
unclear continued workup.
.
Past Medical History:
Multiple Sclerosis - about 14yrs, followed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Location (un) 2274**]
- wheelchair at baseline, lives in nursing home
- has no use of her lower extremities, sometimes spastic
movements
- bladder chronically contracted
UTI with ESBL E.coli--sensitive to zosyn, [**Last Name (un) 2830**], gent in past
[**Last Name (un) 8304**] Depression
Anxiety
PVD s/p lower extremity bypass
COPD
Osteoporosis
Hx of +PPD
bilateral femur supracondylar fractures [**2113**]
hx of Urosepsis - hospitalized about once/yr, per husband
Neurogenic bladder - indwelling foley x [**4-27**] [**Last Name (LF) 1686**], [**First Name3 (LF) **] husband
Recurrent C. Diff
Hx of Sacral Decub
LE spasticity
Hx of jaw pain -- ?TMJ, improved on [**First Name3 (LF) **]
Social History:
Lives in nursing home for last 4 [**First Name3 (LF) 1686**]. Husband is HCP, lives
with one of their daughters. [**Name (NI) **] daughter married and lives
in the area. Nonambulatory and in wheelchair at baseline,
dependent for transfers and some of ADLs. Has no use of lower
extremities at baseline. On pureed thickened liquids at rehab.
-Tobacco: started at age 20, quit about 15yrs ago
-ETOH: social, occasional, per husband
-[**Name (NI) 3264**]: none
Family History:
No family members with Multiple Sclerosis.
Physical Exam:
Admission exam
Vitals: 101.9 100 117/64 17 100% on 400x18, 5x50%
General: Intubated, sedated, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
blood around mouth, no lesions identified
Neck: supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, ronchi
Abdomen: +BS, soft, non-tender, non-distended, no organomegaly
Back: stage 2 sacral decub on right buttocks, stage 1 decub on
left hip, left perc neph tube in place and c/d/i
GU: +foley
Ext: cool, well perfused, 2+ pulses distally, no clubbing,
cyanosis or edema, moving her toes, PICC line in right upper arm
is c/d/i
Neuro: sedated
Discharge Exam:
Afebrile
Gen: Alert, awake, responding appropriately to questions, soft
spoken with some slurring of speech
HEENT: dry MM
CV: RRR, no MRG
Lungs: poor inspiratory effort, no wheezes, crackles,
consolidations
Abd: +BS, soft, NT, surgical scars
Back: Decub
GU: Foley and left perc nephrostomy CDI
Neuro: baseline
Pertinent Results:
ADMISSION LABS:
[**2118-12-11**] 01:49PM GLUCOSE-103* UREA N-16 CREAT-0.7 SODIUM-142
POTASSIUM-4.2 CHLORIDE-110* TOTAL CO2-25 ANION GAP-11
[**2118-12-11**] 01:49PM CALCIUM-8.0* PHOSPHATE-2.7 MAGNESIUM-1.8
[**2118-12-11**] 06:23AM CK-MB-7 cTropnT-0.50*
[**2118-12-11**] 06:23AM ALT(SGPT)-30 AST(SGOT)-72* CK(CPK)-90 ALK
PHOS-183* TOT BILI-0.4
[**2118-12-11**] 06:23AM WBC-14.7*# RBC-3.40* HGB-9.9* HCT-31.1*
MCV-91 MCH-29.0 MCHC-31.7 RDW-15.5
DISCHARGE LABS:
[**2118-12-20**] 06:07AM BLOOD WBC-6.0 RBC-3.09* Hgb-8.6* Hct-27.4*
MCV-89 MCH-27.7 MCHC-31.2 RDW-15.5 Plt Ct-407
[**2118-12-19**] 10:46AM BLOOD Neuts-67.6 Lymphs-22.0 Monos-4.6 Eos-5.1*
Baso-0.6
[**2118-12-20**] 06:07AM BLOOD Glucose-75 UreaN-7 Creat-0.4 Na-141 K-3.9
Cl-106 HCO3-31 AnGap-8
[**2118-12-13**] 05:54AM BLOOD ALT-16 AST-20 LD(LDH)-180 AlkPhos-130*
TotBili-0.2
[**2118-12-20**] 06:07AM BLOOD Calcium-8.3* Phos-2.9 Mg-2.0
TTE:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is mild to moderate regional left ventricular systolic
dysfunction with hypokinesis of the distal half of the septum
and apical anterior and inferior walls. The remaining segments
contract well (LVEF 40%). The apex is not aneurysm and no apical
thrombus is seen. The estimated cardiac index is normal
(>=2.5L/min/m2). 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 and
no aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with regional systolic dysfunction c/w CAD (mid-LAD
distribution). Pulmonary artery hypertension.
CTAbd/pelvis:
IMPRESSION:
1. Foley catheter is now positioned with its distal tip seen in
the right
ureter. Repositioning is recommended. These findings were
discussed with Dr. [**Last Name (STitle) **] Dr. [**Last Name (STitle) **] by telephone at 12:10 a.m. on
[**2118-12-12**].
2. Left nephrostomy tube with small left subcapsular hematoma
and unchanged left ureteropelvic junction stone.
3. No evidence of small-bowel obstruction despite large amount
of stool seen within the rectum and sigmoid.
4. Unchanged right renal staghorn calculus.
Renal US:
IMPRESSION:
1. Right renal stones without hydronephrosis.
2. Unchanged mild left collecting system fullness.
Brief Hospital Course:
65 yo female with history of MS [**First Name (Titles) 151**] [**Last Name (Titles) **] indwelling foley
and left percutaneous nephrostomy tube found to be unresponsive
admitted to the MICU with septic shock secondary to Pseudomonas
urosepsis. The patient was started on Meropenem and did well on
the floor.
.
1. Sepsis: Urosepsis due to pseudomonas in setting of
obstructing stone. Pt with known obstructing staghorn in R, & L
percutaneous nephrostomy for ureteral stone. The patient had
been on suppressive ertapenem, but this was switched to
Meropenem 500mg IV Q6hr given ID recs and better urinary
penetration. ID evaluated the patient and felt she should
continue on this antibiotic until obstruction relieved. The
patient was started on methemazine and ascorbic acid for
symptomatic relief. Pt will follow up with outpatient urology to
undergo intraoperative lithotripsy/stone extraction.
.
2. Elevated troponin/Possible NSTEMI: Pt's troponin found to be
elevated on admission. This was likely secondary to demand
ischemia in the setting of hypotension. An echo was formed that
showed wall motion abnormalities, the chronicity of which could
not be determined. The patient's troponin trended down and she
was monitored on telemetry for several days with no events.
.
3. Multiple sclerosis: The patient had relapsing and remitting
MS treated with Glatimer. Our neuro colleagues were initially
consulted to determine whether her altered mental status was
neurological in origin. They determined that it was not and did
not change her treatment regimen. She remains on Baclofen,
Glatimer, and cyclobenzaprine.
.
4. Hyperlipidemia: Continue simvastatin
.
5. Depression: Continue citalopram
.
6. CODP: Respiratory status stable. Continue nebulizers/inhalers
.
7. Follow Up: The patient will follow up with urology for
elective stone removal. She will continue on meropenem until
urinary obstruction is remedied.
.
Transitional Issues: The patient had yeast grow in 2 of 2 urine
cultures. With her h/o urosepsis and indwelling catheters, we
called her rehab facility and recommended starting Fluconazole.
As an outpatient, the patient should be started on a low dose
B-blocker given her NSTEMI. She should have outpatient
cardiology follow-up at some point as well.
Medications on Admission:
1. methenamine hippurate 1 gram Tablet Sig: One (1) Tablet PO
bid
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
3. carbamazepine 100 mg Tablet, Chewable Sig: one daily
4. Carbamazepine 100 mg Tablet, Chewable Sig: Three (3) Tablet
[**Hospital1 **]
5. baclofen 10 mg Tablet Sig: One (1) Tablet PO twice a day.
6. glatiramer 20 mg Kit Sig: Twenty (20) mg Subcutaneous Daily
7. Os-Cal 500 + D 500 mg(1,250mg) -200 unit Tablet daily
8. alendronate 70 mg Tablet PO once a week.
9. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. donepezil 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS prn insomnia.
12. cranberry 250 mg Tablet Sig: One (1) Tablet PO once a day.
13. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet daily
14. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for nebs
q4h
15. ipratropium bromide 0.02 % Solution Sig: One (1) neg q6h
16. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
17. vitamin E 1,000 unit Capsule Sig: One (1) Capsule PO daily
18. senna 8.6 mg Tablet Sig: One (1) Tablet PO prn constipation
19. potassium chloride 20 mEq Packet Sig: One (1)daily
20. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) Rectal q
M/W/F.
21. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID
22. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff [**Hospital1 **]
23. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush q8h
prn
24. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC
25. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID
26. meropenem 500 mg Recon Soln Sig: One (1)IV q8 hours for 5
days.
Discharge Medications:
1. methenamine hippurate 1 gram Tablet Sig: One (1) Tablet PO
BID (2 times a day).
2. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. baclofen 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Other
glatiramer 20 mg Kit Sig: Twenty (20) mg Subcutaneous Daily
5. Os-Cal 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1)
Tablet PO once a day.
6. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
7. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
9. Other
Trazodone 25 mg QHS PRN insomnia
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Nebulizer Inhalation every 4-6 hours
as needed for SOB, wheeze.
12. ipratropium bromide 0.02 % Solution Sig: One (1) Nebulizer
Inhalation every 6-8 hours as needed for shortness of breath or
wheezing.
13. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
14. vitamin E 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for Constipation.
16. potassium chloride 20 mEq Packet Sig: One (1) Packet PO once
a day.
17. Other
Fleet enema Q M/W/F
18. docusate sodium 50 mg/5 mL Liquid Sig: Two (2) Tablespoons
PO BID (2 times a day).
19. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puffs
Inhalation twice a day.
20. 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.
21. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
22. Meropenem 500 mg IV Q6H
Day 1 = [**12-11**]
23. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
24. carbamazepine 100 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day: Daily at noon.
25. carbamazepine 300 mg Cap, ER Multiphase 12 hr Sig: One (1)
Cap, ER Multiphase 12 hr PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 583**] House Rehab & Nursing Center
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Sepsis from a urinary source related to [**Location (un) **] partial
obstruction and [**Location (un) **] nephrolithiasis
- [**Location (un) 8304**] indwelling Foley and Perc nephrostomy tube on Left
- Demand cardiac ischemia
SECONDARY DIAGNOSES:
- Multiple Sclerosis
Discharge Condition:
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Mental Status: Confused - sometimes.
Discharge Instructions:
Ms. [**Known lastname **], it was a pleasure to participate in your care while
you were at [**Hospital1 18**]. You came to the hospital after you were found
unresponsive. You were admitted to the MICU where you were
ultimately found to have septic shock due to a urinary tract
infection and a large infected kidney stone. You were evaluated
by several specialists including the infectious disease team and
the urology team. You antibiotics were changed while you were
here. You will need to follow up with your urologist for kidney
stone removal in the near future.
Followup Instructions:
It is recommended that you have a lithotripsy within the next
1-3 days. Please discuss with your urologist the best time to
have this done.
ICD9 Codes: 2760 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1241
} | Medical Text: Admission Date: [**2124-11-4**] Discharge Date: [**2124-11-7**]
Date of Birth: [**2066-11-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
transferred from OSH with ARF, SBP
Major Surgical or Invasive Procedure:
central venous catheter placement
arterial line placement
intubation
thoracentesis
History of Present Illness:
57 M with PMH of metastatic papillary renal cancer currently on
the phase II XL880 protocol who initially presented today to
[**Hospital3 8544**] with several days of worsened lower extremity
swelling, abd pain, malaise, and vomiting. He was recently
admitted to [**Hospital1 18**] from [**10-23**] - [**10-28**] for "swelling problems" and
says by discharge he was feeling quite well. He was at home when
4 days prior to presentation he began to have worsened lower
extremity and abdominal swelling. He also started to feel weak
and cold, and notes that while he usually has a temp of about 98
PO, his NVA noted he was running presistently low, around 94 PO.
He tried to treat with warming blankets without improvement. He
noted decreased appetite, decreased PO intake, and worsened abd
pain. He decided to go to the ED today after vomiting 3-4 times.
He also notes that he had not had any urine for about 1 day
immediately prior to admission. He says that he has recently
been treated with both lasix and spironolactone for his lower
extremity swelling/ascites with minimal improvement.
.
At [**Hospital3 8544**] ED he had a pericentesis which showed 1750
white cells and was treated with Zosyn for SBP. He also received
Kayexalate 30 grams and an unclear amount of NS with resultant
urine output via foley. He was transferred to [**Hospital1 18**] for further
evaluation and treatment.
.
In the [**Hospital1 18**] ED, patient received 500 cc normal saline, 400 mg
of cipro, and 1 amp of calcium gluconate. Patient has recurrent
emesis x 1 and was treated with zofran.
Past Medical History:
ONC HX:
Diagnosed with metastatic renal cell cancer after he developed a
lingering cough and dyspnea and was found to have loss of lung
volume in the left lung in [**7-14**]. CT scan showed an obstructing
lesion in his left main stem bronchus with atelectasis of his
entire left lung. CT scan of his torso as well as PET scanning
showed lesions in his left kidney, left main stem bronchus,
periaortic lymph node, and his thyroid. On flexible
bronchoscopy, performed on [**2123-9-1**] by Dr. [**First Name (STitle) **] [**Name (STitle) **], he
underwent debulking of the endobronchial lesion and had
resultant hemoptysis. He has subsequently received a course of
radiation treatment which he completed on [**9-29**]. He had a
successful tumor excision, tumor destruction of the left
mainstem obstruction and placement of a 12 mm x 40 mm covered
Ultraflex stent to achieve left lower lobe patency. Since that
time, and has decided to enroll in phase 2 XL 880 treatment and
begin stage 2 XL880 research protocol 06-132 on [**2123-11-22**].
.
PMH:
# metastatic papillary RCC as noted above.
# GERD
# s/p appendectomy
Social History:
He lives alone, is divorced, and has a 16-year-old daughter. [**Name (NI) **]
works as a heavy equipment mechanic and supervisor. He is
currently not working, though he remains employed. He has never
smoked. He drinks approximately one to two drinks per day;
however, he has not drunk since his initial diagnosis.
Family History:
CAD and DM in father. Mother died in 40s from liver disease,
which was possibly alcohol-related.
Physical Exam:
VS: T: 96.7 P: 102 BP: 93/67 RR: 22 O2 sat: 100% on 4L
GEN: cachectic, NAD
HEENT: EOMI, anicteric, clear OP, MMM, neck supple
Lungs: CTAB, decreased BS on the L, no w/r/r
Heart: RRR, nl S1, S2, no m/r/g
Abd: firm, distended, tender to light palpation, no rebound, no
guarding, + 1 pitting edema
Ext: + 2 pitting edema to knees bilaterally, cool to touch but
+2 distal pulses
Neuro: A&Ox3. Appropriate. CN 2-12 grossly intact.
Pertinent Results:
[**2124-11-4**] 04:45PM BLOOD WBC-21.1*# RBC-4.53* Hgb-11.2* Hct-35.8*
MCV-79* MCH-24.7* MCHC-31.3 RDW-19.7* Plt Ct-446*
[**2124-11-5**] 05:35AM BLOOD WBC-28.2* RBC-4.94 Hgb-12.0* Hct-39.2*
MCV-79* MCH-24.3* MCHC-30.6* RDW-18.3* Plt Ct-380
[**2124-11-5**] 03:01PM BLOOD WBC-26.7* RBC-4.79 Hgb-11.8* Hct-38.0*
MCV-79* MCH-24.7* MCHC-31.1 RDW-19.4* Plt Ct-378
[**2124-11-6**] 04:00AM BLOOD WBC-32.0* RBC-4.31* Hgb-10.7* Hct-34.6*
MCV-80* MCH-24.7* MCHC-30.8* RDW-18.4* Plt Ct-284
[**2124-11-4**] 04:45PM BLOOD PT-14.3* PTT-25.9 INR(PT)-1.3*
[**2124-11-5**] 05:35AM BLOOD PT-13.3* PTT-23.6 INR(PT)-1.2*
[**2124-11-5**] 03:01PM BLOOD PT-15.0* PTT-26.4 INR(PT)-1.3*
[**2124-11-6**] 04:00AM BLOOD PT-18.3* PTT-33.7 INR(PT)-1.7*
[**2124-11-4**] 04:45PM BLOOD Glucose-104 UreaN-36* Creat-2.0*# Na-136
K-4.7 Cl-104 HCO3-22 AnGap-15
[**2124-11-6**] 04:00AM BLOOD Glucose-120* UreaN-48* Creat-3.2* Na-134
K-5.6* Cl-100 HCO3-18* AnGap-22
[**2124-11-6**] 06:17PM BLOOD Glucose-125* UreaN-54* Creat-3.7* Na-132*
K-5.4* Cl-98 HCO3-17* AnGap-22*
[**2124-11-6**] 04:00AM BLOOD ALT-21 AST-36 LD(LDH)-622* AlkPhos-106
TotBili-0.3
[**2124-11-4**] 04:45PM BLOOD Albumin-2.0* Calcium-6.3* Phos-5.6*#
Mg-1.7
[**2124-11-6**] 06:17PM BLOOD Calcium-6.2* Phos-8.6* Mg-2.4
[**2124-11-5**] 07:28PM BLOOD Type-ART Temp-34.8 pO2-88 pCO2-41
pH-7.30* calTCO2-21 Base XS--5 Intubat-NOT INTUBA
[**2124-11-6**] 12:37AM BLOOD Type-ART Temp-37.2 PEEP-5 FiO2-100
pO2-227* pCO2-55* pH-7.17* calTCO2-21 Base XS--8 AADO2-439 REQ
O2-75 Intubat-NOT INTUBA
[**2124-11-6**] 04:07AM BLOOD Type-ART Temp-36.5 PEEP-5 pO2-118*
pCO2-42 pH-7.27* calTCO2-20* Base XS--7 Intubat-INTUBATED
[**2124-11-5**] 07:28PM BLOOD Lactate-2.7*
[**2124-11-6**] 12:37AM BLOOD Lactate-2.6*
.
.
.
.
.
Studies:
EKG [**2124-11-4**]:
Sinus tachycardia. Borderline left axis deviation. Small
non-diagnostic
Q waves in lateral leads. Poor R wave progression which is
non-diagnostic.
Low QRS voltage in limb leads. Compared to tracing of [**2124-10-23**]
heart rate is significantly faster. Clinical correlation is
suggested.
CXR [**2124-11-4**]:
IMPRESSION:
No significant interval change versus prior study with no new
airspace
disease. Effusion and consolidation persistent on the left, the
latter
perhaps post-obstructive but superimposed pneumonia cannot be
excluded.
Renal U/S [**2124-11-5**]:
IMPRESSION:
1. No evidence of hydronephrosis. However, both kidneys are
markedly
compressed by very large renal cysts. The left renal cyst is
slightly
increased in size compared to [**2124-10-27**].
2. Insufficient amount of ascites to perform paracentesis
CXR [**2124-11-6**]:
IMPRESSION: Increasing opacification in the left hemithorax
consistent with pleural fluid. Endotracheal tube tip in good
position
CXR [**2124-11-6**]:
FINDINGS: In comparison with earlier films of this date, there
is better
aeration of the upper half of the left lung. There may have been
an interval thoracentesis. Otherwise, little change with tubes
remaining in place.
Brief Hospital Course:
ASSESSMENT/PLAN:
57 M with PMH of metastatic papillary renal cancer on the phase
II XL880 protocol who initially presented to [**Hospital3 8544**]
with several days of worsened lower extremity swelling, abd
pain, malaise, and vomiting, found to have SBP on paracentesis
at [**Hospital **] transfered to ICU with worsening ARF and sepsis.
.
1. SBP / Sepsis / Hypotension:
OSH records reported paracentesis consistent with SBP. He was
given a dose of zosyn then continued on ceftriaxone at [**Hospital1 18**],
which was then changed to vancomycin/zosyn. He was hypothermic
with a leukocytosis and hypotension. He was fluid resiscitated
but required levophed and vasopressin to keep MAP > 65. Other
sources of infection include urine (WBC on UA), lungs (vomited
with possible aspiration). He also had a pleural effusion which
was drained. Despite these interventions, Mr. [**Known lastname **] did not
improve and he was made comfort measures only on [**2124-11-6**]. He
expired on [**2124-11-7**].
.
2. Acute renal failure:
Most likely combination of obstruction and prerenal etiology.
Patient also had hypocalcemia and hyperphosphatemia.
.
3. Respiratory failure:
Most likely multifactorial in nature. Has renal mets to lungs.
?Infection/sepsis. Volume overload may also contribute to SOB.
He was made CMO as above.
Medications on Admission:
celexa 60 mg PO QD
oxycodone 5 mg PO q4-6 hours PRN pain
sunitinib 50 mg PO daily x 28 days, then 14 days off
toprol xl 100 PO QD
verapamil 120 PO QD
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
sepsis
spontaneous bacterial peritonitis
acute renal failure
Renal cell carcinoma
Secondary:
1. Metastatic papillary RCC
Diagnosed with metastatic renal cell cancer after he developed a
lingering cough and dyspnea and was found to have loss of lung
volume in the left lung in [**7-14**]. CT scan showed an obstructing
lesion in his left main stem bronchus with atelectasis of his
entire left lung. CT scan of his torso as well as PET scanning
showed lesions in his left kidney, left main stem bronchus,
periaortic lymph node, and his thyroid. On flexible
bronchoscopy, performed on [**2123-9-1**] by Dr. [**First Name (STitle) **] [**Name (STitle) **], he
underwent debulking of the endobronchial lesion and had
resultant hemoptysis. He has subsequently received a course of
radiation treatment which he completed on [**9-29**]. He had a
unuccessful tumor excision, tumor destruction of the left
mainstem obstruction and placement of a 12 mm x 40 mm covered
Ultraflex stent to achieve left lower lobe patency. Since that
time, and has decided to enroll in phase 2 XL 880 treatment and
begin stage 2 XL880 research protocol 06-132 on [**2123-11-22**].
2. GERD
3. s/p appendectomy
4. Hx of SVT
5. Hx of DVT s/p filter placement
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
ICD9 Codes: 5849, 0389, 2762, 5185 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1242
} | Medical Text: Admission Date: [**2133-11-6**] Discharge Date: [**2133-11-24**]
Date of Birth: [**2077-2-8**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Procardia
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
perforated viscus
Major Surgical or Invasive Procedure:
[**2133-11-9**] washout, transverse colostomy, fascial closure
[**2133-11-8**] washout, transverse colectomy, open/discontinuity
[**2133-11-6**] exlap, L colectomy, open abdomen, dicontinuity
History of Present Illness:
56F with two prior episodes of diverticulitis now with
intermittent abdominal pain for 10-14 days worsening over the
day prior to admission, found to have large recto-sigmoid perf,
taken to OR, sigmoid resected, rectum stapled, proximal colon
stapled, and abdomen left open on [**11-7**], admitted to ICU and
started on CVV for acute renal failure.
Past Medical History:
PMH: diverticulosis c/b LGIB ([**2131**], [**2132**]) and diverticulitis x
2, proteinuria, bladder cancer s/p cystoscopic resection,
diastolic heart failure (EF 55%), asthma, HTN
PSH: TURBT x 2 for bladder tumor, colonoscopy
[**2128**],[**2131**],[**2132**](diverticulosis starting at cecum)
Social History:
The patient currently lives in [**Location **] alone. She is single, 1
son. The patient has no HCP. The patient is currently on
disability for arthritis. She previously worked in food
services, bartending, catering. Tobacco: [**1-4**] PPD x 40 years
ETOH: Prior heavy use, has since quit Illicits: None
Family History:
Mother with DM, HTN, diverticulitis, angina at the age of 38 and
CVA at age 48 from which she passed away.
Physical Exam:
Physical Exam:
Vitals: T 98.1 HR 133 BP 188/122 RR 24 O2 Sat 96% 4L
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes dry
CV: tachycardic, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, distended, absent bowel sounds, diffusely TTP with
rebound but no guarding
DRE: soft, brown stool, guiac negative, no masses
Ext: No LE edema, LE warm and well perfused
Physical examination upon discharge:
[**2133-11-23**]:
vital signs: t=97, bp 124/73, hr=67, oxygenation room air 96%,
resp. rate 18
General: NAD, sitting in chair, pleasant, conversant
CV: ns`1, s2, -s3, -s4, no murmurs
LUNGS: Clear, diminished BS left side and bases
ABDOMEN: Ostomy left side abdomen, stoma retracted, golden
yellow loose stool in bag. Mid-line incision with moist to dry
dressing.
EXT: no pedal edema bil., + dp bil, feet warm, no calf
tenderness bil.
NEURO: alert and oriented x 3, speech clear, no tremors
Pertinent Results:
[**2133-11-23**] 05:03AM BLOOD WBC-14.5* RBC-3.16* Hgb-9.4* Hct-28.5*
MCV-90 MCH-29.6 MCHC-32.9 RDW-15.1 Plt Ct-823*
[**2133-11-22**] 01:54AM BLOOD WBC-14.2* RBC-3.07* Hgb-9.0* Hct-27.9*
MCV-91 MCH-29.3 MCHC-32.3 RDW-15.4 Plt Ct-760*
[**2133-11-6**] 03:50PM BLOOD Neuts-80* Bands-0 Lymphs-12* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-4* Myelos-0
[**2133-11-23**] 05:03AM BLOOD Plt Ct-823*
[**2133-11-22**] 01:54AM BLOOD Plt Ct-760*
[**2133-11-14**] 02:19AM BLOOD PT-15.3* PTT-29.0 INR(PT)-1.3*
[**2133-11-23**] 05:03AM BLOOD Glucose-161* UreaN-33* Creat-0.9 Na-141
K-3.9 Cl-107 HCO3-20* AnGap-18
[**2133-11-22**] 01:54AM BLOOD Glucose-107* UreaN-41* Creat-1.0 Na-146*
K-3.7 Cl-109* HCO3-25 AnGap-16
[**2133-11-21**] 03:29PM BLOOD Glucose-105* UreaN-38* Creat-0.8 Na-147*
K-3.4 Cl-113* HCO3-22 AnGap-15
[**2133-11-16**] 02:00AM BLOOD ALT-23 AST-15 LD(LDH)-268* AlkPhos-309*
TotBili-0.9
[**2133-11-9**] 08:16AM BLOOD ALT-17 AST-35 AlkPhos-82 TotBili-1.3
[**2133-11-23**] 05:03AM BLOOD Calcium-9.4 Phos-3.7 Mg-2.1
[**2133-11-16**] 07:20AM BLOOD Vanco-12.7
[**2133-11-15**] 08:02AM BLOOD Vanco-14.8
[**2133-11-20**] 02:55AM BLOOD Lactate-1.2
[**2133-11-20**] 02:55AM BLOOD freeCa-1.18
[**2133-11-6**]: EKG:
Sinus tachycardia. Poor R wave progression. Non-specific ST
segment depression most pronounced in the lateral leads.
Compared to the previous tracing of [**2133-9-3**] sinus tachycardia and
ST segment depression are new.
[**2133-11-6**]: cat scan of abdomen pelvis:
IMPRESSION:
1. Multiple locules of free air and mesenteric fluid surrounding
abnormal-appearing loops of small bowel in the right lower
quadrant and left mid to lower abdomen consistent with bowel
perforation and concern for ischemia. These loops of bowel
demonstrate wall thickening; however, they remain enhancing. An
air and fluid extraluminal collection in the right pelvis has
the appearance of stool and abuts small bowel and the sigmoid
colon.
Extensive colonic diverticulosis, particularly along the sigmoid
colon.
2. Fat-containing ventral wall hernia with engorged vessels.
[**2133-11-7**]: ECHO:
Conclusions
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is moderate global left ventricular hypokinesis
(LVEF = 30-35 %). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. No mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is no pericardial effusion.
IMPRESSION: Moderately depressed left ventricular systolic
function.
[**2133-11-12**]: chest x-ray:
Continued progressive worsening of volume status, with
increased cardiomegaly, bilateral effusions and pulmonary edema.
Dense retrocardiac opacity most likely reflects volume loss.
[**2133-11-13**]: EKG:
Sinus tachycardia, rate 102. Left atrial abnormality.
Non-specific ST-T wave changes in leads I, II and V3-V6.
Compared to the previous tracing of [**2133-11-6**] the rate has slowed
from sinus tachycardia, rate 129, to sinus tachycardia, rate
102. The non-specific ST-T wave changes are less prominent on
the current tracing. Otherwise, no diagnostic interval change.
[**2133-11-20**]: chest x-ray:
Asymmetric pulmonary edema now involves the left upper lobe.
Left lower lobe remains consolidated, and there is a large band
of atelectasis in the right mid lung. Right upper lung is clear.
Mild cardiomegaly is stable. Tip of the endotracheal tube above
the upper margin of the clavicles is at least 5 cm above the
carina, 15 mm above the optimal placement. Nasogastric tube
passes below the diaphragm and out of view. Left subclavian line
ends in the mid SVC. No pneumothorax.
[**2133-11-21**]: chest x-ray:
FINDINGS: As compared to the previous radiograph, the patient
has been
extubated. The left central venous access line and the
nasogastric tube are in unchanged position. Unchanged left
pleural effusion with retrocardiac atelectasis and right basal
atelectasis. No newly appeared focal parenchymal opacities
[**2133-11-6**]:
[**2133-11-6**] 3:50 pm BLOOD CULTURE #1.
**FINAL REPORT [**2133-11-12**]**
Blood Culture, Routine (Final [**2133-11-12**]):
BACTEROIDES FRAGILIS. BETA LACTAMASE POSITIVE.
Anaerobic Bottle Gram Stain (Final [**2133-11-7**]):
Reported to and read back by [**Doctor First Name 102202**] PAPAVSTRAVROU @ 2100
ON [**11-7**] -
CC6C.
GRAM NEGATIVE ROD(S).
[**2133-11-6**]: peritoneal fluid:
[**2133-11-6**] 9:48 pm PERITONEAL FLUID
**FINAL REPORT [**2133-11-13**]**
GRAM STAIN (Final [**2133-11-7**]):
Reported to and read back by DR. [**Last Name (STitle) **]. RAYKAR ON [**2133-11-7**] AT
0245.
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
FLUID CULTURE (Final [**2133-11-13**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
ANAEROBIC CULTURE (Final [**2133-11-13**]):
Mixed bacterial flora-culture screened for B. fragilis, C.
perfringens, and C. septicum.
BACTEROIDES FRAGILIS GROUP.
HEAVY GROWTH OF TWO COLONIAL MORPHOLOGIES.
BETA LACTAMASE POSITIVE
[**2133-11-16**]: sputum:
[**2133-11-16**] 11:59 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2133-11-18**]**
GRAM STAIN (Final [**2133-11-16**]):
[**10-27**] PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2133-11-18**]): NO GROWTH
Brief Hospital Course:
56 year old female admitted to the acute care service with
diffuse abdomional pain. Upon admission, she was made NPO,
given intravenous fluids, and underwent radiographic imaging.
She was found to have a recto-sigmoid perforation. She was taken
to the operating room for an exploratory laparotomy and left
colecomy.
In the operating room a large rectosigmoid perforation was
noted, the sigmoid was resected, rectum stapled, proximal colon
stapled, an ostomy was not brought up given edema, abdomen was
left open). She received 10 liters of fluid between the
emergency room and the operating room. Post-op, she was kept
intubated and transferred to the intensive care unit on pressor
for blood pressure support and for monitoring.
24 hours post-op, she returned to the operating room for
abdominal washout. Her abdomen was left open because of excess
fluid and she was started on a lasix drip. Despite lasix, she
had a poor urine output and Nephrology was consulted. A
hemodialysis catheter was placed and she was started on CVVH to
remove excess fluid. During this time, she was febrile to 102.7
and cultures sent.
She returned to the operating room on POD #2 for washout and a
transverse colectomy. Her abdomen was left open and CVVH resumed
to remove excess fluid. The CVVH was discontinued on [**11-10**]
after she started to have adequate response from lasix. On POD
#3, she returned again to the operating room for washout,
transverse colostomy and fascial closure.
On POD #8, she was reported to have a rise in her white blood
cell count and became hypertensive. She had a mild elevation in
her creatinine and she was found to be wet on chest x-ray. She
received lasix and had an adequate diuresis. Her pulmonary
status improved and the dialysis cath was discontinued. To help
with her nutritional status, she was started on trophic tube
feedings.
She was reported on POD #9 to have a slight worsening of her
chest x-ray and had a free water restriction placed with her
nutritional supplements. At this time, diuresis continued.
Because she was becoming alkalotic from the diuresis she was
started on diamox with careful monitoring of her electrolytes.
On POD # 14, her electrolytes normalized and her oxygenation and
chest x-ray improved. She was successfully extubated.
Twenty-four hours later, her feeding tube was discontinued and
she was started on a regular diet.
She was transferred to the surgical floor on [**11-22**]. Her foley
catheter was discontinued and she has been voiding without
difficulty. She had a vac dressing placed onto her abdominal
wound to assist with wound closure. She was evaluated by
physical therapy andrecommendations made for discharge to a
rehabilitation facility.
Her vital signs are stable and she is afebrile. Her hematocrit
has stabilized at 29 and her creatinine has stabilized at 0.9.
She is tolerating a regular diet. Her pulmonary status is stable
with an oxygen saturation of 94% on room air. She has resumed
her cardiac medications.
She is preparing for discharge to a rehbilitation facility with
follow-up appoinments with the acute care service, cardiology,
and her primary care provider.
[**Name10 (NameIs) **] will need close monitoring of her electrolytes since she has
resumed her cardiac medications.
She will need re-application of the Vac dressing to the abdomen
with vac dressing changes q 72 hours
Medications on Admission:
[**Last Name (un) 1724**]: albuterol, diltiazem ER 300', enalapril 20'', felodipine ER
5', propafenone225 ER'', spritulina, vit C 500', asa81',
cholecalciferol 1000', mag500', melatonin 2.5HS', MVI, Vit E
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheeze.
3. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain: hold for increased sedation, resp.
rate <12.
5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
hold for diarrhea.
7. diltiazem HCl 300 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily): hold for blood
pressure <100, hr <60.
8. enalapril maleate 20 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): hold for blood pressure <100, hr <60, continue to
monitor K+.
9. felodipine 5 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO DAILY (Daily): hold for blood
pressure <100, hr<60.
10. propafenone 150 mg Tablet Sig: One (1) Tablet PO Q 8H (Every
8 Hours).
11. Insulin sliding scale (as per scale)
12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **], [**Hospital1 8**]
Discharge Diagnosis:
perforated diverticulitis
sepsis
ATN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance, support
Discharge Instructions:
You were admitted to the hospital with abdominal pain. You were
found to have a colon perforation. You were taken to the
operating room for an exploratory laparotomy and you had a
portion of your large bowel removed. You returned to the
operating two other times for cleaning of the wound and for an
ostomy. You had a special dressing called a vac dressing
appllied. Your vital signs are stable and you are preparing for
discharge to a rehabilitation facility.
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2133-12-8**] at 3:30 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 102203**],MD
Specialty: Internal Medicine
Location: [**Hospital6 28009**]
Address: [**Street Address(2) 33773**], [**Location (un) **],[**Numeric Identifier 33774**]
Phone: [**Telephone/Fax (1) 17826**]
Please discuss with the staff at the facility the need for a
follow up appointment to see Dr. [**Last Name (STitle) 23903**] or your nurse
practitioner [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] once you are discharged from the
facility. The staff at the facility can call the number listed
above to make the appointment.
You have an appointment with your Cardiologist which is
scheduled for:
[**2133-12-30**] 11:40a [**Doctor Last Name **]-CC7
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
CC7 CARDIOLOGY (SB)
The telephone number is # [**Telephone/Fax (1) 2934**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2133-11-24**]
ICD9 Codes: 0389, 5845, 486, 2762, 5180, 2760, 4280, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1243
} | Medical Text: Admission Date: [**2106-9-13**] Discharge Date: [**2106-9-24**]
Date of Birth: [**2035-12-17**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
lethargy, worsening left weakness
Major Surgical or Invasive Procedure:
[**2106-9-14**]: Right Craniotomy for evacuation of hematoma
History of Present Illness:
70 woman who was diagnosed with breast cancer in [**2104**] with
metastatic spread to bone. The patient is currently on
emcitabine and was to begin cycle 2 on [**9-1**]; however, the
patient
presented to [**Hospital1 18**] [**Location (un) 620**] with complaints of weakness for the
past two days. The weakness has been mainly noticed in the BLE.
Imaging revealed Right SDH and she subsequently underwent a
craniotomy and evacuation of the SDH on [**9-2**]. She was discharged
to rehab. On [**9-13**] she returned to the ED with reported lethargy.
CT scan revealed increasing chronic R SDH with increased MLS.
She
was afebrile and WBC=10, but U/A was positive.
Past Medical History:
Metastatic breast cancer to bone dx'd [**2104**], colostomy, CHF,
diverticulitis, HTN, hypothyroidism, Cdiff, uveitis, depression,
anemia of chronic disease, GERD, vit B12 deficiency
Social History:
Lives with daughter, [**Name (NI) **], who is the HCP. Quit smoking 2yrs
ago.
Prior to admission and current status, patient was walking with
a
walker.
Family History:
nc
Physical Exam:
On Admission:
O: T:97.2 BP: 148/62 HR: 74 R20 O2Sats 99% 2L
Gen: laying on stretcher, NAD.
HEENT: Pupils: R surgical/irregular L 3mm-2mm EOMs grossly
intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: lethargic, arouses to voice but requires frequent
stimulation to stay awake.
Orientation: Oriented to [**Hospital3 **] & year only. (with
persistant asking)
Language: Speech slow
Cranial Nerves:
I: Not tested
II: Pupils: R surgical/irregular L 3mm-2mm
III, IV, VI: Extraocular movements grossly 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: weak bilaterally and difficult to examine 2.2 lethargy.
antigravity b/l UE's and withdraws b/l LE's. following commands
in b/l UE's.
Sensation: Intact to light touch
Incision- well healing, staples in place
On Discharge:
A&Ox3
PERRL
EOMs intact
Motor: 4-/5 BUE, wiggles toes bilateral LE
Incision: c/d/i
Pertinent Results:
[**2106-9-13**] CT head: IMPRESSION: Increased size of predominantly
hypodense right cerebral subdural collection, likely a CSF
hygroma, with increased shift of midline structures. Effacement
of suprasellar cistern is new and compatible with early
transtentorial herniation.
[**2106-9-13**] CXR: Left lower lobe consolidation could be secondary to
pneumonia, aspiration, or atelectasis. Pleural effusions are
small if any. Volume overload is mild. Left-sided Port-A-Cath
ends in cavoatrial junction. Mediastinal and cardiac contours
are normal.
[**2106-9-14**] CT head postop: Decreased right subdural collection, now
consisting of fluid and air, with improvement in associated mass
effect. No new hemorrhage.
[**2106-9-15**] Chest Xray:FINDINGS: As compared to the previous
radiograph, the pre-existing bilateral pleural effusions have
increased. Also increased are the signs suggestive of moderate
pulmonary edema. Increase in extent of the pre-existing
retrocardiac atelectasis. Unchanged mild cardiomegaly.
Cardiovascular Report ECG Study Date of [**2106-9-15**] 1:58:56 PM
Sinus rhythm with premature atrial contractions. Diffuse
non-spefific
ST-T wave changes. Low voltage in the axial leads. Compared to
the previous tracing of [**2104-8-25**] the heart rate is slower and the
T wave inversion in leads V2-V3 is more prominent. Clinical
correlation is suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
74 176 80 [**Telephone/Fax (2) 86871**] 156
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**2106-9-16**]
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 65%). The right ventricular free wall thickness is
normal. The right ventricular cavity is dilated with depressed
free wall contractility. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. Moderate
[2+] tricuspid regurgitation is seen (may be underestimated due
to the suboptimal nature of this study). There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
CT HEAD W/O CONTRAST Study Date of [**2106-9-16**] 11:37 AM
FINDINGS: The right-sided subdural drainage catheter has been
removed. There is no change in the size of the subdural
hematoma. There has been reduction in extra-axial
pneumocephalus when compared to the prior study. The leftward
shift of midline structures is unchanged, approximately 6 mm.
The ventricular size and configuration is unchanged from the
prior study. There is no evidence of new hemorrhage or acute
vascular territorial infarction. The imaged portion of the
mastoid air cells and paranasal sinuses are well aerated.
IMPRESSION: No significant interval change since removal of the
right
subdural drainage catheter.
CHEST (PORTABLE AP) Study Date of [**2106-9-17**] 4:25 AM
Mild pulmonary edema has improved, now persisting mainly at the
lung bases. Moderate left pleural effusion stable. Heart size
normal. No pneumothorax. Infusion port catheter ends in the
low SVC. Heart size normal. No pneumothorax.
[**9-17**] CT Head- 1. Status post evacuation of the right subdural
hemorrhage. Minimally increased right lateral ventricular
effacement and increased size of the right subdural collection
by measurements. This may be technical as there are no new
hyperdense blood products, but small interval reaccumulation
cannot be entirely excluded.
COMMENTS ON ATTENING REVIEW: There is interval enlargement of
the right
epidural fluid collection underlying the craniotomy flap, which
explains the slightly increased effacement of the right lateral
ventricle, compression of the third ventricle, and slightly
increased leftward shift of midline structures. The right
subdural fluid collection is stable.
[**9-18**] EEG: IMPRESSION: This is an abnormal continuous ICU
monitoring study because of continuous focal slowing and
attenuation of faster frequencies in the right hemisphere. There
are occasional runs of very rhythmic delta activity or sharp and
slow wave discharges in the right posterior quadrant which do
not clearly involved in frequency or field. These findings are
indicative of a highly potentially epileptogenic focal
structural lesion in the right posterior quadrant. The
background on the left shows mixed theta and delta activity,
suggesting moderate diffuse encephalopathy. There are no
definite electrographic seizures.
[**9-18**] CT Head: IMPRESSION:
1. Increased right epidural fluid collection underlying the
right craniotomy flap, compared to [**2106-9-16**], with associated
increased effacement of the right lateral ventricle, compression
of the third ventricle, and slightly increased leftward shift of
midline structures.
2. Stable right subdural fluid collection.
[**9-18**] CXR: NG tube tip is coiled in the stomach that is
intrathoracic in a moderate hiatal hernia, the tip projects at
the level of the hemidiaphragm . Cardiac size is top normal,
accentuated by low lung volumes. Port-A-Cath is in standard
position. Small-to-moderate bilateral pleural effusions with
adjacent atelectases are unchanged allowing the difference in
positioning of the patient. Of note, the atelectasis in the
right lower lobe has minimally increased. Mild-to-moderate
pulmonary edema is stable.
[**9-19**] EEG: IMPRESSION: This is an abnormal continuous ICU EEG
monitoring study because of continuous focal attenuation and
prolonged runs of quasi-rhythmic 1 Hz delta activity with
intermixed sharp waves in the right posterior quadrant. These
findings are indicative of a potentially epileptogenic focal
structural lesion in the right posterior quadrant. The
background shows disorganized mixed delta and theta activities
suggestive of moderate to severe encephalopathy of non-specific
etiology. Compared to the prior day's recording, there are no
significant changes.
[**9-20**] EEG: IMPRESSION: This is an abnormal continuous ICU EEG
monitoring study because of continuous focal attenuation and
prolonged runs of quasi-rhythmic 1 Hz delta activity with
intermixed sharp waves in the right posterior quadrant. These
runs of delta activity do not evolve into clear electrographic
seizures. Focal attenuation and runs of delta activity with
intermixed sharp waves are indicative of a potentially
epileptogenic focal structural lesion in the right posterior
quadrant. Background activity is characterized by disorganized
mixed delta and theta activities indicative of moderate to
severe encephalopathy of non-specific etiology. There are no
electrographic seizures. Compared to the prior day's recording,
there are no significant changes.
[**9-20**] CT Head: IMPRESSION: The right epidural collection is
minimally decreased. Unchanged subdural collection along the
right convexity. Stable 9 mm leftward shift of normally midline
structures.
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the Neuro ICU for frequent neuro
checks and blood pressure control with a plan for evacuation of
right SDH. She was maintained on Cipro for treatment for UTI.
On [**9-14**] she underwent right craniotomy for evacuation of SDH. A
subdural drain was placed and set on thumbprint JP suction.
Postoperatively she was extubated and transferred to the ICU.
POstop head CT showed good evacuation of SD collection without
new hemorrhage.
POD 1 [**9-15**] her HCT was noted to be 23 and she was hypotensive to
the low 90s. Otherwise she was asymptomatic. She was
transfused 1 unit PRBCs and post transfusion HCT bumped to 27.
On [**9-16**], The sub dural drain was discontinued. A repeat head
CT was performed and was stable. The SQH was restarted after the
drain was discontiued. The cardiac echocardiogram, but
suggestive of Right Heart failure. The patient was initiated on
midodrine while trying to wean off intravenous vasopressors.
On [**9-17**], The foley catheter was discontinued. Physical and
occupational therapy consults were placed. The intravenous
vasopressors were weaned as tolerated. A chest X ray was
consistent with mild pulmonary edema which has improved,
persisting mainly at the lung bases.moderate left pleural
effusion stable. heart size normal. No pneumothorax. Infusion
port catheter ends in the low SVC. Heart size normal.
Overnight she was noted to be more lethargic. A CT was performed
which was questionable for slightly enlarging SDH vs
positioning. On [**9-18**] her exam continued to decline with less left
sided movement. Another CT was performed which revealed
increased MLS. She was started on EEG to evaluate for seizures.
These findings were conveyed to the family who stated that they
would not consent to another surgery if things were to progress
to that. She was started on tube feeds. On [**9-19**] she remained
stable. Her SQH was decreased to 5000units [**Hospital1 **] due to an
increased ptt on AM labs. A palliative care consult was called
per her primary oncologists recommendation.
[**9-18**], A head CT demonstrated worsening changes and the patient
exhibited less movement on the left. CXR demonstrated pleural
effusions.
[**9-20**], A repeat head CT was stable and a family meeting resulted
in the decision to progress toward palliative care.
[**9-21**], She was transferred to the floor with palliative care
following. On [**9-22**] her NGT was removed and she was started on a
PO diet. Morphine concentrate was added. The process was
initiated to find a discharge facility. On [**9-23**], patient's exam
was unchanged. She was eating with assistance and OOB to chair.
No changes were made to her medication regimen. On [**9-24**], patient
was discharged to hospice in stable condition.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Rehab [**3-18**]. Calcium Carbonate 750 mg PO BID
2. Citalopram 10 mg PO DAILY
3. Diltiazem Extended-Release 240 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Metoprolol Succinate XL 75 mg PO DAILY
8. Miconazole Powder 2% 1 Appl TP [**Hospital1 **]
9. Omeprazole 20 mg PO DAILY
10. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
11. Oxycodone SR (OxyconTIN) 20 mg PO Q12H
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES [**Hospital1 **]
14. Prochlorperazine 10 mg PO Q8H:PRN nausea
15. Heparin 5000 UNIT SC TID
Start in AM on [**9-3**]
16. Morphine Sulfate 2-4 mg IV Q3H:PRN pain
17. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
18. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
19. Acetaminophen 325-650 mg PO Q6H:PRN Pain/fever
20. Docusate Sodium 100 mg PO BID
21. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
22. LeVETiracetam 500 mg PO BID
23. Cyanocobalamin 1000 mcg IM/SC MONTHLY
24. Alendronate Sodium 4 mg PO EVERY 3 MONTHS
25. Ondansetron 8 mg PO Q8H:PRN nausea
26. Vitamin D 50,000 UNIT PO MONTHLY
27. Milk of Magnesia 60 mL PO Q12H:PRN constipation
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain/fever
2. Calcium Carbonate 750 mg PO BID
3. Citalopram 10 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
6. Docusate Sodium 100 mg PO BID
7. Heparin 5000 UNIT SC TID
Start in AM on [**9-3**]
8. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
9. LeVETiracetam 500 mg PO BID
10. Ondansetron 8 mg PO Q8H:PRN nausea
11. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES [**Hospital1 **]
14. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
15. Levothyroxine Sodium 75 mcg PO DAILY
16. Miconazole Powder 2% 1 Appl TP [**Hospital1 **]
17. Fentanyl Patch 37 mcg/h TP Q72H
18. Midodrine 10 mg PO TID
19. Morphine Sulfate (Concentrated Oral Soln) 10-15 mg PO
Q2H:PRN resp distress/pain
20. Senna 2 TAB PO BID:PRN constipation
21. Alendronate Sodium 4 mg PO EVERY 3 MONTHS
22. Cyanocobalamin 1000 mcg IM/SC MONTHLY
23. Diltiazem Extended-Release 240 mg PO DAILY
24. Furosemide 20 mg PO DAILY
25. Milk of Magnesia 60 mL PO Q12H:PRN constipation
26. Oxycodone SR (OxyconTIN) 20 mg PO Q12H
27. Prochlorperazine 10 mg PO Q8H:PRN nausea
28. Vitamin D 50,000 UNIT PO MONTHLY
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1894**] [**Last Name (NamePattern1) **] - [**Location (un) **]
Discharge Diagnosis:
Right Subdural Hematoma
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:
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. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, 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
You are currently being discharged to hospice. Please contact
our office if you have any further questions. Neurosurgery can
be contact[**Name (NI) **] by calling [**Telephone/Fax (1) 1669**].
Completed by:[**2106-9-24**]
ICD9 Codes: 486, 5990, 4280, 2859, 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1244
} | Medical Text: Admission Date: [**2162-8-8**] Discharge Date: [**2162-8-30**]
Date of Birth: [**2078-11-3**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Abdominal Pain.
Major Surgical or Invasive Procedure:
[**2162-8-20**] Exploratory laparoscopy,lap assisted small bowel
resection
History of Present Illness:
This is an 83 year old woman with a history of CAD s/p CABG, R
sided HF on home O2 presenting with LLQ abdominal pain. Sharp
and intermittent squeezing pain in LLQ, [**7-18**] in severity on
admission; no n/v/d, no f/c, no dysuria/hematuria, BRBPR, or
melena. BM yesterday was normal. Never has experienced this type
of pain before; denies postprandial pain. Has had decreased
appetite over past week because has been feeling down due to
second husband's passing. Recently moved back from FL per her
[**Hospital1 **] request when they saw she was depressed.
Initial VS in the ED were T97 HR88 BP100/54 RR18 95% ra. Labs
showed evidence of a urinary tract infection (+WBC, Lg Leuk, Mod
Bx). Lactate was normal, CMP grossly normal, LFTs and lipase
normal. CBC showed a normal white count and a macrocytic anemia
with HCT of 33.1. CT abdomen showed a 12 cm segment of distal
small bowel with circumferential wall thickening and surrounding
mesenteric edema.
Received ciprofloxacn and metronidazole for UTI and vague GI
process. VS prior to transfer were T98.1 HR96 RR18 BP108/73 84
on r/a 91 2L. On the floor, metronidazole was discontinued.
This morning, she is feeling fine. Pain has resolved. Denies CP,
SOB, abdominal pain, n/v, diarrhea, melena, BRBPR. No BM yet
today, passing flatus. Has not eaten since admission. No
dysuria, hematuria.
Note she is unable to give details about any aspects of her
history, including prior diagnosis of UC. She denies any history
of recent diarrhea or BRBPR. Per notes from [**2156**], she was
diagnosed with UC due to symptoms of rectal bleeding and
diarrhea at that time, was on prednisone until [**2157**], when it was
discontinued. Also does not know why she is on prednisone, but
per PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **], it is for PMR.
Past Medical History:
CAD s/p angiogram on [**2147-12-18**] (50-60% mLAD, 70-80% dLAD, LCx
and RCA ok; medical therapy recommended), complex PCI on
[**2155-8-20**] (LMCA/LAD dissection during attempted Taxus stenting
of 80-90% pLAD stenosis-->3x20mm perfusion balloon passed into
LAD-->VT/VF and respiratory failure-->defibrillation, lidocaine,
amiodarone, pressors-->3x18mm Cypher DES to LMCA/pLAD-->flow
re-established-->IABP inserted-->emergent CABG (presumably
LIMA-LAD)
H/o pAF, seen by Dr [**Last Name (STitle) 1911**] here in [**2153**]; on quinidine; not
documented here prior to EKG on [**2162-8-13**]
HTN
HLD
HFpEF, on 80mg [**Hospital1 **] lasix at home
L-sided ulcerative colitis in remission
Infrarenal abdominal aortic aneurysm measuring up to 4 cm in
transverse diameter (noted previously, and again on CT here on
[**2162-8-8**])
H/o PE s/p IVC filter [**1-/2157**]
Hypothyroidism
Tobacco history
PMR, on prednisone at home
CCY
Appendectomy age 18
Inguinal hernia repair
Face lift age 50
Social History:
She is widowed. 60 pack-year history of smoking, stopped 30
years ago. No alcohol or coffee.
Family History:
Son has Crohn's disease.
Physical Exam:
EXAM ON ADMISSION:
VITALS: 98.3|106/86| HR 92| RR 18| 96% on 2L Wt. 73.1
GENERAL: Well appearing NAD. Pleasant.
HEENT: Anicteric sclera MMM. No cervical LAD
NECK: No carotid bruits.
LUNGS: Good inspiratory effort, CTAB with no wh/r/rh
HEART: Sternotomy scar. RRR, [**4-13**] crescendo decrescendo systolic
murmur along the LUSB. No heave or carotid radiations.
ABDOMEN: Protuberant abdomen. Soft, NBS. RLQ mildly tender to
deep palpation, no rebound or guarding. No organomegaly. No
suprapubic tenderness.
EXTREMITIES: Multiple scattered ecchymoses. Thin skin. LLE
bandaged from skin tear. Scant LE edema.
NEUROLOGIC: A+OX3. No focal CN deficits.
Pertinent Results:
CBC:
ADMISSION:
[**2162-8-8**] 07:30PM BLOOD WBC-5.6 RBC-3.12* Hgb-10.9* Hct-33.1*
MCV-106*# MCH-35.1* MCHC-33.0 RDW-13.4 Plt Ct-248
Diff: [**2162-8-8**] 07:30PM BLOOD Neuts-83.2* Lymphs-9.1* Monos-6.3
Eos-1.0 Baso-0.5
COAGS:
ADMISSION:
[**2162-8-9**] 06:54AM BLOOD PT-10.7 PTT-25.3 INR(PT)-1.0
ELECTROLYTES:
ADMISSION:
[**2162-8-8**] 07:30PM BLOOD Glucose-107* UreaN-27* Creat-1.0 Na-138
K-3.4 Cl-101 HCO3-28 AnGap-12
[**2162-8-9**] 06:54AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.9 Iron-16*
LFTs:
ADMISSION:
[**2162-8-8**] 07:30PM BLOOD ALT-18 AST-18 AlkPhos-56 TotBili-0.3
[**2162-8-8**] 07:30PM BLOOD Lipase-43
[**2162-8-8**] 07:30PM BLOOD Albumin-3.9
Lactate: [**2162-8-8**] 07:38PM BLOOD Lactate-0.9
CRP: [**2162-8-9**] 06:54AM BLOOD CRP-37.0*
TSH: [**2162-8-9**] 06:54AM BLOOD TSH-2.0
Anemia work up:
[**2162-8-9**] 06:54AM BLOOD calTIBC-296 VitB12-190* Folate-GREATER TH
Ferritn-73 TRF-228
[**2162-8-9**] 06:54AM BLOOD Ret Aut-2.1
Micro:
[**2162-8-14**] URINE URINE CULTURE-PENDING
[**2162-8-14**] MRSA SCREEN MRSA SCREEN-PENDING
[**2162-8-14**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2162-8-8**] BLOOD CULTURE Blood Culture, Routine-FINAL
[**2162-8-8**] BLOOD CULTURE Blood Culture, Routine-FINAL
Imaging:
[**2162-8-8**] CT abd/pelvis: 1. Approximately 12 cm segment of distal
small bowel with circumferential wall thickening and mild
associated mesenteric edema. Findings are concerning for
ischemic, infectious or inflammatory causes of small bowel
enteritis. Given the dense vascular calcifications, ischemic
etiologies are favored. However, the aortic branch vessels
appear patent without focal thrombus. 2. Infrarenal abdominal
aortic aneurysm measuring up to 4 cm in transverse diameter. 3.
Duodenal diverticulum. 4. Stable hepatic cysts.
[**2162-8-9**] KUB: There is a non-specific bowel gas pattern with air
seen in some loops of non-dilated small bowel as well as within
the colon. Contrast is seen in the colon and in the rectum. An
IVC filter is in place. There are splenic artery
calcifications. There is no evidence of free air or
degenerative changes in the lumbar spine. IMPRESSION:
Non-specific bowel gas pattern with no definite obstruction.
[**2162-8-10**] MRE: 1. Again noted is a 15-cm segment of mid-distal
ileum with wall thickening with edema and mild mucosal
hyperenhancement. These findings are most likely representative
of an ischemic/infectious etiology affecting the ileumand
unlikely to be Crohn's disease. Celiac artery, SMA, [**Female First Name (un) 899**] and
splanchnic veins do not show concerning findings. 2. 3.8 x
3.7 cm infrarenal abdominal aortic aneurysm. 3. Hepatic cysts
as described above. 4. Duodenal diverticulum.
[**2162-8-12**] KUB (prelim report): There are mildly dilated gas-filled
small bowel loops as well as decompressed colon with residual
oral contrast. There is no definite evidence of obstruction or
free air. An IVC filter is in place. There is contrast seen
within the large bowel and splenic artery calcifications.
Degenerative changes are noted in the spine. Median sternotomy
wires are present. IMPRESSION: Mildly dilated gas-filled small
bowel loops. No definite obstruction or free air.
[**2162-8-13**] CXR: The course of the nasogastric tube is unremarkable,
with the
exception of a slight deviation of the tube at the level of the
lower
esophageal third, suggesting the potential presence of a hiatal
hernia. The site of the tube is located at the gastroesophageal
junction, the tip of the tube projects over the proximal parts
of the stomach. The tube should be advanced by approximately 5
cm. There is no evidence of complication, notably no
pneumothorax. Mild retrocardiac areas of atelectasis.
[**2162-8-14**] LENI's: IMPRESSION: No evidence of deep venous thrombosis
in bilateral lower extremities.
[**2162-8-14**] TTE: The left atrium is mildly dilated. The right atrium
is moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). There is no ventricular septal defect. The
right ventricular cavity is dilated with depressed free wall
contractility. There is abnormal systolic septal motion/position
consistent with right ventricular pressure overload (? acute
pulmonary embolism vs. acute on chronic pulmonary hypertension).
The ascending aorta is mildly dilated. The aortic valve leaflets
are moderately thickened. There is moderate to severe aortic
valve stenosis (valve area 0.9 cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion. There are no echocardiographic signs of tamponade.
[**2162-8-17**]: KUB IMPRESSION: Resolving SBO with normal gas pattern.
No evidence of obstruction or free air.
[**2162-8-18**]: KUB IMPRESSION: Findings worrisome for worsening ileus
vs partial or early full obstruction.
[**2162-8-19**]: KUB IMPRESSION: Improving bowel obstruction.
Brief Hospital Course:
83 year old woman with history of CAD s/p CABG, previous
diagnosis of UC, PMR on low dose prednisone, and atrial
tachycardia who was initially admitted to the Medicine service
with abdominal pain, found to have SBO with concern for Crohn's,
hospital course complicated by Afib with RVR with hypotension.
Her hospital course as follows by problems:
Partial SBO: Presented with obstructive symptoms and evidence of
narrowing of a 12-15 cm segment of the ileum on CT and MRE.
Initial concerns for infectious vs. inflammatory vs. ischemic
etiology; did not improve despite completely a course of
Cipro/Flagyl. Given history of UC, she was started on empiric IV
Solu-Medrol as the patient was not amenable to endoscopic
evaluation with sampling of this area. Her symptoms did not
improve the final read of MRE came back inconsistent with
Crohn's so her IV steroids were tapered down. She was kept NPO
except meds with decompression with an NGT until her NGT output
ceased; she continued to experience episodes of significant pain
despite remaining NPO. She was started on TPN. Single balloon
retrospective enteroscopy was planned for tissue biopsy for
diagnosis; however, the patient was unable to tolerate PO for
prep and was sent for surgical management. She was taken to the
operating room on [**2162-8-20**] for exploratory laparoscopy with lap
assisted small bowel resection. There were no complications.
Tissue for pathology was obtained; final path report revealed
neuroendocrine tumor. Postoperatively she remained on the TPN
that was started while on the Medicine service and also while
awaiting return of bowel function. Over the course of the next
several days post op she did have flatus and her NG was removed.
Sips were started slowly advancing to clears. Once able to
tolerate this she was advanced to solids but her appetite was
poor. Marinol was started with improvement in her overall
appetite. The TPN was then stopped and she is tolerating a
regular diet. Her staples will remain in place at time of
discharge and will need to be removed on [**2162-9-2**].
.
Afib with RVR: She has a h/o atrial tachycardia but no known AF
and was noted with unstable episode on the medical floor with
SBP 70 without any anginal symptoms to suggest acute coronary
syndrome. Her TSH was normal and LENI's were negative. Further
dropped to SBP 60 with beta blockade and was transferred to the
MICU. Dilt IV was effective at rate control. She remained
stable on metoprolol 5 mg IV q 6 hours after returning from the
MICU. Anticoagulation with warfarin was recommended by
cardiology; this is to be discussed after surgery. She was again
was noted with intermittent episodes of hypotension as low as 68
systolic and was orthostatic while working with PT. Her
Valsartan was being withheld for several doses based on hold
parameters and subsequently this was stopped. Once her blood
pressures stabilize this should be restarted. Her beta blocker
does was decreased initially until an episode on HD#20 she was
noted with Afib with RVR and was transferred to the ICU for a
short period of time. Her Lopressor was increased to 50mg tid
and her heart rates have ranged in the 90's. Anticoagulation was
recommended by Cardiology once able to take po's but the
decision was made to have her follow up with her PCP after
discharge from rehab for further evaluation of initiating this.
.
Hypoxia: Known right sided heart failure on nocturnal O2 that
was exacerbated by volume resuscitation .During her hospital
stay she required continuous oxygen therapy to maintain her
saturations >93%
Anemia: She was followed by Hematology during her stay who
recommended B12 and iron supplementation once taking po's.
Given her low hematocrit she was transfused with 1 unit packed
red cells. Post transfusion hematocrit was 27.6 and on day of
discharge it was 26.3.
Neuroendocrine tumor: Hematology/Oncology were consulted and it
is being recommended that she have serial follow up every three
months up until 1 yr. In the meantime an appointment has been
scheduled for her to follow up in their clinic after hospital
discharge.
Right sided heart failure: Diuretics and antihypertensives were
held initially given hypotension. Her home dose Lasix was
restarted and her electrolytes followed closely and repleted as
needed.
CAD: Known history, asymptomatic now, but troponin continues to
rise with change in morphology in V5 and V6. Serial EKG's were
followed and she was continued on an aspirin, beta blocker and
statin.
Complicated UTI: While on the medicine service she was treated
for a positive UA with ciprofloxacin 400 mg IV q12 hours.
Dispo: She was evaluated by Physical therapy and was recommended
for rehab after his acute hospital stay.
Medications on Admission:
Klor Con 20 mEq 1 packet [**Hospital1 **]
Tramadol-acetaminophen 37.5/325mg 1 tablet q4hrs prn
Diovan 80 mg po BID
Zolpidem 5 mg 1-2 tablets po qhs prn
prednisone 4 mg PO qday
prednisone 3 mg PO qhs
aspirin 81 mg PO qday
furosemide 80 mg po BID
pravastatin 20 mg po qhs
slow release iron 140 mg po qday
metoprolol tartrate 75 mg po qday
symbicort 160 mcg 4.5 mcg/actuation HFA inhlaer [**Hospital1 **]
Synthroid 75 mcg 1 tab po qday
OXYGEN 2L qhs and prn SOB
glucosamine chondroitin
perser vision
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Aspirin 81 mg PO DAILY
3. Furosemide 80 mg PO BID
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Metoprolol Tartrate 50 mg PO TID
6. Pravastatin 20 mg PO HS
7. PredniSONE 4 mg PO DAILY
8. PredniSONE 3 mg PO QHS
9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
10. Dronabinol 2.5 mg PO BID
11. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]
12. Heparin 5000 UNIT SC TID
13. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION [**Hospital1 **]
14. FoLIC Acid 400 mcg PO DAILY
15. Ferrous Sulfate 45 mg PO DAILY
16. Vitamin D 800 UNIT PO DAILY
17. Klor-Con M20 *NF* (potassium chloride) 20 mEq Oral [**Hospital1 **]
18. traZODONE 100 mg PO HS:PRN insomnia
19. Senna 2 TAB PO HS
20. OxycoDONE (Immediate Release) 5-10 mg PO Q3H:PRN pain
21. Docusate Sodium 100 mg PO BID
22. Calcium Carbonate 500 mg PO QID:PRN indigestion
23. Pantoprazole 40 mg PO Q24H
24. Insulin SC
Sliding Scale
Fingerstick q6hrs
Insulin SC Sliding Scale using HUM Insulin
25. Simethicone 80 mg PO QID:PRN indigestion
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] Senior Healthcare of [**Location (un) 55**]
Discharge Diagnosis:
Small bowel obstruction
Ileal Neuroendocrine tumor
Malnutrition
Acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital with an obstruction in your
intestines requring an operation to remove the blockage.
Biopsies of the intestinal tissue were taken at the time and you
were found to have a tumor that will need further evalution by
the Hematology/Oncology doctors.
You required a blood transfusion for anemia during your hospital
stay.
You were also evaluated by the Physical therapy team and being
recommended for rehab after your hospital stay.
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2162-9-21**] at 2:00 PM
With: Dr. [**Last Name (STitle) **] [**Name (STitle) **] in the ACUTE CARE CLINIC
Phone: [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2162-9-22**] at 8:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2502**], 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:[**2162-8-30**]
ICD9 Codes: 5990, 2851, 2449, 4168, 4019, 2724, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1245
} | Medical Text: Admission Date: [**2123-2-22**] Discharge Date: [**2123-3-13**]
Date of Birth: [**2064-3-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Hydrochlorothiazide / Demerol / Ambien
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
58 year old white male with CHF.
Major Surgical or Invasive Procedure:
Cardiac catheterization [**2123-2-22**]
Endotracheal intubation (outside hospital)
Central venous line placement
CABGx4(LIMA->LAD, SVG->OM, ramus, RCA) [**2123-3-4**]
History of Present Illness:
Mr. [**Known lastname **] is a 58 year-old male with known 3-vessel CAD, severe
systolic dysfunction with EF 18% on ventriculogram in [**1-/2123**],
DM type 2, and [**Hospital 15134**] transferred from [**Hospital 4068**] hospital for
management of fever, CHF and NSTEMI. He was recently discharged
from [**Hospital1 18**] on [**2123-1-28**] after a 3-week admission for pulmonary
edema, and pneumonia. During that admission, a cardiac
catheterization revealed diffuse 3-vessel CAD with 60% LMCA
disease, serial LAD lesions as well as diffuse disease of LCx
and TO of RCA with collaterals. He had a BiV pacer placed during
that admission (for polymorphic VT). Per report, medical
management of his CAD was advised.
He had been managing well as home for 3 weeks, with ongoing
treatment of a sacral decubitus ulcer. Over the past 2 days, he
developed anorexia, fatigue and "cold symptoms". He denies C/P.
He subsequently developed a low-grade fever and progressive
shortness of breath, with dry heaves during the night prior to
admission. He was taken to [**Hospital 4068**] hospital, where he was found
to have a temperature of 101, leukocytosis (WBC 13), positive
cardiac enzymes (CK 492/MB 26), EKG A-sensed, BiV paced. He was
started on NTG drip, and given Levaquin/Zosyn and Lasix 40. CXR
was consistent with CHF. At the outside hospital, he developed
worsening respiratory distress, ABG 7.18/84/89 and he was
intubated. En route to [**Hospital1 18**], he became hypotensive with SBP in
70s, and was started on a Dopamine drip.
In [**Hospital1 18**] ED, Mr. [**Known lastname **] was started on Heparin and Integrillin
IV. He had a 20-beat run, then a 2-minute run of WCT at 120-130
while on Dopa, BP approximately 100. Lidocaine was started at 2
mg/min for presumed VT, Dopa changed to Levophed. Zosyn and
Vancomycin given in the ED.
Past Medical History:
Coronary artery disease with severe 3-vessel disease
Congestive heart failure with EF 18% on ventriculogram in [**1-/2123**]
Hypercholesterolemia
Diabetes mellitus type 2
Hypertension
Infrarenal AAA of 3 cm status post repair [**2119**]
Bilateral iliac artery aneurysms
Anxiety disorder
Gastroesophageal reflux disease
S/p excision of melanoma of the lower back in [**2088**]
S/p septoplasty surgery and tonsillectomy
Social History:
Ex-smoker, with 40 pack-year smoking history. He quit in [**2106**].
He lives with his wife. [**Name (NI) **] history of EtOH consumption.
Family History:
Father with MI in 50s
Physical Exam:
Physical examination prior to admission to CCU:
VITALS: T 100, BP 105/50 on Dopamine 2.5, Levophed 0.03, HR 83
Vent: AC 600 X 12, PEEP 5, FiO2 100%, Sat 100%
GEN: Intubated, alert, not sedated.
HEENT: ETT in place, OGT in place.
NECK: JVP to jaw.
RESP: ICD in place left anterior chest. Ronchorous breath sounds
bilaterally, with inspiratory crackles.
CVS: Normal S1, S2. No S3, S4. No murmur or rub appreciated.
GI: Obese abdomen. BS normoactive. Abdomen soft and non-tender.
Reported guaiac negative in ED.
EXT: No femoral bruits. Trace bilateral pedal edema. Strong
peripheral pulses.
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2123-3-13**] 06:45AM 5.7 3.54* 9.8* 30.8* 87 27.7 31.9 15.2
239#
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2123-3-13**] 06:45AM 239#
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2123-3-13**] 06:45AM 90 24* 1.4* 143 4.4 107 29 11
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2123-3-13**] 06:45AM 2.1
Cardiology Report ECHO Study Date of [**2123-3-11**]
PATIENT/TEST INFORMATION:
Indication: H/O cardiac surgery. Left ventricular function.
Height: (in) 69
Weight (lb): 237
BSA (m2): 2.22 m2
BP (mm Hg): 120/70
Status: Inpatient
Date/Time: [**2123-3-11**] at 10:02
Test: TTE (Complete)
Doppler: Full doppler and color doppler
Contrast: None
Tape Number: 2005W054-0:30
Test Location: West Echo Lab
Technical Quality: Suboptimal
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.6 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.9 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.9 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 1.1 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: *7.1 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 20% to 30% (nl >=55%)
Aorta - Valve Level: *3.9 cm (nl <= 3.6 cm)
Aortic Valve - Peak Velocity: *2.1 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - A Wave: 1.1 m/sec
Mitral Valve - E/A Ratio: 1.00
Mitral Valve - E Wave Deceleration Time: 250 msec
TR Gradient (+ RA = PASP): *28 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire
is seen in the RA.
LEFT VENTRICLE: Normal LV wall thickness. Severely dilated LV
cavity. Severely
depressed LVEF. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber
size. RV function
depressed.
AORTA: Mildly dilated aortic root. Focal calcifications in
aortic root.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Normal mitral valve leaflets. No MVP. Normal
mitral valve
supporting structures. Mild (1+) MR. Normal LV inflow pattern
for age.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal
tricuspid valve supporting structures. Borderline PA systolic
hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic PR. Normal main PA. No Doppler evidence for PDA
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal
image quality - poor parasternal views. Suboptimal image quality
- poor apical
views.
Conclusions:
The left atrium is moderately dilated. Left ventricular wall
thicknesses are
normal. The left ventricular cavity is severely dilated. Overall
left
ventricular systolic function is severely depressed (ejection
fraction 20-30
percent). Right ventricular chamber size is normal. Right
ventricular systolic
function appears depressed. The aortic root is mildly dilated.
The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present.
Trace 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 borderline pulmonary artery systolic
hypertension.
Compared with the findings of the prior study (tape reviewed) of
[**2123-2-22**], the left ventricular ejection fraction, while still
significantly
impaired, is increased, and the end-diastolic dimension has
decreased.
Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD on [**2123-3-11**] 10:58.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
([**Numeric Identifier 100530**])
Brief Hospital Course:
58 year-old male with diffuse 3-vessel CAD with 60% LMCA disease
on last cath in [**2123-1-2**], also with DM and HTN, admitted
with fever, hypotension, CHF, and NSTEMI.
In the ED, Mr. [**Known lastname **] was started on Heparin IV, and
Integrillin. Decision was made to perform LHC and RHC to
reevaluate the LMCA lesion and assess intracardiac pressures. He
was taken to the cath lab on [**2123-2-22**], where coronary
angiography revealed critical 70% LMCA, proximal and mid 80% LAD
lesions, moderate diffuse disease in Lcx and proximal RCA
occlusion. He was admitted to the CCU post-procedure. His peak
cardiac enzymes were CK 421, MB 24 and troponin T 2.77 on
admission. EKG without ST elevations.
Given the above cath results, cardiac surgery was consulted. Per
cardiac surgery, a viability study at rest was obtained to
evaluate for viable myocardium. The latter was performed on
[**2123-2-24**] and revealed a moderate, medium sized perfusion defect
in the LAD territory which showed partial reversibility in the
24 hour images, as well as a severe, medium distal inferior wall
perfusion defect, also reversible at 24 hours. Per CT surgery, a
CHF/Transplant consult was also requested to evaluate for LVAD
back-up/transplant candidacy prior to taking a decision re:
CABG.
As part of the work-up, carotid series were obtained which
showed no significant disease. After aggressive diuresis he was
extubated on HD#2. He came in with a large sacral decubitus
ulcer which was fully evaluated and treated. He the had an
increased creatinine with a high of 2.6.
His creatinine came down to 1.9 and on [**2123-3-4**] he underwent a
CABGx4 with LIMA->LAD, SVG->OM, ramus, and RCA. Cross clamp
time was 68 mins., and total bypass time was 88 mins. He
tolerated the procedure well and was transferred to the CSRU on
Neo, Milrinone, Epi, Vasopressin, and Amiodorone.
POD#1 the Epi was weaned and he was extubated and his chest
tubes were d/c'd on POD#3. The Milrinone and Neo were gradually
weaned. POD#5 he was transferred to the floor in stable
condition. He continued to progress well and was discharged to
rehab on POD#9 in stable condition. Plastic surgery followed
his sacral decubitus throughout his stay and general surgery
ruled out a peri-rectal abcess.
Medications on Admission:
Lipitor 80 mg PO QD
Amiodarone 400 mg PO QD
Lopressor 12.5 mg PO BID
Klonopin 0/5 mg PO TID
Lasix 40 mg PO BID
Glyburide 15 mg PO QD
Escitalopram 20 mg PO QD
ASA 325 mg PO QD
Zetia 10 mg PO QD
Folate
Discharge Medications:
1. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day. Capsule, Sustained
Release(s)
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
6. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 weeks.
11. Escitalopram Oxalate 10 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
12. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
13. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Glyburide 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
16. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
17. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] Of [**Location (un) 620**]
Discharge Diagnosis:
Coronary artery disease.
NIDDM
GERD
CHF
Decubitis ulcer
Sleep apnea
PVD
HTN
Cardiomyopathy
^chol.
Ventricular arrythmias
Discharge Condition:
Good.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Follow medications on discharge instructions.
You may not drive for 6 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.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) 1407**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 2-3 weeks.
Make an appointment with Dr. [**Last Name (STitle) 284**] for 4 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
Follow up with Dr. [**First Name (STitle) **] of plastic surgey as needed.
Completed by:[**2123-3-13**]
ICD9 Codes: 4280, 4254, 4271, 0389, 486, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1246
} | Medical Text: Admission Date: [**2168-8-25**] Discharge Date: [**2168-8-26**]
Date of Birth: [**2097-5-5**] Sex: M
Service: MEDICINE
Allergies:
Lipitor
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
CVL
A-Line
History of Present Illness:
71 yom w history of CLL, ESRD on HD (MWF), on home oxygen (2L
NC), now presenting with a fever and SOB. According to the
patient, he was in his usual state of good health until
yesterday after dialysis. He completed his dialysis session
(removed 3L), and felt SOB upon going home. This persisted
through the evening so his sister decided to bring him to the
[**Name (NI) **]. According to his sister, he as feeling increasingly short of
breath for the past couple of days.
He denies recent, fevers, chills, sick contacts, myalgias, chest
pain, diarrhea, dysuria (still produces some urine), headaches,
neck stiffness, cough, sputum production.
He presented to an outside hospital where he was given
vancomycin and (?) gentamycin. He was then transferred to the
[**Hospital1 18**] ED for further treatment and evaluation.
Initial VS in ED: 99.8 102 90/50 28 96% 3L nc
Labs notable for WBC of 44.1, HCT of 31.4 and Plt of 59.
Creatinine was 3.4. Lactate of 1.2. CXR showed compared to
[**1-/2168**] left lower lobe opacity concerning for consolidation +/-
effusion. He was given levaquin.
In the ED, the patient received roughly 1 L NS with a good
response in his BP (increased transiently to 100-110s). His
blood pressure, however, subsequently decreased to mid 90s so he
was admitted to the MICU. He also spiked a temperature to 101.
On arrival to the MICU, he complains of some pain in LLQ, which
he says he "always gets after dialysis". Feels SOB, but no other
complaints.
VS on arrival: 103 106 98/56 31 96 on 4L NC
Past Medical History:
- ESRD on hemodialysis MWF (last dialysis day before admission)
- left arm AV fistula failed and s/p jump AV graft
- CAD (may have had a prior inferior infarction per note by Dr. [**Doctor Last Name 11723**] in [**2166-7-11**])
- anemia (baseline Hct= 20-23)
- peripheral neuropathy
- s/p bronchial lymph node biopsy + for CLL
- hypertension
- cataracts
- anemia
- cholelithiasis
- splenomegaly
- prior hypovolemic shock
- BPH
Social History:
Retired police officer. Lives with son and his family; sister's
family lives downstairs. Denies alcohol or illicit drug use.
Quit smoking 40 years ago
Family History:
Multiple relatives with DM; brother and sister both died from
complications from DM. Sister had fatal ovarian cancer. +CAD in
family.
Physical Exam:
ADMISSION PHYSICAL EXAM:
103 106 98/56 31 96 on 4L NC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
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: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: b/l bka.
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
Pertinent Results:
ADMISSION LABS:
[**2168-8-25**] 10:54PM TYPE-ART TEMP-37.8 TIDAL VOL-500 PEEP-5
O2-100 PO2-135* PCO2-43 PH-7.27* TOTAL CO2-21 BASE XS--6
AADO2-535 REQ O2-89 INTUBATED-INTUBATED
[**2168-8-25**] 10:54PM LACTATE-2.1*
[**2168-8-25**] 10:54PM O2 SAT-98
[**2168-8-25**] 10:54PM freeCa-1.03*
[**2168-8-25**] 07:42PM TYPE-ART PO2-172* PCO2-34* PH-7.35 TOTAL
CO2-20* BASE XS--5
[**2168-8-25**] 07:42PM LACTATE-3.1*
[**2168-8-25**] 07:42PM freeCa-1.06*
[**2168-8-25**] 09:10AM WBC-36.1* RBC-2.74* HGB-9.0* HCT-27.5*
MCV-100* MCH-32.7* MCHC-32.6 RDW-22.9*
[**2168-8-25**] 02:36PM GLUCOSE-89 UREA N-52* CREAT-3.6* SODIUM-143
POTASSIUM-5.2* CHLORIDE-110* TOTAL CO2-24 ANION GAP-14
IMAGING:
CXR [**2168-8-25**]
IMPRESSION: Pulmonary edema and large left sided pleural
effusion in the
setting of chronic left lower lobe collapse and central
lymphadenopathy.
ECHO
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. LV systolic
function appears moderately-to-severely depressed (ejection
fraction approximately 30 percent). However, there is
considerable beat-to-beat variability of the left ventricular
ejection fraction due to an irregular rhythm. The right
ventricular free wall thickness is normal. The right ventricular
cavity is moderately dilated with severe global free wall
hypokinesis. The aortic valve leaflets (3) 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. There is no
pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2165-10-29**], significant right ventricular and left
ventricular contractile dysfunction is now present.
MICRO:
Positive E. Coli Blood Cx x2
Positive E. Coli Urine Cx
Positive GNR in Sputum Cx
Brief Hospital Course:
71 yom with multiple medical problems including DM2, ESRD on HD,
b/l BKAs who presents with SOB, fever, respiratory failure.
PLAN:
# SEPSIS: Pt was admitted with acute respiratory failure and met
SIRS criteria. He was intubated soon after admission to MICU for
hypoxia. CXR was consistent with PNA. Both blood cultures and
urine cultures demonstrated E.coli. He was started on meropenem
and double covered with amikacin. He was also started on
vancomycin. He required 4 vasopressors to maintain adequate
blood pressures within first 24hrs of admission. An aterial line
and central venous line were placed. Family was contact[**Name (NI) **] and
confirmed his DNR status. Pt's BP continued to drop despite
maximal amounts of vasopressors. He became bradycardic and
expired on the evening of [**2168-8-26**].
# CAD: Denies chest pain at the moment. [**Name2 (NI) **] metoprolol (given
hypotension) and aspirin (given thrombocytopenia).
# CLL: Pt pancytopenia with appears near baseline, however his
diff reveals promyelocytes and I am wondering if he has
converted to AML. Heme/Onc did not think this was a blast
crisis.
# ESRD: Completed dialysis yesterday. Electrolytes wnl. Will
need to make HD/renal aware. Renal was consulted. Monitor lytes.
# DM2: Holding insulin for now.
# HTN: Holding home meds.
Medications on Admission:
Metoprolol 25 [**Hospital1 **]
Protonix 40mg QD
Nephrocaps one
Gabapentin 100 2 cap [**Hospital1 **]
Ferrous sulfate 325 mg qd
Actos 15mg qd
Renagel 800 mg tabs t.i.d. after the each meals
Rocaltrol 0.5 mcg.
Furosimde 80mg QD [**Month (only) **] (dialysis)
Aspirin 81mg this am
PhosLo 667 mg after each meals
Discharge Medications:
Patient Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient Expired
Discharge Condition:
Patient Expired
Discharge Instructions:
Patient Expired
Followup Instructions:
Patient Expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
ICD9 Codes: 5856, 486, 5119, 5180, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1247
} | Medical Text: Admission Date: [**2114-7-9**] Discharge Date: [**2114-7-14**]
Date of Birth: [**2046-8-12**] Sex: M
Service: CARDIAC SURGERY
CHIEF COMPLAINT: Coronary artery disease
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 67-year-old
gentleman, transferred from [**Hospital3 1280**] status post cardiac
catheterization demonstrating left main and three vessel
coronary artery disease. He recently had brief chest pain
while golfing and another episode while walking. Both of
these events resolved with rest. Stress test on [**2114-7-6**] was
positive, and cardiac catheterization on [**2114-7-9**] revealed the
above results. Catheterization results are also remarkable
for good biventricular function and normal valves. He has
been asymptomatic since admission to [**Hospital3 1280**]. His cardiac
risk factors include ten cigars a day, which he quit two
years ago, hyperlipidemia, hypertension, noninsulin dependent
diabetes mellitus, and two brothers with coronary artery
disease. Mr. [**Known lastname **] now presents to [**Hospital1 190**] for coronary artery bypass graft.
PAST MEDICAL HISTORY:
1. As above
2. Glaucoma with blindness in right eye following retinal
detachment
3. Status post open cholecystectomy
4. Status post laparoscopic procedure for small bowel
obstruction
5. Noninsulin dependent diabetes mellitus
ALLERGIES: No known drug allergies.
MEDICATIONS: Aspirin 325 mg once daily, Glucotrol XL 10 mg
once daily, Lescol 20 mg once daily.
PHYSICAL EXAMINATION: The patient is afebrile. Vital signs
are stable. The head is normocephalic, atraumatic. The neck
is supple, with no carotid bruits. The chest is clear to
auscultation bilaterally. The heart is regular rate and
rhythm, with no murmurs, rubs or gallops. The abdomen is
soft, nontender, nondistended, with normal active bowel
sounds. The extremities are without cyanosis, clubbing or
edema.
HOSPITAL COURSE: Mr. [**Known lastname **] was taken to the operating room
on [**2114-7-10**] for coronary artery bypass graft x 5. Grafts
included left internal mammary artery to diagonal I to [**Doctor First Name **],
saphenous vein graft to ramus to obtuse marginal, and
saphenous vein graft to posterior descending artery. The
procedure was performed without complication, and Mr. [**Known lastname **]
was subsequently transferred to the Cardiac Surgical
Intensive Care Unit. In the Unit, Mr. [**Known lastname **] was extubated,
weaned off drips, and hemodynamically stabilized. His stay
in the Unit was unremarkable, and he was subsequently
transferred to the floor on postoperative day one.
Mr. [**Known lastname 43782**] recovery progressed well on the floor. He
progressively increased his ambulation and was eventually
able to complete a Level V physical therapy evaluation. He
was tolerating an oral diet, and his pain was controlled with
oral medications.
On [**2114-7-14**], Mr. [**Known lastname **] was felt stable for discharge home.
Physical examination at discharge showed vital signs of a
temperature of 97.9, pulse 79, blood pressure 146/70,
respiratory rate 18, oxygen saturation 95% on room air. The
heart is regular rate and rhythm. The lungs are clear to
auscultation bilaterally. The abdomen is soft, nontender,
nondistended, with normal active bowel sounds. The
extremities are without cyanosis, clubbing or edema.
DISCHARGE MEDICATIONS: Docusate 100 mg twice a day while
taking percocet, enteric-coated aspirin 325 mg once daily,
Glucotrol XL 10 mg once daily, calcium carbonate 1000 mg
twice a day, metoprolol 500 mg twice a day, Lescol 20 mg once
daily, percocet one to two tablets every four to six hours as
needed.
FOLLOW UP: Mr. [**Known lastname **] should follow up with Dr. [**Last Name (STitle) 1537**] in four
weeks, and Dr. [**Last Name (STitle) 43783**] in three to four weeks.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Mr. [**Known lastname **] is to be discharged home with
visiting nurse assistance.
DISCHARGE DIAGNOSIS:
1. Status post coronary artery bypass graft x 5
[**Known firstname 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Doctor First Name 24423**]
MEDQUIST36
D: [**2114-7-14**] 18:09
T: [**2114-7-15**] 00:00
JOB#: [**Job Number 9299**]
ICD9 Codes: 4111, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1248
} | Medical Text: Admission Date: [**2130-4-28**] Discharge Date: [**2130-5-8**]
Date of Birth: [**2075-3-5**] Sex: F
Service: CSU
ADMISSION DIAGNOSES:
1. Sternal wound infection.
2. Coronary artery disease status post coronary artery bypass
grafting x2 ([**2130-4-12**]).
3. Insulin dependent diabetes mellitus, hypertension and
hypercholesterolemia.
DISCHARGE DIAGNOSES:
1. Sternal wound infection - status post sharp debridement,
VAC placement.
2. Right thyroid nodule.
3. Right lower lobe lung nodule.
4. Left adrenal nodule.
5. Coronary artery disease - status post CABG.
6. Insulin dependent diabetes mellitus.
7. Hypertension.
8. Hypercholesterolemia.
ADMISSION HISTORY AND PHYSICAL: Ms. [**Known lastname 17025**] is a 55 year
old female with a history of coronary artery disease who
underwent coronary artery bypass grafting on [**2130-4-12**].
She was subsequently discharged to Rehab in good condition,
but several days prior to her presentation on [**2130-4-28**],
she noticed a slight amount of drainage from the inferior
aspect of her wound. This became progressively foul-smelling
and she presented for a wound check and was found clinically
to have about a 3 cm x 10 cm lower sternal wound infection.
She had otherwise denied any sense of fever or chills. She
had not noticed any sort of crepitus or cracking in her
chest. On her initial examination, her temperature was 101.0,
her pulse was in the low 100s and her pressures were in the
110s. She was otherwise oxygenating well. Her exam was
essentially remarkable for a 4 x 15 cm area of erythema with
tenderness at the inferior aspect of her sternal wound with
necrotic debris emanating from the incision. There was
otherwise no evidence of sternal instability. Her white count
was 11.7. Her BUN and creatinine were 23 and 0.7. She had a
chest x-ray which showed that her sternal wires were still
intact, but CT scan to further evaluate the wound showed a
defect in the anterior soft tissue with inflammatory changes
with gas in the region of the mediastinum. There was no
evidence of defect in the osseous structures. Incidentally,
on CT scan, a 22 x 17 mm right thyroid nodule was noted as
was a 4 mm lung nodule at the right lung base and a 26 x 28
mm adrenal nodule, all of which require follow-up imaging in
the future for further characterization.
HOSPITAL COURSE: The patient was admitted and started on
broad spectrum antibiotics which included vancomycin and
levofloxacin. Blood cultures were obtained as were wound
cultures. The wound was sharply debrided down to healthy
tissue with a significant amount of necrotic tissue removed
and was treated initially with saline wet-to-dry dressing
changes. Plastic Surgery was consulted who recommended
further debridement with dressing changes with future
placement of VAC. We changed over to acetic acid dressing
changes for a short course with subsequent placement of a VAC
on hospital day 4 as the wound looked good. The patient
remained afebrile throughout the remainder of her
hospitalization with a normal white blood cell count. Her VAC
dressing was changed every 3 days in consultation with
Plastic Surgery with development of good early granulation
tissue by the time she was ready for discharge. She never
evidenced any sort of sternal instability and follow-up chest
x-rays did not show any change in location of her sternal
wires or development of any new pleural effusions. We
consulted the [**Last Name (un) **] Diabetes Service for aid and management
of her diabetes with improved control with change in her
morning and evening insulin regimen. It was felt on hospital
day 11 that the patient had been afebrile and was otherwise
showing no infection of infection and had a nicely healing
wound with the VAC that she be discharged to Rehab in fair
condition. On the day of her discharge, her T-max was 100.0.
She was otherwise hemodynamically normal. Her white blood
cell count was 6.7. Her wound had grown out coag-negative
staphylococcus. One of four blood culture bottles did also
grow out coag-negative staphylococcus, but this was felt to
be a contaminant and follow-up surveillance blood cultures
were negative.
She was sent to Rehab on the following medications - Tylenol
#3 with codeine 1-2 tabs every 4-6 hours as needed for pain,
Zantac 150 mg p.o. b.i.d., aspirin 81 mg p.o. once daily,
pravastatin 80 mg p.o. once daily, Colace 100 mg p.o. b.i.d.,
metformin 500 mg p.o. b.i.d., ibuprofen 400 mg p.o. q.8h. as
needed for pain, furosemide 60 mg p.o. b.i.d., lisinopril 5
mg p.o. once daily, carvedilol 6.25 mg p.o. b.i.d.,
vancomycin 1 g IV q.12h. to finish a 6-week course, insulin
NPH 26 units at breakfast, 20 units at bedtime with a Regular
insulin sliding scale. She was to have her VAC changed at
Rehab. She will have her VAC changed every 3 days with follow-
up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of Plastic Surgery in 1 week at his
office. The patient will follow up with her primary care
physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**8-6**] days for further
outpatient workup of the incidental thyroid, lung and adrenal
nodules found during workup of the wound infection. She will
follow with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] in the clinic as per her
previously scheduled postoperative appointment in [**1-28**]/2
weeks. She will be discharged to Rehab on a cardiac,
diabetic, heart healthy diet and strict sternal precautions.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Doctor Last Name 3763**]
MEDQUIST36
D: [**2130-5-8**] 08:42:01
T: [**2130-5-8**] 09:19:46
Job#: [**Job Number 58965**]
ICD9 Codes: 2761, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1249
} | Medical Text: Admission Date: [**2195-5-4**] Discharge Date: [**2195-5-14**]
Date of Birth: [**2123-12-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Right lower extremity swelling and discoloration
Major Surgical or Invasive Procedure:
[**2195-5-7**] 1. Aortic valve replacement with a size 23 onyx
mechanical
valve.
2. Coronary artery bypass graft x3, left internal mammary
artery to left anterior descending artery and saphenous
vein grafts to obtuse marginal and left posterior
descending arteries.
3. Endoscopic harvesting of the long saphenous vein.
History of Present Illness:
71 year old male presented to outside hospital for right leg
swelling with bluish foot, and in workup was found to have deep
vein thrombosis involving common femoral vein to popiteal. He
was started on heparin drip for
anticoagulation due to prescheduled cardiac catheterization,
coumadin was not started. He was scheduled for cardiac cath due
to positive stress test.
Past Medical History:
Diabetes Mellitus
Diabetic nephropathy - End stage renal disease on HD (M/W/F)
Peripheral Vascular disease
Coronary artery disease
Legally blind [**3-3**] retinopathy
Hypertension
Glaucoma
bypass grafting in his left leg [**11-7**] [**Doctor Last Name 1391**]
hernia repair
Left 5th met head resection [**2188**]
Right BK [**Doctor Last Name **]-DP(NRSVG)[**2194-5-5**]
Left arm AV shunt
Aortic Stenosis
Social History:
Lives with: spouse
Occupation: [**Name2 (NI) **]
Tobacco: denies
ETOH: denies
Family History:
non contributory
Physical Exam:
Pulse: 60 Resp: 18 O2 sat: 100 % RA
B/P Right: 148/70 Left: AV fistula
Height: 5'8" Weight: 77.7 kg
General: no acute distress
Skin: Dry [x] intact [x] healed scars from vascular surgery
inner
aspect bilateral lower extremities
HEENT: PERRLA [] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 2/6 systolic
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x] no palpable masses
Extremities: Warm [x], perfused [x] Edema - none Varicosities:
None [x]
Neuro: alert and oriented x3 nonfocal
Pulses:
Femoral Right: +2 Left: +2 cath site
DP Right: +2 Left: doppler
PT [**Name (NI) 167**]: doppler Left: doppler
Radial Right: +1 Left: +1
AV fistula left forearm + bruit and thrill
Carotid Bruit Right: no bruit Left: no bruit
Pertinent Results:
[**2195-5-13**] 05:17AM BLOOD WBC-8.3 RBC-3.34* Hgb-10.2* Hct-31.1*
MCV-93 MCH-30.6 MCHC-32.9 RDW-17.1* Plt Ct-182
[**2195-5-14**] 03:34AM BLOOD PT-23.3* PTT-99.5* INR(PT)-2.2*
[**2195-5-14**] 03:34AM BLOOD K-4.1
[**2195-5-13**] 05:17AM BLOOD Glucose-94 UreaN-28* Creat-5.2*# Na-140
K-4.0 Cl-102 HCO3-30 AnGap-12
ECHO:
PRE-BYPASS: No spontaneous echo contrast or thrombus is seen in
the body of the left atrium or left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is low normal (LVEF 50-55%). The right
ventricular cavity is mildly dilated with normal free wall
contractility. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets are moderately
thickened. There is moderate aortic valve stenosis (valve area
1.0-1.2cm2). No aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. Mild to moderate ([**1-31**]+)
mitral regurgitation is seen. There is no pericardial effusion.
POST CPB:
1. Preserved [**Hospital1 **]-ventricular systolic function.
2. Mechanical vqalve inaortic position. Well seated and stale
with good leaflet excursion. Trace AI, PG = 16 mm Hg.
3. Intact aorta.
4. MR is now mild
Brief Hospital Course:
Transferred in from outside hospital for surgical evaluation on
intravenous heparin for deep vein thrombosis diagnosed by
ultrasound at outside hospital. He underwent preoperative
workup, including vascular consultation due to deep vein
thrombosis. Decision was made to proceed with surgery and
restart heparin on postoperative day one for anticoagulation.
Renal was consulted for ongoing hemodialysis. On [**2195-5-8**] he was
brought to the operating room and underwent coronary artery
bypass graft and aortic valve replacement surgery. See
operative report for further details. He received vancomycin
for perioperative antibiotics and transferred to the intensive
care unit for post operative management. In the first twenty
four hours he was weaned from sedation, awoke, and was extubated
without complications. He underwent hemodialysis on post
operative day one, started on heparin for deep vein thrombosis,
and was then transferred to the postoperative floor. He
continued to progress and was started on Coumadin in addition to
the heparin. Physical therapy worked with him on strength and
mobility. He was continued on Coumadin with an INR goal 2.5-3.0
and INR was 2.2 at the time of discharge. Dr.[**Name (NI) 44062**] office is to
follow Coumadin and all information was faxed to his office at
the time of discharge.
He continued to progress and was ready for discharge home with
services on post operative day 7.
Medications on Admission:
Sevelamer HCl 2400 mg before each meal
Dorzolamide-Timolol 2-0.5 % Drops 1 Drop [**Hospital1 **]
Travoprost 0.004 % Drops 1 daily
Atenolol 25 mg TID
B Complex-Vitamin C-Folic Acid 1 mg Daily
Aspirin 81 mg Daily
Glargine 16 units at breakfast
Humalog sliding scale 150-200 - 1 unit [**Unit Number **]-250 - 2 units etc...
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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*100 Tablet(s)* Refills:*2*
7. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
Disp:*1 1* Refills:*0*
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
9. Travoprost 0.004 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
Disp:*1 1* Refills:*0*
10. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*0*
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses: Give 5 mg on [**5-14**] and draw INR [**5-15**] with results faxed
to Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] further dosing instructions with INR goal 2.5-3.0.
Disp:*30 Tablet(s)* Refills:*1*
13. Insulin Glargine 100 unit/mL Solution Sig: Sixteen (16)
units Subcutaneous Q AM.
Disp:*QS 1 month units* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary artery disease s/p cabg
Deep vein thrombosis (right leg)
Diabetes mellitus type 2
Diabetic nephropathy - ESRD on HD (M/W/F)
Peripheral vascular disease
Legally blind [**3-3**] retinopathy
Hypertension
Glaucoma
Left arm AV shunt
Discharge Condition:
alert and oriented x3 nonfocal
ambulating independently
pain controlled with Ultram
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your 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:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2195-6-1**] 1:15
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2195-7-20**] 1:20
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2195-7-20**] 2:30
Please call to schedule appointments with
Primary care physician Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3314**] for 1-2 weeks
[**Telephone/Fax (1) 3183**]
Cardiologist Dr [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] for 1-2 weeks [**Telephone/Fax (1) 8725**]
Labs: PT/INR for coumadin dosing with goal INR 2.5-3.0 for right
leg DVT and mechanical aortic valve. Results to Dr [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] # [**Telephone/Fax (1) 8725**] fax [**Telephone/Fax (1) 8719**] with first draw
Info faxed at discharge
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2195-5-14**]
ICD9 Codes: 4241, 5856 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1250
} | Medical Text: Admission Date: [**2172-5-1**] Discharge Date: [**2172-5-14**]
Date of Birth: [**2134-12-19**] Sex: F
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: The patient is a 37 year old
female who has a history of endstage liver disease secondary
to hepatitis C, who was just recently discharged from the
hospital for uncontrolled bleeding. The patient was doing
well at rehabilitation. The patient was just recently
discharged to rehabilitation on [**2172-4-30**], and on [**2172-5-1**],
the patient returned from rehabilitation for bloody output
from her [**Location (un) 1661**]-[**Location (un) 1662**] drain.
PAST MEDICAL HISTORY: Endstage liver disease.
Esophageal cancer.
NonHodgkin's lymphoma.
Small bowel obstruction, status post exploratory laparotomy
and lysis of adhesions.
Status post lumpectomy.
Clostridium difficile infection.
Right lower extremity trauma and chronic lower extremity
cellulitis.
MEDICATIONS ON ADMISSION:
1. Ursodiol 300 mg p.o. three times a day.
2. Potassium Chloride 300 mEq p.o. once daily.
3. Lasix 40 mg p.o. once daily.
4. Spironolactone 50 mg p.o. once daily.
5. Protonix 40 mg p.o. once daily.
6. Mycelex 10 mg p.o. three times a day.
7. Nadolol 20 mg p.o. once daily.
8. Lactulose.
9. Colace.
10. Multivitamin.
PHYSICAL EXAMINATION: The patient was putting out frank
bloody material from her [**Location (un) 1661**]-[**Location (un) 1662**] drain from her
abdominal wound. She is afebrile and vital signs are stable
although a little bit tachycardic, heart rate 95 beats per
minute. The belly was soft, nondistended.
HOSPITAL COURSE: The patient was admitted to the Transplant
Surgery service and at that time, the patient had a INR of
2.5. The patient was given several units of fresh frozen
plasma in an attempt to correct her coagulopathy. The
patient also had low platelet count. The patient was
admitted to Intensive Care Unit for further care. Her bloody
output from her [**Location (un) 1661**]-[**Location (un) 1662**] drain has somewhat decreased
and in an attempt to control her bleeding, the patient was
transfused several units of fresh frozen plasma and the
patient was also transfused several units of packed red blood
cells. A hematology consultation was then obtained and
according to Hematology/Oncology, they believed her
coagulopathy was actually all resulting from her liver
failure and the patient was continued on tube feed. The
patient also had a history of methicillin resistant
Staphylococcus aureus infection so she was started on Zosyn
and Octreotide in an attempt to slow down the [**Location (un) 1661**]-[**Location (un) 1662**]
output. Subsequently, the patient developed renal failure
and was anuric. Tube feed was continued at 40cc per hour.
However, on [**2172-5-13**], the patient was made comfort measures
only by the family. On [**2172-5-14**], the patient expired at 6:00
a.m.
DISCHARGE DIAGNOSES: Endstage liver disease, awaiting
transplant.
NonHodgkin's lymphoma.
Esophageal cancer.
Small bowel obstruction, status post exploratory laparotomy.
Chronic lower extremity cellulitis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern4) 47386**]
MEDQUIST36
D: [**2172-5-16**] 14:52:09
T: [**2172-5-16**] 15:12:17
Job#: [**Job Number 47387**]
ICD9 Codes: 5715, 5849, 2851, 0389 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1251
} | Medical Text: Admission Date: [**2125-1-15**] Discharge Date: [**2125-1-26**]
Service: Cardiology
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: The patient is a hospital
transfer from [**Hospital3 417**] Hospital for evaluation of chest
discomfort. This occurred after undergoing an arteriogram
for symptomatic carotid stenosis.
The patient's initial enzymes showed a CK of 179, MB 3.1,
index 1.7, troponin I less than 0.05. The patient underwent
cardiac catheterization, which
INCOMPLETE DICTATION.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2125-1-26**] 12:07
T: [**2125-1-26**] 14:21
JOB#: [**Job Number 19580**]
ICD9 Codes: 4111, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1252
} | Medical Text: Admission Date: [**2140-3-28**] Discharge Date: [**2140-4-4**]
Date of Birth: [**2068-10-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 710**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
71 year-old M with esophageal Ca s/p recent lap esophagectomy
who presents with altered MS, intubated in ED for MRI to r/o
spinal cord process. History is obtained per chart, as
patient's wife is not reachable by telephone. She had reported
mental status changes and confusion starting yesterday. He also
had worsened abdominal pain. She denied any fever, chills,
diarrhea, or vomiting.
.
Of note, he had his J-tube changed in Dr.[**Name (NI) 1482**] office 2
weeks prior due to obstruction.
.
In the ED surgery was consulted to rule out surgical issues. A
foley was placed with 1 L of urine, with good relief of
abdominal pain. He received morphine 2mg IV x 2 and ativan 2 mg
IV. He also received levoflox 500 mg and flagyl 500 mg for
concern for GI pathology. Out of concern for spinal abscess or
cord compression, he underwent intubation with propofol and
fentanyl. Post-intubation he became bradycardic to 24 but
spontaneously resolved before atropine could be given. He also
vomited peri-intubation. He received 5L NS in total in the ED.
..
On exam he denies abdominal or back pain.
Past Medical History:
Past Medical History:
Esophageal CA
GERD/ Barrett's esophagus
Asthma
Left knee arthritis
Past Surgical History:
Tonsillectomy
Submandibular gland excision
Social History:
Married, works as a dentist; seven drinks per week, non-smoker
Family History:
Father and 2 half sisters with CAD
Physical Exam:
Vitals: T: 99.0 BP: 118/62 P: 79 RR: 14 SaO2: 99% on AC:
500/12/0.60/5
General: Opens eyes to voice, intubated, bites at ETT.
HEENT: NC/AT, PERRL, EOMI, sclera anicteric.
Neck: supple, no JVD, no cervical or supraclavicular LAD.
Pulm: decr breath sounds to left base, otherwise clear
anteriorly.
Cardiac: RRR, nl S1/S2, no M/R/G appreciated
Abdomen: soft, NT/ND, faint BS, no masses or hepatomegaly noted.
J-tube site erythematous, but without frank discharge,
fluctuance. well-healed laparoscopy scars.
Rectal: deferred
Ext: No edema b/t, 2+ DP pulses b/l.
Skin: xerosis, J-tube site as above.
Neurologic:
-mental status: intubated and sedated, but opens eyes to voice
and follows simple commands. in soft restraints
-cranial nerves: II-X grossly intact
-DTRs: [**Name2 (NI) **] Babinskis bilaterally.
Pertinent Results:
[**2140-3-28**] 06:52PM CK(CPK)-100
[**2140-3-28**] 06:52PM CK-MB-NotDone cTropnT-<0.01
[**2140-3-28**] 06:52PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2140-3-28**] 01:00PM URINE HOURS-RANDOM
[**2140-3-28**] 01:00PM URINE HOURS-RANDOM
[**2140-3-28**] 01:00PM URINE UHOLD-HOLD
[**2140-3-28**] 01:00PM URINE GR HOLD-HOLD
[**2140-3-28**] 01:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.027
[**2140-3-28**] 01:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2140-3-28**] 09:54AM GLUCOSE-100 LACTATE-1.8 NA+-128* K+-3.9
CL--94* TCO2-25
[**2140-3-28**] 09:54AM HGB-13.5* calcHCT-41
[**2140-3-28**] 09:40AM GLUCOSE-108* UREA N-14 CREAT-0.6 SODIUM-128*
POTASSIUM-4.4 CHLORIDE-91* TOTAL CO2-29 ANION GAP-12
[**2140-3-28**] 09:40AM estGFR-Using this
[**2140-3-28**] 09:40AM ALT(SGPT)-20 AST(SGOT)-22 CK(CPK)-90 ALK
PHOS-148* AMYLASE-46 TOT BILI-0.5
[**2140-3-28**] 09:40AM LIPASE-69*
[**2140-3-28**] 09:40AM CK-MB-NotDone cTropnT-<0.01
[**2140-3-28**] 09:40AM TOT PROT-6.7 CALCIUM-9.4 PHOSPHATE-3.3
MAGNESIUM-2.1
[**2140-3-28**] 09:40AM WBC-7.5 RBC-4.24* HGB-12.6* HCT-36.7* MCV-87
MCH-29.7 MCHC-34.2 RDW-13.8
[**2140-3-28**] 09:40AM NEUTS-75.9* LYMPHS-12.7* MONOS-6.8 EOS-4.5*
BASOS-0.2
[**2140-3-28**] 09:40AM PLT COUNT-469*
[**2140-3-28**] 09:40AM PT-12.1 PTT-38.0* INR(PT)-1.0
Brief Hospital Course:
Assessment and Plan: 71 year-old M s/p recent lap esophagectomy
who presents with altered MS, intubated in ED for MRI to r/o
spinal cord process.
.
* Altered MS: In the emergency room, a Foley catheter was placed
upon arrival which found 1000cc urine. Due to urinary retention
and the patient's delirium and inability to follow commands,
there was concern for cauda equina vs. epidural abscess/mass.
The patient was intubated in the ED and transferred for an
emergent lumbar and sacral MRI. There were no abnormalities
found. The patient was transferred to the ICU intubated for
further management. A Head CT and UA were normal. Mild
hyponatremia was noted. A serum tox screen was negative. The
patient was afebrile with nl white count. Ambien and Celexa were
held. A surgery consult was obtained which determined that the
patient's Jtube site was not infected. The patient was extubated
and transferred to the medicine service on Hospital Day 2. He
was alert and oriented x 2, however he was noted to have slow
verbal response times but was overall alert and able to carry on
shortened conversation.
.
Upon transfer to the floor, the patient was noted to be
delirious. He was speaking Spanish and no longer speaking
English (English is primary language and has never spoken
spanish before according to his wife). A psychiatry and
neurology consult was obtained to which both thought that the
etiology of this language shift was likely acute delirium. The
patient had a 1:1 sitter. Blood cultures from admission returned
negative. A Head MRI was obtained which was negative for masses
or acute event.
.
The patient's delirium improved over time. Neurology felt that
there was no acute neurological issue that could cause this
language shift. Psychiatry believed that this language shift was
likely due to resolving delirium on top of longer-standing
depression and a new conversion disorder. Remeron was started.
.
Psychiatry continued to follow the patient closely; he improved
spontaneously and with the addition of Remeron. The patient was
discharged to home with an outpatient partial psych
hospitalization program set up.
.
* Hyponatremia: The patient was rehydrated in the ED with 5L NS
and the Na did not improve. TSH, cortisol were normal. Serum
osms were noted to be low indicating that there was excessive
ADH secretion. Fluid restriction to 1500cc per day corrected the
patient's hyponatremia. A nutrition consult was obtained and the
patient's tube feeds were changed to Nutren 2.0 for a more
concentrated formula with no free water. He was discharged on
this Nutren 2.0 formula. His sodium remained normal x 3 days at
the end of his hospitalization.
.
* Esophageal Ca s/p esophagectomy
The patient was continued on his Jtube feeds as above and his
outpatient regimen of isoprostol and carafate and prevacid and
lansoprazole. The patient tolerated small amounts of regular
food.
.
* Urinary Retention:
The patient failed two voiding trials; his Flomax was increased
to 0.8 and on the third voiding trial, he was able to void
spontaneously with this new increase in medication. The patient
did not receive any narcotics or any anti-cholinergics.
.
*Prophylaxis: PPI, SC heparin, bowel regimen
Medications on Admission:
misoprostol 100 mcg 4 x daily
Flomax 0.4 mg daily
Carafate 1 gram 4 x daily
Zantac syrup 150 mg [**Hospital1 **]
Prevacid 30 mg [**Hospital1 **]
Senna
Colace
Flovent 110 mcg 2 puffs [**Hospital1 **]
Albuterol p.r.n.
Celexa 40 mg daily
Ambien CR 6.25 mg QHS
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
2. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 inhaler* Refills:*0*
3. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
Disp:*30 * Refills:*2*
4. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
6. Mirtazapine 7.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO daily at
evening.
Disp:*30 Tablet(s)* Refills:*1*
7. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
8. Sucralfate 1 g Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Last Name (STitle) **]: Two (2)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*60 Capsule, Sust. Release 24 hr(s)* Refills:*2*
10. Zolpidem 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*40 Tablet(s)* Refills:*0*
11. Misoprostol 100 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QIDPCHS (4
times a day (after meals and at bedtime)).
Disp:*40 Tablet(s)* Refills:*2*
12. Nutren 2.0 Liquid [**Last Name (STitle) **]: 4.5 cans PO once a day: as
prescribed.
Nutren 2.0 or caloric equivalent in J tube.
Disp:*QS cans* Refills:*3*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Delirium
Urinary retention
Possible Conversion Disorder / psychogenic amnesia
.
Secondary Diagnoses:
T2N0 Esophageal cancer; no evidence of metastasis on Head MRI
Asthma
Benign Prostatic Hyperplasia
Depression
Discharge Condition:
Stable; delirium resolved.
Afebrile.
Discharge Instructions:
You presented to the hospital because of confusion. You were
found to have a low sodium level. Your sodium level was
corrected with a new tube feeding formula. You had images of
your brain which did not find anything concerning. You had some
urinary retention which resolved.
.
2pm Tomorrow [**4-5**]:
[**Hospital6 **]
[**Hospital1 **], [**Location (un) 583**]
Floor [**Location (un) **] 6
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 100416**], Licensed Social Worker
[**Telephone/Fax (1) 104433**]
.
Continue with the current tube feedings (will be delivered
tomorrow by [**Last Name (un) 6438**]).
-2.0 calorie formula 4.5 cans per day.
45cc/hour for 24 hours/day
60cc/hour for 18 hours/day
90cc/hour for 12 hours/day
Do not increase beyond 90cc/hour on your pump.
If you feel distention, diarrhea, abdominal pain, decrease the
infusion rate on your pump.
You may continue to eat your regular diet as tolerated.
.
Please call your doctor if: confusion, delirium, fever, chest
pain, shortness of breath, urinary retention or other worrisome
signs.
.
Please keep Jtube site covered with gauze. You may change the
gauze every 2 days. Please apply bacitricin ointment with the
dressing changes. Call physician if increased redness or pus
seen at Jtube site.
.
Please continue your medications as prescribed. Please continue
Remeron at 7.5 mg every night. Your Flomax dose has increased to
0.8 mg. We have discontinued your Celexa.
Medications:
1. Lansoprazole Oral Disintegrating Tab 30 mg by mouth twice a
day
3. Acetaminophen 325-650 mg up to 4g daily
13. Misoprostol 100 mcg by mouth with meals
4. Albuterol [**11-24**] PUFF every 6 hours as needed
Mirtazapine 7.5 mg every night
5. Bacitracin Ointment 1 Application WITH DRESSING CHANGES
Senna 1 TAB by mouth twice a day if needed for bowels
Docusate Sodium 100 mg twice daily please administer by JTube
Fluticasone Propionate 110mcg 2 PUFF inhaler twice a day
Sucralfate 1 gm PO QID
Flomax: Tamsulosin HCl 0.8 mg PO HS
Ambien: Zolpidem Tartrate 5 mg by mouth every night
Followup Instructions:
-Please keep your appointment as described above with [**Hospital 7302**] with Mr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 100416**]
.
-Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17811**] for follow-up appointment.
.
Call Dr.[**Name (NI) 1482**] office on Thursday: [**Telephone/Fax (1) 2981**]
to discuss J-tube removal.
Will have to maintain weight for period of time without Jtube
feedings for 1 week-10 days.
.
Provider: [**Name10 (NameIs) **] INJECTIONS Phone:[**Telephone/Fax (1) 1723**]
Date/Time:[**2140-4-12**] 8:55
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2847**], MD Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2140-6-6**] 9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2140-8-19**] 7:30
ICD9 Codes: 2761, 5119, 2930, 311, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1253
} | Medical Text: Admission Date: [**2140-4-13**] Discharge Date: [**2140-4-22**]
Date of Birth: [**2062-11-17**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
EGD and colonsocopy with gastric biopsy, [**2140-4-20**].
History of Present Illness:
77 y/o WF was was initially transferred from [**Hospital3 **]
[**4-13**] for descending thoracic and infrarenal aortic aneurysms
found after CTA done for severe chest/epigastric pain with
radiation to back. Initially there was concern for dissection.
Patient arrived to [**Hospital1 18**] with SBPs in low 200s and HR in 50s and
started on nipride drip. She had no other complaints except
epigastric tenderness on exam.
Past Medical History:
1. CVA/stroke-no deficits except memory and aphasia(uncertain
which side)
2. HTN
3. GERD
4. hypercholesterolemia
5. skin Cancer NOS
6. right hip fx
7. s/p TAH
9. 4.3 cm infrarenal AAA noted on CT [**2137**]
10. Recent (4-5 months ago)PNA 3 week stay at [**Hospital3 5365**],
details unknown.
11. ? Dementia
12. No cardiologist. No history of cath. Does not know of ETT in
past. Dr [**First Name (STitle) **] at [**Hospital1 392**] is PCP.
Social History:
Lives with husband at [**Hospital3 **]. Has a son, [**Name (NI) **], who
is very involved in her care.
Tob: Quit 10 years ago
EtOH: Social drinker.
Family History:
Non-contributory
Physical Exam:
VITALS: 97.3, 67(62-67), 111/69(111-154/70's), 97% 4L
GEN: NAD, [**Name (NI) 22031**], pt had difficulty sticking tongue out all the
way. OP clear with MMM. Neck Supple, no JVD, no bruit
appreciated.
CV: regular, nl s1s2, no murmurs
CHEST: Decreased breath sounds at bases. Isolated area of
wheezes on R, b/l rhonchi at bases more prominent on expiration.
ABD: Flat NT/ND NABS
Ext: No edema, 2+ pulses. Warm and well perfused. Full ROM all
ext with 5/5 strength.
Neuro: A+O x 3, Slow but apporiate response to all questions,
repeats answers, occasional word finding difficulties.
Pertinent Results:
[**2140-4-13**] 02:54PM LACTATE-2.0
[**2140-4-13**] 02:28AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.033
[**2140-4-13**] 02:28AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2140-4-13**] 01:50AM UREA N-30* CREAT-1.1 SODIUM-138 POTASSIUM-4.2
CHLORIDE-100 TOTAL CO2-25 ANION GAP-17
[**2140-4-13**] 01:50AM ALT(SGPT)-14 AST(SGOT)-18 CK(CPK)-76 ALK
PHOS-96 AMYLASE-71 TOT BILI-0.3
[**2140-4-13**] 01:50AM LIPASE-19
[**2140-4-13**] 01:50AM cTropnT-<0.01
[**2140-4-13**] 01:50AM CK-MB-2
[**2140-4-13**] 01:50AM CALCIUM-9.2 PHOSPHATE-3.5 MAGNESIUM-2.0
[**2140-4-13**] 01:35AM WBC-12.1* RBC-4.60 HGB-13.1 HCT-39.2 MCV-85
MCH-28.4 MCHC-33.4 RDW-13.5
[**2140-4-13**] 01:35AM NEUTS-62.6 BANDS-0 LYMPHS-30.9 MONOS-3.7
EOS-2.3 BASOS-0.6
[**2140-4-13**] 01:35AM PLT COUNT-250
[**2140-4-13**] 01:35AM PT-12.3 PTT-30.1 INR(PT)-1.0
CTA [**2140-4-13**]: IMPRESSION: Penetrating ulceration and aneurysmal
dilatation of the descending thoracic aorta, with areas of
intramural hematoma in the thoracic aorta. The areas of
penetrating ulceration continue into the upper abdominal aorta,
with a 3.7 cm infrarenal abdominal aortic aneurysm as described.
CXR [**2140-4-14**]: There is widening of the mediastinum, which has a
slightly ill- defined margin. While this may be positional,
there are no prior radiographs for comparison. Given that the
recent CT scan, performed yesterday demonstrated an aortic ulcer
with intramural hematoma and that there is a new left pleural
fluid collection, clinical correlation and followup CT scan are
recommended.
CXR [**2140-4-15**]: Left lower lobe pneumonia versus atelectasis.
CXR [**2140-4-16**]:
There is continued marked tortuosity of the thoracic aorta.
Please refer to recent CT scan report.There is continued left
lower lobe consolidation most likely indicating atelectasis. The
possibility of pneumonia cannot be excluded. There is continued
small left pleural effusion. The lungs are clear otherwise. The
heart is normal in size. No pneumothorax is seen.
CXR [**2140-4-17**]: Mild congestive heart failure with cardiomegaly and
small bilateral pleural effusion.
ECHO [**2140-4-20**]: Mild symmetric left ventricular systolic function
with preserved global and regional biventricular systolic
function. Mild mitral regurgitation.
Based on [**2131**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate a low risk (prophylaxis not recommended).
Clinical decisions regarding the need for prophylaxis should be
based on clinical and echocardiographic data.
CULTURE RESULTS:
URINE CULTURE (Final [**2140-4-17**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Trimethoprim/sulfa sensitivity confirmed by
[**Doctor Last Name 3077**]-[**Doctor Last Name 3060**].
PRESUMPTIVE STREPTOCOCCUS BOVIS. 10,000-100,000
ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Blood and sputum Cx's neg.
Brief Hospital Course:
1. Abdominal pain. This is a 77 F with history of HTN, AAA, and
CVA who presented with acute onset of abdominal pain on [**4-13**].
The patient was initially admitted to Vascular surgery service.
CT done at OSH was concerning for aortic dissection. Upon
further evaluation of images and comparison with [**2137**] studies,
it was found that descending aortic aneurysm was unchanged from
2 years ago and there was no dissection. On CT done at [**Hospital1 18**] AAA
size was measured 3.7 cm. Her abdominal pain resolved without
intervention soon after transfer. CT did show that she had
several large gallstones within the gallbladder. There was no
evidence of acute cholecystitis. Possible etiologies of her
abdominal pain included passing of a gallstone or gastritis
(later confirmed on EGD). LFT's were WNL on admission. The
patient was continued on PPI during this admission. She remained
asymptomatic and was tolerating po's well.
2. UTI. On [**4-14**], the patient developed T 102 with UCx positive
for E. coli >100,000 and Strep bovis in urine. She was started
empirically on a 3-day course of Bactrim.
She was then continued on a 7-day course of Levaquin per ID
because of better coverage of Strep bovis with Levaquin and also
because of CXR finding concerning of pneumonia. Would recommend
repeating UA and culture after she completes treatment course to
ensure resolution.
3. Atrial fibrillation, new diagnosis. [**4-16**] the patient was
found with new onset Afib with rapid ventricular response
130-150 with decrease in BP (SBP from 130 to mid 80s for 3
minutes). IV Lopressor was given without success and she was
loaded with IV amiodarone with subsequent return to NSR.
Cardiology were consulted. Cardiology consultants advised to
continue amiodarone po loading followed by 400 mg po bid dose x
7 days then 200 mg po daily. Vascular surgery were reconsulted
with question of anticoagulation in the setting of AAA and
advised that AAA is not a contraindication to anticoagulation.
The patient was started on anticoagulation with unfractionated
heparin while in the hospital in anticipation of colonoscopy.
After EGD/colonoscopy, she was then started on lower dose
Coumadin, 3 mg daily, (as she was also on Levaquin and
Amiodarone). Given history of a prior stroke which puts her at a
high risk for thromboembolic events, it was felt that the
patient needs to be bridged with Heparin to overlap with
therapeutic INR x 2days. Prior to discharge, the patient's son
learned to do Lovenox injections. Her INR was 1.3 on the day of
discharge (goal [**12-24**]). Dr. [**Last Name (STitle) 4541**] will be the patient's outside
cardiologist. Dr.[**Name (NI) 54594**] office was contact[**Name (NI) **] and they will
follow [**Name (NI) 62023**]. The patient was in sinus for the remained of her
hospitalization. Cardiology consultants recommended that the
patient will absolutely need continuous loop recorder after her
discharge. A close f/u appointment with Dr. [**Last Name (STitle) 4541**] was arranged
for the patient. Of note, the patient's TSH and free T4 were
checked and were 1.1 and 1.3 respectively. The patient did have
an echocardiogram during this admission which showed normal EF,
symmetric LVH and mild MR. There was no evidence of intracardiac
thrombi.
4. H/o prior embolic stroke. The patient was continued on low
dose aspirin.
5. AAA. Stable, 3.7 cm. The patient needs tight BP control. Goal
SBP <130.
6. HTN. The patient was continued on Lopressor, Imdur, and
Lisinopril. She had severe HTN with SBP in 200's requiring doses
of IV Hydralazine. Lopressor and Lisinopril were titrated up.
The patient c/o increased cough during this admission and an ACE
inhibitor was later changed to [**First Name8 (NamePattern2) **] [**Last Name (un) **] to eliminate it as a cause
of her cough. (the patient was on a low dose Prinivil as an
outpatient). Her BP medications will likely need further
adjustment as an outpatient.
7. Anemia. Iron studies revealed low serum Fe/TIBC ratio, but
Ferritin was >500. B12 level was also low, 230. The patient was
started on Vitamin B12 supplements and was continued on iron
supplements. Given suspicion for iron deficiency anemia and need
for chronic anticoagulation as well as finding of Strep bovis in
urine, GI were consulted and the patient underwent EGD and
colonoscopy which were significant for gastritis and diverticuli
in duodenum and sigmoid but showed no evidence of malignancy in
colon. Stomach biopsy was done and the results are pending at
the time of this discharge. GI recommended capsule endoscopy as
an outpatient and this was scheduled for [**2140-4-29**].
Instructions regarding bowel prep were communicated to the
patient's son.
8. Pulmonary. The patient was on inhalers including steroids as
an outpatient. The was no h/o COPD documented. She did not have
evidence of bronchospasm and her only pulmonary complaint during
this admission was cough, which could have been due to a
respiratory infection, post-nasal drip or ? ACE side effect. CXR
intially showed evidence of CH which improved clinically
throughout her admission. The patient was continued on Lasix 20
mg po daily. ACE was stopped to eliminate this as cause for
cough. The patient was on Levaquin for UTI which will also cover
a pulmonary source. Clinically her cough was not worse at night.
She was told to resume her outpatient inhalers and to continue
with a nasal spray. She will follow up with her PCP.
11. Hypercholesterolemia. She was continued on Pravachol
12. Code: FULL
Medications on Admission:
Meds On Admission:
Protonix 40 mg po qd
Actonel 35 mg po q week
Albuterol 2 puffs q4 hrs prn
[**Doctor First Name **] [**Hospital1 **]
ASA 81 mg po daily
Ferrous sulfate 325 mg
Flonase
Flovent 2 puffs [**Hospital1 **]
Lasix 20 mg daily
Imdur 30 mg po daily
Lopressor 75 mg po bid
Os-Cal 500 mg [**Hospital1 **]
Pravachol 40 mg po qd
Prinivil 2.5 mg po qd
Zetia 10 mg po qd
Cipro (recently completed a 5 day course)
MEDS on transfer:
Isosorbide Dinitrate 20 mg PO TID
Lisinopril 10 mg PO DAILY
Acetaminophen 325-650 mg PO Q4-6H:PRN
Metoprolol 100 mg PO TID
Pantoprazole 40 mg PO Q24H
Dolasetron Mesylate 12.5-25 mg IV Q8H:PRN nausea
Furosemide 20 mg PO DAILY
HydrALAZINE HCl 10 mg IV Q4H
Sulfameth/Trimethoprim DS 1 TAB PO
Amiodarone
Discharge Medications:
1. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: Three (3)
Tablet Sustained Release 24HR PO once a day.
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
2. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Enoxaparin Sodium 80 mg/0.8 mL Syringe Sig: One (1)
Subcutaneous Q24H (every 24 hours) for 4 days: Please consult
Dr. [**Last Name (STitle) 4541**] after you have INR checked on Monday if you need to
continue Lovenox.
Disp:*4 pre-filled syringes* Refills:*0*
7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
8. Pravastatin Sodium 40 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
11. Actonel 35 mg Tablet Sig: One (1) Tablet PO once a week:
take as before, before breakfast with full glass of water.
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime): your IRN needs to be closely monitored and dose
adjusted. .
Disp:*10 Tablet(s)* Refills:*0*
14. Albuterol Sulfate 0.083 % Solution Sig: Two (2) Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
15. Os-Cal 500 mg Tablet Sig: One (1) Tablet PO twice a day.
16. Flovent 44 mcg/Actuation Aerosol Sig: Two (2) Inhalation
twice a day.
17. Flonase 50 mcg/Actuation Aerosol, Spray Sig: One (1) Nasal
once a day.
18. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO as
directed: please take 2 pills twice a day for 5 days then take
one pill once a day and follow up with Dr. [**Last Name (STitle) 4541**].
Disp:*30 Tablet(s)* Refills:*1*
19. Atrovent 18 mcg/Actuation Aerosol Sig: One (1) Inhalation
every six (6) hours as needed for shortness of breath or
wheezing.
Disp:*1 unit* Refills:*0*
20. Losartan Potassium 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
21. Outpatient [**Name (NI) **] Work
PT-INR and Chem 7.
Please call results to Dr. [**Last Name (STitle) 4541**] or Dr. [**First Name (STitle) **] at ([**Telephone/Fax (1) 62024**].
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnoses:
1. Abdominal pain, self-resolved
2. Atrial fibrillation with rapid ventricular response
3. Urinary tract infection
4. Hypertension
Secondary diagnoses:
1. Abdominal aortic aneurysm
2. Anemia
3. Gastritis
4. Diverticulosis, sigmoid
5. Duodenal diverticuli
Discharge Condition:
Asymtpomatic. Vital signs stable.
Discharge Instructions:
Please take all medications as prescribed.
Please keep all follow up appointments. You will need to have
you INR monitored closely and coumadin dose adjusted as needed.
Dr. [**Last Name (STitle) 4541**], your new cardiologist, will follow your INR.
Please follow up with Dr. [**First Name (STitle) 437**] about your GI biopsy results.
Please return to care if you have chest pain, fever, abdominal
pain, if you have bleeding that does not stop.
Followup Instructions:
Cardiology: Dr. [**Last Name (STitle) 4541**] ([**Telephone/Fax (1) 62025**] on [**2140-4-25**] at 1:45
pm. You will need to be set up for cardiac monitor (continuous
loop recorder) and your medications will likely need to be
adjusted.
You need to return for capsule endoscopy on [**Last Name (LF) 2974**], [**4-29**]. You
need to have bowel prep prior to the procedure. Please follow
the instructions that were provided to you. Please come to the
[**Hospital Ward Name **], [**Hospital Ward Name 1950**] building, [**Location (un) 453**], at 7:45 am. ([**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1982**], MD Where: [**First Name8 (NamePattern2) **] [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **]
COMPLEX) ENDOSCOPY SUITE Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2140-4-29**]
8:00)
Primary care: Please call Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 62025**] to arrange
for a follow up appointment within 2 weeks of discharge from the
hospital.
GI: Dr. [**First Name (STitle) 437**], [**2140-5-17**], at 1:20 pm.
Completed by:[**2140-4-24**]
ICD9 Codes: 5990, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1254
} | Medical Text: Admission Date: [**2182-6-13**] Discharge Date: [**2182-6-22**]
Date of Birth: [**2114-2-15**] Sex: M
Service: NEUROLOGY
Allergies:
Bactrim
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
aphasia, rightside plegia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Professor [**Known lastname 111203**] is a 64-year-old gentleman with a history
of atrial fibrillation last INR 1.2, who was last seen normal
at
11:30 to 12 am who presents with new onset aphasia and right
hemiplegia. Patient had spent the day playing with his
grandchildren. He then was watching the Red Sox game on TV and
it is unclear when he went to bed. The son was [**Location (un) 1131**] a book
and thinks he heard him around midnight. At some point in the
night he woke up and went down stairs. The wife also went down
stairs and noted his speech was garbled. The daughter came home
a little after 2 and noted he had a right facial droop and
called
911. His wife observed that his right arm and leg were becoming
weak.
EMS was called at 2:45 for slurred speach, he was found to
be aphasic with right sided weakness and a facial droop. He
went
to [**Hospital3 **] where a CT had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] left MCA sigh, loss of
[**Doctor Last Name 352**] weight differentiation. An MRI was done which showed some
restricted diffusion in the left insula and a cut off of the M1.
The [**Hospital3 **] medical staff considered that he was past the
time window for
iv TPA and thought that he was not a candidate. He was then
transferred to [**Hospital1 18**] for possible intervention with the
mechanical clot retrieval device.
Of note his INR was 1.2 at the OSH. Wife states he is
inconsistent with taking his medications and sometimes forgets.
On general review of systems, the pt denies recently had some
diarrhea from his return from Barcelona this past week. But no
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, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria.
Past Medical History:
-Atrial fibrillation.
-Noninsulin dependent diabetes mellitus.
-Hypertension.
-Hyperlipidemia.
-CAD w stents
-Depression
Social History:
Minimal EtOH, Former smoker. Lives at home with his
wife. [**Name (NI) **] is a [**University/College 5130**] professor of business. He has 4
children.
Family History:
no history of strokes
Physical Exam:
Vitals: T:98.4 P:82-103 R:18-24 BP:96-140/45-74 SaO2:94-99% RA
to 2LNC
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: irregularly irregular
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
Skin: no rashes or lesions noted.
Neurologic:
Mental Status: Alert, Global aphasia
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF
III, IV, VI: EOMI
V: sensation intact
VII: right facial droop
VIII: appears intact
IX, X: Palate elevates symmetrically.
XII: Tongue protrudes in midline.
-Motor:
RUE: no movement. plegic, flaccid
RLE: toes wiggle, but unable to move in plane of gravity or
antigravity
Full spontaneous movement of left upper and lower extremity.
-Sensory: Grimaces to noxious stimuli in RUE, withdraws on RLE
as well as left side
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor on left and extensor on the right.
Pertinent Results:
Laboratory:
ADMISSION LABS
[**2182-6-13**] 05:44AM BLOOD WBC-8.6 RBC-4.24* Hgb-14.1 Hct-41.5
MCV-98 MCH-33.2* MCHC-33.9 RDW-13.8 Plt Ct-163
[**2182-6-17**] 10:10PM BLOOD Neuts-82.0* Lymphs-10.9* Monos-4.7
Eos-2.2 Baso-0.2
[**2182-6-13**] 05:44AM BLOOD PT-14.5* PTT-25.3 INR(PT)-1.3*
[**2182-6-13**] 05:44AM BLOOD Glucose-263* UreaN-28* Creat-1.1 Na-140
K-4.8 Cl-104 HCO3-28 AnGap-13
[**2182-6-13**] 09:39AM BLOOD ALT-22 AST-27 LD(LDH)-224 CK(CPK)-131
AlkPhos-56
.
RISK FACTORS
[**2182-6-13**] 09:39AM BLOOD CK-MB-5
[**2182-6-13**] 09:39AM BLOOD cTropnT-<0.01
[**2182-6-13**] 11:39PM BLOOD CK-MB-5
[**2182-6-17**] 10:10PM BLOOD Calcium-8.6 Phos-2.6* Mg-1.9 Iron-19*
Cholest-131
[**2182-6-13**] 09:39AM BLOOD Albumin-3.7 Cholest-129
[**2182-6-17**] 10:10PM BLOOD Triglyc-81 HDL-56 CHOL/HD-2.3 LDLcalc-59
[**2182-6-13**] 09:39AM BLOOD %HbA1c-6.4* eAG-137*
[**2182-6-17**] 10:10PM BLOOD calTIBC-295 TRF-227
[**2182-6-13**] 09:39AM BLOOD TSH-2.9
[**2182-6-13**] 09:39AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG.
.
Discharge labs:
DISCHARGE LABS
[**2182-6-22**] 07:10AM BLOOD WBC-7.5 RBC-3.78* Hgb-12.5* Hct-36.0*
MCV-95 MCH-33.0* MCHC-34.6 RDW-13.9 Plt Ct-260
[**2182-6-22**] 07:10AM BLOOD PT-27.6* PTT-37.8* INR(PT)-2.6*
[**2182-6-22**] 07:10AM BLOOD Glucose-255* UreaN-24* Creat-0.7 Na-138
K-4.6 Cl-97 HCO3-32 AnGap-14
[**2182-6-22**] 07:10AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.2
.
.
Urine:
[**2182-6-13**] 05:42PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.025
[**2182-6-13**] 05:42PM URINE Blood-LG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2182-6-13**] 05:42PM URINE RBC-56* WBC-9* Bacteri-FEW Yeast-NONE
Epi-0
[**2182-6-13**] 05:42PM URINE Mucous-RARE
[**2182-6-13**] 05:42PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
.
IMAGING
Cardiology Report ECG [**2182-6-13**]: IMPRESSION: Atrial fibrillation,
average ventricular rate 91. There appears to be aberrant
conduction during short coupled beats. No previous tracing
available for comparison.
.
ED STROKE CTA HEAD & NECK WITH PERFUSION [**2182-6-13**]: IMPRESSION:
1. Hyperdense left MCA, with absent filling on angiography
indicative of
occlusion. 2. Large area of increased MTT in left MCA
distribution with smaller area of low blood volume indicating
area of ischemia to be larger than infarct.
.
CHEST (PORTABLE AP) Study Date of [**2182-6-13**]: IMPRESSION: There is
mild cardiomegaly. There are low lung volumes. There are
bibasilar atelectasis. No evidence of aspiration. There is no
pneumothorax or pleural effusion.
.
CHEST (PORTABLE AP) Study Date of [**2182-6-14**]: IMPRESSION: Mild
cardiomegaly is stable, but pulmonary vascular engorgement
suggests early cardiac decompensation or volume overload.
Pleural effusion is minimal if any. No pneumothorax.
.
MR HEAD W/O CONTRAST [**2182-6-14**]: IMPRESSION: Thrombus is
visualized in the left cavernous and petrous portion of the
internal carotid artery with infarction visualized in the left
frontal lobe, caudate, and putamen. Areas of microhemorrhage are
visualized in the left caudate and putamen with no evidence of
macrohemorrhage.
.
CHEST (PORTABLE AP) [**2182-6-15**]: Study was centered in the
thoracoabdominal region. NG tube tip is in the stomach.
Evaluation of the chest is very limited due to technique and
projection. The visualized lungs and cardiomediastinum are
unchanged.
.
CHEST (PA & LAT) [**2182-6-17**]: Low lung volumes with incresed
vascular congestion suggesting cardiac decompensation or volume
overload. Bilateral pleural effusions if any appear minimal.
.
CHEST (PORTABLE AP) [**2182-6-19**]: In comparison with study of [**6-17**],
the tip of the nasogastric tube extends well into the stomach.
Continued enlargement of the cardiac silhouette with pulmonary
edema. The possibility of a supervening consolidation at one or
both bases cannot be definitely excluded.
.
CHEST (PORTABLE AP) [**2182-6-21**]: Tip of Dobbhoff in the stomach,
but the end of the weight portion is near the GE junction.
Recommend advancing 4 to 5 cm to ensure proper position.
.
.
Cardiology:
PORTABLE TTE [**2182-6-14**]: IMPRESSION: The left atrium is moderately
dilated. The right atrium is markedly dilated. No atrial septal
defect is seen by 2D or color Doppler. The estimated right
atrial pressure is 10-15mmHg. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect.RV with
normal free wall contractility. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. The mitral valve
leaflets are elongated. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
ECG Study Date of [**2182-6-13**] 6:05:22 AM
Atrial fibrillation, average ventricular rate 91. There appears
to be aberrant
conduction during short coupled beats. No previous tracing
available for
comparison.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] S.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
91 0 88 [**Telephone/Fax (2) 111204**]3
Brief Hospital Course:
Primary diagnoses:
Left middle cerebral artery stroke secondary to atrial
fibrillation with subtherapeutic INR
.
Secondary diagnosis:
Hypertension
Diabetes
Possible sleep apnea
.
.
.
Mr. [**Known lastname 111203**] is a 64 year old Professor [**First Name (Titles) **] [**Last Name (Titles) 111205**] at [**University/College 5130**]
with h/o AF (poorly compliant with therapy as last INR 1.2) who
presented with new onset aphasia and right hemiplegia with R
facial droop. Symptoms were of a stuttering infarct suggestive
of cardioembolic disease.
.
.
# Left MCA infarct: He initially presented to [**Hospital3 **] where
head CT showed a dense left MCA sign, loss of [**Doctor Last Name 352**] weight
differentiation. Patient did not receive TPA. An initial MRI at
OSH showed restricted diffusion in the left insula and a cut off
of the M1. The [**Hospital3 **] medical staff determined that he was
outside of the window for giving iv TPA. He was then transferred
to [**Hospital1 18**] for the possibility of intervention with a mechanical
clot retrieval device.
Upon arrival to [**Hospital1 18**] he had an NIHSS of 21, he was alert,
aphasic, right hemianopia, right facial droop, plegic right
upper, and paretic right lower extremity. A follow up CTA
demonstrated ~50% narrowing of L internal carotid artery just
after the bifurcation and CTP demonstrated increased MTT
throughout MCA distribution. Given extensive infarction the
decision was made that given the extended time window and
already decreased CBV in a sizeable area of the brain, the
decision against intervention was made for fear of high-risk for
hemorrhagic complications.
Patient was transferred to the Neuro ICU and started on a
heparin gtt in hopes of stabilizing the clot. Repeat MRI here
showed infarction in the left frontal lobe as well as the left
caudate and putamen and MRA showing thrombus in the left
cavernous and petrous portion of the internal carotid artery
with areas of microhemorrhage in the left caudate and putamen
with no evidence of macrohemorrhage. Warfarin was restarted on
[**6-16**].
Additional Stroke Risk factors were addressed with HbA1c 6.4%,
cholesterol 131 and LDL 59 TSH 2.9. Echo showed no cardiac cause
for his stroke with no VSD/ASD or PFO noted and normal LV
systolic function with EF>55%. In addition, there was
moderate-severe biatrial dilatation.
Patient received PT and OT. Patient initially failed swallow
assessment and an NG tube was inserted. As his clinical picture
improved, his swallow improved and did well with assessment on
[**6-21**] with coughing afterwards ? representing aspiration. Advice
was that he should have a Dobbhoff tube placed with repeat
evaluation later in the week. He has evidence of improvement
and would likely not require PEG tube.
As with speech, he neurologically improved, especially speech -
at the time of discharge he was slightly antigravity at hip
flexion.
IV heparin was transitioned to enoxaparin and INR was 2.6 on
discharge and LMWH was stopped and warfarin dose reduced to 5mg.
We continued pravastatin 40mg daily. Patient was transferred to
rehab on [**2182-6-21**] and has neurology follow-up on [**2182-8-13**].
# Cardiovascular:
Patient has a history of AF but admission INR was subtherapeutic
at 1.2. Echo showed no cardiac cause for his stroke with no
VSD/ASD or PFO noted and normal LV systolic function with
EF>55%. In addition, there was moderate-severe biatrial
dilatation. Patient was rate controlled initially with IV
metoprolol PRN and we continued dofetilide. Given that patient
is on dofetilide, we monitored patient with daily Chem 7 and
repleted electrolytes of K to 4 and Mg to 2. Patient had mild
HTN and we added half dose lisinopril [**6-21**]. We continued
pravastatin 40mg daily. metoprolol should be restarted at
rehabiliation and his lisinopril increased as tolerated back to
his home dose.
# Diabetes: Patient has a history of T2DM on glipizide and
pioglitazone. BGLc was well controlled in house with an ISS and
oral diabetic medications were held. HbA1c 6.4%. Oral
medications should be restarted at rehab.
# Pulmonary: Patient had difficulty with secretions while on the
ICI and likely had some problems with mucus plugging. He
required regular suctioning and once on the floor he greatly
improved and suctioning frequency had greatly diminished. He
remains at risk for aspiration and should be seen by speech
therapy as above for repeat swallow evaluation. In addition,
the patient likely has sleep apnea as sats were seen to drop
when he falls asleep. His wife confirmed a history of snoring
and respiratory changes in sleep. We did not pursue CPAP given
risks for aspiration. PCP should consider [**Name Initial (PRE) **]/p eval for sleep
apnea work up on d/c.
# FEN: NG tube was inserted in ICU and Dobbhoff placed on [**6-21**]
and in correct place on CXR. Currently receiving NG feed but
signs of fluid overload should be assessed and of the patient
appears to have congestion, a more concentrated feed can be
considered.
#Precautions: Falls and aspiration
# CODE: FULL CODE
# Contact: home: Wife [**Name (NI) **] [**Telephone/Fax (1) 111206**]
Children:
[**Location (un) **]: [**Telephone/Fax (1) 111207**]
[**Doctor First Name **]: [**Telephone/Fax (1) 111208**]
[**Doctor First Name **]: [**Telephone/Fax (1) 111209**]
[**Female First Name (un) **]: [**Telephone/Fax (1) 111210**]
Medications on Admission:
Tikosyn 500 mcg p.o. b.i.d.
Coumadin 4 mg p.o. daily.
Prastatin 40 mg p.o. daily.
Lopressor 25 mg p.o. b.i.d.
Glipizide XL 20 mg p.o. daily.
Actos 45 mg p.o. daily.
Lisinopril 20 mg p.o. daily.
Paroxetine 20 mg p.o. daily.
Folic Acid and Vitamin D
Discharge Medications:
1. dofetilide 500 mcg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
2. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day).
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. paroxetine HCl 10 mg/5 mL Suspension Sig: Two (2) PO DAILY
(Daily).
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing, sob.
8. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing, sob.
9. acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q6H (every 6 hours) as needed for pain, fever.
10. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours): while NG Tube in place.
11. warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
12. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
15. Actos 45 mg Tablet Sig: One (1) Tablet PO once a day.
16. glipizide 10 mg Tablet Extended Rel 24 hr Sig: Two (2)
Tablet Extended Rel 24 hr PO once a day.
17. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary diagnoses:
Left middle cerebral artery stroke secondary to atrial
fibrillation with subtherapeutic INR
.
Secondary diagnosis:
Possible sleep apnea
Discharge Condition:
Mental Status: Patient understands questions but is
significantly aphasic, can follow simple commands
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neurologic: No movement of the right arm, proximal>distal
weakness of the right leg.
Discharge Instructions:
It was a pleasure taking care of you during your stay at the
[**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. You presented following
sudden onset right-sided weakness and speech problems. [**Name (NI) **] had a
CT scan in the ED which showed evidence of a stroke involving he
left side of the brain which accounts for your symptoms. You
were transferred to the ICU for closer monitoring. Your stroke
affected your swallowing and an NG tube was placed.
The likely cause for your stroke was due to your atrial
fibrillation which in light of an indaequate warfarin level
(INR) meaning that the blood was not sufficiently thin,
predisposes to clot formation in the heart which can then travel
to the brain and cause a stroke. For your atrial fibrillation,
you were started initially on an IV form of heparin, to thin
your blood until another blood thinner called warfarin is at an
appropriate level.
As you are now on warfarin you must be careful regarding any
falls as you will bleed more and especially if you were to hit
your head as this can cause bleeding in the brain. If you fall,
you should seek medical attention.
You had a new feeding tube placed on [**6-21**] prior to transferring
to rehab. And you will need continued swallowing evaluation to
determine when it will be safe to take food and medications by
mouth.
Your oxygen level was noted to fall when you went to sleep and
this suggests that you have sleep apnea. Your PCP should arrange
[**Name9 (PRE) 8019**] for this.
You were transferred to a rehab facility to continue your stroke
rehabilitation. You have neurology follow-up as below.
Medication changes:
We INCREASED warfarin to 5mg daily
We DECREASED lisinopril to 10mg daily
We STARTED albuterol and ipratropium nebulisers as required for
your breathing difficulties
We STARTED laxatives
Please continue your other medications as prescribed
Followup Instructions:
You should follow-up with your PCP [**Name Initial (PRE) 176**] 1 week after discharge
from rehab. [**Last Name (LF) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 26774**]
You also have the following neurology follow-up appointment.
Department: NEUROLOGY
When: TUESDAY [**2182-8-13**] at 1 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2182-6-22**]
ICD9 Codes: 4019, 2724, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1255
} | Medical Text: Admission Date: [**2159-1-1**] Discharge Date: [**2159-1-2**]
Date of Birth: [**2099-8-27**] Sex: F
Service: SURGERY
Allergies:
Phenothiazines
Attending:[**Doctor First Name 5188**]
Chief Complaint:
ventral hernia x 2
Major Surgical or Invasive Procedure:
ventral hernia repair with mesh
History of Present Illness:
59F s/p TAH with infraumbilical incisional hernia & painful
epigastric hernia. No GI symptoms or concern for incarceration.
CT revealed nonobstructed hernias. Patient presented for
elective repair
Past Medical History:
TAH
HTN
^chol
depression
Social History:
noncontrib
Family History:
noncontrib
Physical Exam:
AVSS
NAD
RRR
CTA B
Soft obese NT ND
Palp nonreducible midline epigastric & infraumb incisional
hernias
No CCE
Pertinent Results:
Fasting fingerstick levels: 160-180
[**2159-1-1**] 08:42PM BLOOD %HbA1c-PND [Hgb]-PND [A1c]-PND
Brief Hospital Course:
[**1-1**]: Uncomplicated hernia repair with mesh. Patient admitted
for overnight observation given extension of incision to repair
markedly weakened fascia between hernias. 2 subcutaneous JP
drains left to drain possible seroma.
During routine postop check 6 hours after skin closure, patient
was lethargic given excessive narcotic administration. She was
transferred to [**Hospital Unit Name 153**] for close respiratory monitoring while
narcotics wore off. foley placed for failure to void.
fingersticks 160-180, HBA1C sent (still pending)
[**1-2**]: foley DC'd in AM. given oxycodone without narcosis.
diet advanced & sent home with drain instruction.
Medications on Admission:
norvasc
triamterene
lipitor
premarin
celexa
trazodone prn
Discharge Medications:
norvasc
triamterene
lipitor
premarin
celexa
trazodone prn
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): use while taking percocets.
Disp:*60 Capsule(s)* Refills:*2*
3. Motrin 800 mg Tablet Sig: One (1) Tablet PO three times a
day: take with meals for the next 5 days.
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
ventral incisional & epigastric hernias
hypertension
depression
hypercholesterolemia
hyperglycemia (perioperative vs new onset diabetes mellitus)
Discharge Condition:
good
Discharge Instructions:
Diet as tolerated. Drain your JP drains as directed. No
bathing (showers okay - pat wound dry), no driving if taking
narcotics, and no strenuous activity.
Continue all of your preoperative medications. You may take
motrin or tylenol to minimize your narcotic requirement. You
should take an OTC stool softener like colace while using
percocets to prevent constipation.
Contact your MD if you develop fevers>101, redness or drainage
from your surgical wound, increasing abdominal pain, inability
to tolerate PO's, or if you have any questions or concerns
whatsoever.
Followup Instructions:
Contact [**Name2 (NI) 54841**] office at [**Telephone/Fax (1) 5189**] to arrange a
follow up appointment in 1 week.
You should follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in [**4-8**] weeks
to discuss your high blood sugars.
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
Completed by:[**2159-1-2**]
ICD9 Codes: 4019, 2720, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1256
} | Medical Text: Admission Date: [**2195-12-24**] Discharge Date: [**2196-1-2**]
Date of Birth: [**2128-11-8**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
Nausea/vomiting, abdominal pain. Transferred from OSH.
Major Surgical or Invasive Procedure:
ERCP with stent placed in CBD [**2195-12-24**]
Endotracheal intubation [**2195-12-24**]; extubated [**2195-12-29**]
History of Present Illness:
67 yo male, h/o 3vd, [**Month/Day/Year **] s/p ablation in [**4-27**] at [**Hospital1 2025**], RA,
diastolic dysfunction, who presented from [**Hospital 1263**] hospital with
?biliary sepsis. Pt reports that on day of admission, he woke
up with malaise, nausea, vomiting, fevers, and rigors. He went
to [**Doctor Last Name 1263**] ED, found to be febrile with abnormal LFT's, was
started on antibiotics (clinda/ceftaz) and IVF, and was
transferred to [**Hospital1 18**] for presumed biliary sepsis and further
management. On transfer, he was started on zosyn/levo/flagyl,
was hemodynamically unstable, was intubated prior to ERCP. ERCP
showed no obstruction, no stones, some biliary sludging only
(normal cholangiogram). A stent was placed in the CBD. He
continued to by hypotensive/unstable post ERCP, was found to
have an evolving NSTEMI (tnt leak, 2mm ST depre in v3-v6; peak
tnt 1.8, now trended down). He remained intubated. SWAN on
[**12-24**] showed PCWP 35, BP 95/43, FA=22, and the next warning, he
went into rapid afib with decompensation requiring single 200 J
shock. He was on 3 pressors at the time (levophed, vasopressin,
dopa), converted into NSR temporarily, was started on amio. He
had recurrence of afib. DCCV was repeated 2 times without
success; he spontaneously reverted to NSR (?s/p DCCV on [**12-26**])
has remained in this rhythm, and is on an amio taper (drip).
Cardiology is following. Etiology of this new onset afib was
thought to be in the setting of volume resuscitation and acute
illness.
With respect to his sepsis, he required 3 pressors as above, was
on vanco/zosyn/lev/flagyl. Blood cultures from [**Doctor Last Name 1263**] grew out
[**4-26**] E. coli (with E. coli also in urine) resistant to
amp/pip/sulbactam. Ciprofloxacin was added to regimen on [**12-26**].
He is currently just on cipro and is to complete a 14 day course
for E. coli. He continued to improve clinically, was extubated
on [**12-29**], and he was transferred to the floor on [**12-30**] (stable,
mentating). Other MICU events include a drop in platelets
following 48 hours of heparin therapy (HIT negative, Hep d/c'ed,
and platelets recovering). He had a bump in his creatinine to
3.0 (baseline 1.3-1.5 as per PCP) which is resolving (?ATN [**2-23**]
hypotension but no muddy brown casts on sediment). Renal US was
obtained that did not show hydronephrosis or cause or ARF. Hct
has been stable, but he has been guaiac positive on exam. Pt
was stable on transfer to the floor.
Past Medical History:
Cardiac:
1. Severe 3vd by report; apparently not a surgical candidate.
Cardiologist is Dr. [**First Name8 (NamePattern2) 59998**] [**Last Name (NamePattern1) **] at [**Hospital1 2025**], recent P-MIBI on [**5-26**]
2. History of [**Month/Year (2) **]/SVT, s/p ablation in [**5-26**]
3. MI [**6-29**] yrs ago; few episodes of angina since that time
Other PMH:
1. RA x 30 yrs, on remicaide and MTX, symptoms stable; usually
has sx in shoulders and knees; Rheum: Dr. [**First Name (STitle) **] [**Name (STitle) **] in [**Hospital1 392**]
2. ?h/o HBV
3. GERD
4. Pilonidal cyst in 20's
Meds on transfer:
Ciprofloxacin 500 [**Hospital1 **] (d4/14; d1=[**12-26**])
Amiodarone taper
Oxybutynin 5 mg TID
SSI
ASA 325
Lansoprazole
Ativan PRN
MsO4 PRN
Nystatin suspension
ALL: NKDA
Social History:
Quit smoking 30 yrs ago; smoked [**1-23**] ppd prior to this
Social EtOH
No drugs/IVDU ever
Homosexual, lives with partner; had neg HIV test 3 yrs ago, has
been monogamous with his partner since that time
Family History:
Mother died lung ca age 76 (smoker)
Uncle-CABG
Physical Exam:
VS: 98.4 57 129/62 15 98% RA wt=132 kg; admission
118.7 kg
Gen: very pleasant male, nad, sitting in bed, comfortable, A&Ox3
HEENT: PERRL, EOM grossly intact, OP clear
Neck: no JVD appreciated, no LAD, no bruits
CV: RRR, nl S1/S2, no m/r/g
Lungs: CTA B from anterior exam, no w/r/r
Abd: soft, nt/nd, nabs
Extr: [**2-24**]+ edema in UE and LE (with pneumoboots on UE/LE); still
with foley and rectal tube
Pertinent Results:
[**2195-12-24**] 10:10PM HGB-12.7* calcHCT-38 O2 SAT-77
[**2195-12-24**] 10:09PM TYPE-ART TEMP-37.6 PO2-195* PCO2-36 PH-7.28*
TOTAL CO2-18* BASE
[**2195-12-24**] 10:09PM O2 SAT-98
[**2195-12-24**] 07:27PM LACTATE-3.3*
[**2195-12-24**] 05:03PM freeCa-1.11*
[**2195-12-24**] 04:50PM GLUCOSE-130* UREA N-34* CREAT-2.6* SODIUM-140
POTASSIUM-4.8 CHLORIDE-109* TOTAL CO2-16* ANION GAP-20
[**2195-12-24**] 04:50PM CK-MB-49* MB INDX-7.7* cTropnT-0.51*
[**2195-12-24**] 03:18AM FIBRINOGE-654*
[**2195-12-24**] 03:18AM ALT(SGPT)-181* AST(SGOT)-191* CK(CPK)-405*
ALK PHOS-175* AMYLASE-55 TOT BILI-4.5* DIR BILI-3.8* INDIR
BIL-0.7
[**2195-12-24**] 03:18AM LIPASE-13
[**2195-12-24**] 03:18AM ALBUMIN-3.1* CALCIUM-7.5* PHOSPHATE-3.1
MAGNESIUM-1.0*
[**2195-12-24**] 03:18AM HBsAg-NEGATIVE HBs Ab-POSITIVE HAV
Ab-NEGATIVE
[**2195-12-24**] 03:18AM HCV Ab-NEGATIVE
[**2195-12-24**] 03:18AM WBC-33.7* RBC-4.30* HGB-14.2 HCT-42.0 MCV-98
MCH-33.0* MCHC-33.8 RDW-15.4
[**2195-12-24**] 03:18AM NEUTS-78* BANDS-6* LYMPHS-3* MONOS-11 EOS-0
BASOS-0 ATYPS-0 METAS-2* MYELOS-0
[**2195-12-24**] 03:18AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2195-12-24**] 03:18AM PLT COUNT-250
[**2195-12-29**] 3:59 PM
PORTABLE RENAL ULTRASOUND: Limited views of both kidneys were
obtained. The right kidney measures 11.7 cm. The left kidney
measures 11.2 cm. There is no evidence of renal stones,
hydronephrosis, or perinephric fluid collections.
IMPRESSION:
Limited portable exam shows no significant abnormalities.
CHEST (PORTABLE AP) [**2195-12-24**] 3:21 AM
An AP portable study of the chest was obtained. No prior studies
available for comparison. There is poor inspiratory effort. The
lungs are clear of an active congestion or infiltration. No
evidence of pleural effusion or pneumothoraces. The cardiac size
cannot be evaluated on this AP portable study of the chest. A
left subclavian CVP line is in place the tip is entering the
superior vena cava.
IMPRESSION: No evidence of active diseases in the lungs or
heart.
ABDOMEN (SUPINE ONLY) PORT [**2195-12-24**] 6:44 PM: There are multiple
mildly gas distended loops of small bowel and gas present in the
colon. A plastic biliary stent is present in the right upper
quadrant. The diaphragms are not included on the film.
IMPRESSION: Mildly gas distended loops of small bowel,
nonspecific.
LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT [**2195-12-24**] 3:53 AM:
FINDINGS: Examination is limited due to patient body habitus.
Allowing for this, liver appears echogenic, consistent with
fatty infiltration. No focal masses are identified. There is no
intrahepatic or extrahepatic ductal dilatation. The common bile
duct measures 6 mm in diameter. The gallbladder contains sludge,
but there are no secondary signs of cholecystitis. Specifically,
there is no wall edema, pericholecystic fluid, or gallbladder
distention. Normal color flow is identified within the main
portal and hepatic veins. There is no ascites. Note is made of a
markedly atrophic right kidney, with evidence of cortical
thinning.
IMPRESSION:
1) Echogenic liver consistent with fatty infiltration. Please
note that more severe forms of liver disease, including
significant hepatic fibrosis and cirrhosis, cannot be excluded
on the basis of this study.
2) Gallbladder sludge but no secondary signs of cholecystitis.
3) No evidence of biliary obstruction.
4) Patent portal and hepatic veins
[**2195-12-24**] ECG: Sinus rhythm Premature ventricular contractions
Inferior/lateral ST-T changes are nonspecific
Since pervious tracing, no significant change
Intervals: Rate 93 PR 148 QRS 86 QT/QTc 378/428 Axis: P 43 QRS
0 T -16
Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K.
Cardiology Report ECHO Study Date of [**2195-12-25**]
PATIENT/TEST INFORMATION:
Indication: Left ventricular function. Myocardial infarction.
Height: (in) 68
Weight (lb): 300
BSA (m2): 2.43 m2
BP (mm Hg): 74/60
HR (bpm): 66
Status: Inpatient
Date/Time: [**2195-12-25**] at 10:55
Test: Portable TTE (Complete)
Doppler: Full doppler and color doppler
Contrast: None
Tape Number: 2004W487-1:24
Test Location: West MICU
Technical Quality: Suboptimal
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.8 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.8 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 5.0 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: *5.7 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: *<= 25% (nl >=55%)
Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.5 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.0 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - E Wave Deceleration Time: 148 msec
TR Gradient (+ RA = PASP): *25 to 30 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is
seen in the RA and/or RV.
LEFT VENTRICLE: Mildly dilated LV cavity. Severe global LV
hypokinesis.
Severely depressed LVEF.
RIGHT VENTRICLE: RV not well seen.
AORTA: Normal aortic root diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions:
1. The left atrium is mildly dilated.
2. The left ventricular cavity is mildly dilated. There is
severe global left
ventricular hypokinesis. Overall left ventricular systolic
function is
difficult to assess but is probably severely depressed.
3. The aortic valve leaflets (3) are mildly thickened.
4. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1445**], MD on [**2195-12-25**] 11:19.
Date: Thursday, [**2195-12-24**] Endoscopist(s): [**Name6 (MD) **] [**Name8 (MD) **],
MD
[**First Name (Titles) **] [**Last Name (Titles) 59820**], MD (fellow)
Patient: [**Known firstname **] [**Known lastname **]
Ref.Phys.: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Birth Date: [**2128-11-8**] (67 years) Instrument: TJF 160
ID#: [**Numeric Identifier 59999**] ASA Class: P2
Medications: General anesthesia
Indications: 67 y o male with nausea, vomiting, epigastric pain,
elevated LFT and hypotension. ERCP to evaluate for biliary
obstruction. Level 3 consult was performed.
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. The
patient was placed in the prone position and an endoscope was
introduced through the mouth and advanced under direct
visualization until the second part of the duodenum was reached.
Careful visualization was performed. The procedure was not
difficult. The quality of the preparation was good. The patient
tolerated the procedure well. There were no complications.
Findings: Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: Major papilla was located inside a diverticulum.
Cannulation: 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. The
procedure was not difficult. An additional cannulation attempt
of the biliary duct was successful and superficial with a
sphincterotome using a free-hand technique. Contrast medium was
injected resulting in partial opacification. The procedure was
not difficult.
Biliary Tree: Normal cholangiogram without biliary obstruction.
Small stone in CBD can't be ruled out. Opacified portion of
pancreatic duct in the head was normal.
Procedures: A 9 cm by 10 fr Cotton-[**Doctor Last Name **] biliary stent was
placed successfully in the CBD .
Impression: 1. Major papilla was located inside a diverticulum.
2. Normal cholangiogram without biliary obstruction. Small stone
in CBD can't be ruled out.
3. Given sepsis of unclear source and the fact that a small
stone could not be ruled out, a 9 cm by 10 fr Cotton-[**Doctor Last Name **]
biliary stent was placed successfully in the CBD.
4. Opacified portion of pancreatic duct in the head was normal.
Additional notes: The procedure was performed by Dr. [**Last Name (STitle) **]
(attending physician) and ERCP fellow.
Brief Hospital Course:
A/P: 67 yo male, h/o severe 3vd, RA, presenting from OSH with
?biliary sepsis, s/p ERCP with stent placed, being treated for
urosepsis vs biliary sepsis, extubated and doing well.
1. Sepsis: The patient's initial picture was consistent with
septic + cardiogenic shock. Initial SG numbers revealed high
SVR, low CO, and high PCWP. He remained hypotensive despite IVF,
and pressors were continued, with eventual triple pressor
therapy (Levo, Dopamine and Vasopressin) required for
hemodynamic support. A random cortisol was 20, and 29
post-cosyntropin. Despite appropriate response, the low random
cortisol prompted initiation of steroid therapy, initially
Dexamethasone, then hydrocortisone and Fludrocortisone with plan
to complete 7 days of Rx (completed). His lactate, elevated on
admission, came down. He was successfully weaned off Levo and
Vasopressin on [**2195-12-28**], then off Dopamine on [**2195-12-29**]. ERCP did
not show obstruction, ?biliary sludge. He was initially on
vanco/zosyn/flagyl-->cipro/vanco/flagyl. Vanco/flagyl were
discontinued on [**12-27**] (c. diff neg x 3), and he will continue a
course of cipro for ?urosepsis. All cultures here have been
NGTD, but he is being treated for [**4-26**] E. coli blood culture
bottles at [**Doctor Last Name 1263**]. Ciprofloxacin was continued for the 14 day
course (until [**1-9**]). He was hemodynamically stable throughout
hospitalization. Blood pressure medications were initially held
[**2-23**] hypotension. Lisinopril was restarted prior to discharge
after renal function improved. Atenolol was held given patient
was still on amiodarone taper. This should be restarted after
he follows up with his PCP/cardiologist.
2. NSTEMI: The [**Hospital 228**] hospital course was complicated by
troponin elevation felt secondary to demand in the setting of
acute illness (peak troponin 1.86). He received 48 hours of
intravenous heparin, D/C'd in the setting of thrombocytopenia.
An echo was performed on [**12-25**], which revealed severe global LV
hypokinesis with EF<25%. Cardiology followed in-house.
Lisinopril, ASA, were continued. Lipitor was added upon
discharge at a lower dose, and atenolol was held. This should
be restarted when amiodarone taper is completed and he follows
up with his primary cardiologist. He also had an echo in-house
showing a very depressed EF (<25%), likely [**2-23**] myocardial
suppression from sepsis. He should have a follow up TTE after
discharge from rehab.
3. Afib: Patient went into atrial fibrillation on [**12-25**] with RVR
and hypotension. Cardioversion was attempted without success. He
was loaded with amiodarone IV and an amiodarone drip was
initiated. He converted to NSR in PM. Then, he reverted back
into afib on [**12-26**] after an increase in dopamine dose to 3
(?true-true and unrelated?). Given low cardiac output and
ongoing hypotension requiring 3 pressors, cardioversion was
performed with conversion to NSR after a single 200J shock. The
patient was switched to PO amiodarone on [**12-26**], to be continued
TID until [**1-2**], then [**Hospital1 **] for 1 week, then QD for 1 week, then
200 mg PO QD until cardiology follow-up. He remained in NSR
throughout hospitalization after transfer out of the unit. His
atenolol was held and should be restarted after he finishes his
amiodarone taper and follows up with his cardiologist, Dr.
[**Last Name (STitle) **]. He was started on fondaparinux/coumadin for
anticoagulation (afib and low EF). Goal INR is [**2-24**],
fondaparinux can be d/c'ed when INR=1.8.
4. ARF on CRF: Per patient's PCP (Dr. [**Last Name (STitle) **], baseline
creatinine around 1.3-1.5. Peak creatinine 3.0 at OSH. Mr. [**Known lastname **]
was initially oliguric on admission. His urine output slowly
improved with better hemodynamics, with slowly improving
creatinine. Urine lytes suggestive of renal etiology (likely ATN
[**2-23**] hypotension from sepsi), and urine sediment bland. Currently
2.1, and auto-diuresing and mobilising fluid. RUS without
evidence of hydronephrosis or other abnormality. His creatinine
returned to baseline (1.3) and was stable on discharge. He
diuresed very well on IV lasix (goal 2L/d). He was discharge on
PO bumex 1 mg daily. This should be continued until he is
clinically euvolemic and his peripheral edema is resolved.
5. Transaminitis: s/p ERCP with stent placement, but only
finding of sludge. Query transaminitis in setting of sepsis.
LFT's were back to normal at time of discharge. They should be
checked within a week of discharge. Lipitor was restarted at
lower dose upon discharge and can be titrated up.
7. Thrombocytopenia: While in ICU, platelets were noted to drop
to a nadir in the 80s. Concern for HIT was raised and Heparin
was discontinued after 48 hours of therapy. HIT screen negative.
Picture no c/w DIC. Ultimately, thrombocytopenia was felt
medication-induced, query direct effect of Heparin versus
antibiotics (vanco, Flagyl). Now slowly rising. This was likley
multifactorial in the setting of sepsis, medications, pressors
and not [**2-23**] heparin. Platelets continued to go up and were
stable at time of discharge.
8. ?Glucose intolerance: continue on SSI, no history of DM,
likely in setting of steroids for sepsis. SSI should be
continued as long as pt has abnormal blood sugars. If this
intolerance persists, PCP should recommend further therapy.
9. Code: Full
10. Dispo: Patient was seen by physical therapy in house and
was thought to require acute level rehabilitation for
deconditioning. He was discharged to [**Hospital1 **] Rehabiliation for
physical therapy and diuresis.
Medications on Admission:
Aspirin 325 po daily
Lipitor 80 daily
Protonix 40 daily
Folate 1 mg po daily
Zestril 10 po daily
atenolol 25 daily
remicaid q weeks
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
3. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale
Injection ASDIR (AS DIRECTED): for BS 150-200, give 2 U, for BS
201-250, give 4 U, for BS 251-300, give 6U, for BS 301-350, give
8U, for BS 351-400, give 10 U.
4. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed.
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days: Continue until [**1-9**].
6. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 7 days: Continue [**Date range (1) 60000**].
7. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): Continue until you follow up with cardiology.
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
10. Zolpidem Tartrate 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime) as needed.
11. Fondaparinux Sodium 2.5 mg/0.5 mL Syringe Sig: One (1)
Subcutaneous DAILY (Daily): Continue until therapeutic on
coumadin. Overlap therapy for 2 days with therapeutic coumadin
dosing.
12. Morphine Sulfate 2-4 mg IV Q4H:PRN
13. Lorazepam 0.5-2 mg IV Q4H:PRN
14. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): Please ck INR every other day for goal INR [**2-24**].
Adjust coumadin dosing accordingly.
15. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
16. Bumex 1 mg Tablet Sig: One (1) Tablet PO once a day.
17. Lipitor 40 mg Tablet Sig: One (1) Tablet PO once a day.
18. Cyanocobalamin 1,000 mcg Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary diagnoses
1. Sepsis
2. Biliary stenting (ERCP), ?biliary sepsis
3. Respiratory failure
Secondary diagnoses
1. New onset Atrial fibrillation in setting of illness
2. NSTEMI in setting of acute illness
3. Acute renal failure/ATN
4. Thrombocytopenia
5. 3 vessel coronary artery disease
6. CHF with diastolic dysfunction
Discharge Condition:
Stable--afebrile, all blood cultures negative, breathing
comfortably on room air, requires further diuresis and physical
therapy.
Discharge Instructions:
1. Please take all your medications as described in the
discharge instructions. We made a few changes to your
medication regimen.
-We added Bumex 1 mg PO qam, for diuresis. Goal is 2L neg/day
until you are clinically euvolemic, peripheral edema is
resolved.
- You should finish a course of antibiotics (ciprofloxacin);
continue until [**1-9**], for positive blood cultures
- You can continue the oxybutynin for bladder spasms if you
continue to requires this
- We started you on Fondaparinux and coumadin (anticoagulation
for your atrial fibrillation and low ejection fraction). The
Fondaparinux will only be continued until you are therapeutic on
your coumadin.
- You should finish amiodarone taper as outlined in medications
section.
- We are holding your beta blocker (you were on atenolol 25 mg
daily) for now until you complete the amiodarone taper and
follow up with your cardiologist.
- We are also holding your rheumatoid arthritis medications at
this time (MTX, Remicaide). These should be restarted after you
leave rehab and follow up with your primary rheumatologist.
- We also decreased your lipitor to 40 qd. You should increase
this after having your LFT's rechecked by your PCP.
2. Follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], within 1 week of
leaving rehab. He may want to make adjustments to your
medication regimen at this time. You should also follow up with
the cardiology clinic here and your rheumatologist upon leaving
rehab.
3. Call your physician if you experience chest pain, shortness
of breath, fevers > 101. Take your medications as prescribed.
Weigh yourself daily and record your weight. Call your physician
if your weight increases by 3 lbs.
Followup Instructions:
1. Follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] ([**Telephone/Fax (1) 60001**]), within
1 week of leaving rehab. He may want to make adjustments to
your medication regimen at this time. He can consider stopping
your bumex at this time, restart your beta blocker and your
rheumatoid arthritis medications.
2. You should also follow up with your cardiologist, Dr. [**First Name8 (NamePattern2) 59998**]
[**Last Name (NamePattern1) **], at [**Hospital1 2025**]. You will be on an amiodarone taper until this
time. She should consider restarting your atenolol at this time
and monitor your coumadin therapy. She should also consider
titrating up your Lisinopril to your usual dose (10 mg daily) at
this time. We are discharging you on 2.5 mg daily.
3. Follow up with Liver clinic, Dr. [**First Name (STitle) **] [**Name (STitle) **] ([**Telephone/Fax (1) 60002**]), in 2 months for removal of your biliary stent. Call
to make this appointment as soon as possible
3. Follow up with your rheumatologist upon leaving rehab. She
may decide when to restart your Methotrexate and Remicaide
BRING THIS DISCHARGE PAPERWORK WITH YOU AT TIME OF ALL FOLLOW UP
APPOINTMENTS
ICD9 Codes: 5185, 2875, 5990, 5845 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1257
} | Medical Text: Admission Date: [**2163-7-18**] Discharge Date: [**2163-7-21**]
Date of Birth: [**2112-9-10**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: A 50-year-old Caucasian male
with a past medical history significant for coronary artery
disease confirmed by catheterization in [**2158**] presents status
post PTCA at approximately 6 am this morning. The patient
began having chest pain radiating to the jaw at approximately
noon yesterday, which was [**2163-7-17**]. The patient presented to
[**Hospital3 3583**] at approximately 6 pm.
At that time, he was given aspirin, nitroglycerin only, mild
relief reported. Complete relief with Lovenox and Morphine.
Cardiac enzymes drawn. CK of 449. Electrocardiogram
unremarkable. Later laboratories revealed CK of 1,486 and
electrocardiogram revealing 1.[**Street Address(2) 1755**] changes in the inferior
leads. Patient's systolic blood pressure found to be 85 and
was diagnosed with acute myocardial infarction complicated by
cardiogenic shock. At that time the patient was transferred
to [**Hospital1 69**]. On arrival, the
patient's blood pressure was in the 120s.
The patient was then taken to the catheterization laboratory
for PTCA. RCA was found to be TO distal filled via left to
right collaterals. A ...........stent was deployed distally
and ............. stent was deployed more proximally. The
patient at that time was given Aggrastat drip IV, metoprolol
intravenously, and given bolus of nitroglycerin. The patient
was transferred to unit at approximately 8 am [**7-18**].
On arrival, the patient was given Integrilin, Plavix 75 mg,
aspirin 325 mg with Lipitor 10 mg and a fluid bolus of 750
cc. Patient was not given ACE inhibitor or beta blocker
because of decreased systolic blood pressure. Per interview,
the patient states that he previously had episodes of chest
pain, but they were milder than most recent episode.
Described pain as a constricting sensation, positive history
of palpitations. Currently the patient stated that he has
had mild shortness of breath and was continuing to have
questioned sensation in chest. No palpitations, no
dizziness, no lightheadedness, or nausea.
Three times overnight, the patient complained of chest pain
and each time an electrocardiogram was done, and cardiac
enzymes were ordered. On the second electrocardiogram, it
showed T waves which is consistent with old infarct that is
basically progressing, but no new changes that would lead us
to believe that there were any new ischemic events occurring.
PHYSICAL EXAMINATION: Patient's heart normal S1, S2, no S3
appreciable, no murmur noted, no pericardial rub. Lungs were
clear to auscultation, no rales, no rhonchi, no wheezes.
Abdomen: Positive bowel sounds, nontender, no abdominal or
renal bruit noted. Extremities: Right incision site
catheter, no exsanguination, no hematoma noted, no edema,
positive tenderness. Both DP and PT pulses were noted in
lower extremities. No audible bruits noted.
LABORATORIES WERE AS FOLLOWS: White blood cell count 15.0,
hemoglobin 12.7, hematocrit 13.3, platelet count 236. PT
13.6, PTT 44.3. Chem-7: Sodium 141, potassium 4.2, chloride
110, bicarb 25, BUN 10, creatinine of 0.8, and glucose of
114. ALT of 51, AST of 268. CK of 3,067, alkaline
phosphatase of 78, total bilirubin 0.7. CK MB of 456.
Cardiac index 14.9, troponin-T 13.19. Calcium 8.0,
phosphorus 2.5, magnesium 1.7.
Echocardiogram revealed an ejection fraction of 35%-40%.
Left atrium was found to be normal in size. Right atrium:
Interatrial septum, right atrium normal in size. Left
ventricle: Normal wall thickness, cavity size normal,
moderate regional ventricular systolic dysfunction, left wall
motion resting, regional left ventricular wall motion
abnormalities. Basal inferior - akinetic. Mid inferior -
akinetic. Basal inferolateral - hypokinetic. Mid
inferolateral - hypokinetic. Right ventricle normal size,
focal hypokinesis of apical free wall. Aortic valve peak
velocity 1.2 m/second. Aortic valve normal. Mitral valve
trivial mitral regurgitation. Tricuspid valve normal.
Pericardium normal.
The catheterization on [**2163-7-18**] was right atrial
pressures of 17/11/11. Right ventricle: 44/15. Pulmonary
artery 44/21/34. Pulmonary wedge: 32/39/29. Aorta:
106/72/88. Heart rate in the 80s. Cardiac index 3.7. SVR
751, PVR 49. Proximal RCA normal. Mid RCA: Discrete
disease, acute marginal normal, diagonal discrete disease.
Proximal circumflex discrete. Mid circumflex normal. Distal
circumflex normal. Obtuse marginal #1 discrete disease.
Obtuse marginal #2 normal. Proximal LAD discrete disease.
Septal - 1 diffusely diseased.
The patient received stent placement in the mid and proximal
RCA, continued Integrilin, Plavix, aspirin, Aggrastat per
postangio protocol. Continued Lipitor. Initially did not
give ACE inhibitor or beta blocker because of history of
hypotension.
The following day systolic blood pressure became stable at
approximately 120. Was started on 6.25 captopril and 12.5 of
metoprolol, both per post-MI protocol. Beta blocker was
later increased to 37.5 and then a final dose of 50 mg po bid
per post-MI protocol. Medications were titrated to patient's
blood pressure and heart rate.
Patient initially arrived received 1 liter of normal saline,
but because of stabilization of blood pressure, patient no
longer needed other IV fluids.
Pulmonary: The patient had right basilar rales found on
second day of admission most likely secondary to atelectasis
given incentive spirometer with positive use.
Renal: The patient had stable BUN and creatinine.
GI: The patient was given bowel regimen of Colace and milk
of magnesia to prevent unnecessary straining.
Prophylaxis: SubQ Heparin for DVT prophylaxis.
FEN: Hemodynamically stable, no fluids needed. Electrolytes
stable. At one point, magnesium dropped to below 0.1 below
normal, repleted.
Nutrition: Cardiac diet with 2 grams of salt.
Physical Therapy was consulted. Patient was able to actively
exercise walk around the [**Hospital1 **] with no problems.
Social: Patient has severe coronary artery disease. RCA was
stented. Repeat catheterization is necessary. Patient does
not insurance and not financially covered by hospital because
it has become elective and not emergent procedure. Patient
was given option of having surgery during stay in hospital or
to come back within the next two weeks. Case manager was
[**Name (NI) 653**], and it was found that free care would pay for two
week for medications and the procedure, however, would not
cover physician's costs. The patient will not be able to
apply for disability because he has no kids, however, he is
able to work.
Risks/benefits was discussed with the patient. He
understands the importance of having the procedure as soon as
possible. Patient offered to come back in two weeks. Will
repeat catheterization.
DISCHARGE STATUS: Discharged today [**2163-7-21**].
DISCHARGE DIAGNOSIS: Acute myocardial infarction.
DISCHARGE MEDICATIONS:
1. Atorvastatin 10 mg po q day.
2. Plavix 75 mg po q day, duration of six months.
3. Aspirin enteric coated 325 mg po q day.
4. Lisinopril 2.5 mg po q day.
FOLLOW-UP PLAN: The patient is to followup with Dr.
[**Last Name (STitle) **] in two weeks, and follow up with his primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] within the next month. Appointment
times were given at discharge. Patient is to return for
elective catheterization within the next four weeks. Patient
is also to complete free care paperwork for further coverage
of medications.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Name8 (MD) 51859**]
MEDQUIST36
D: [**2163-7-21**] 16:03
T: [**2163-7-26**] 05:43
JOB#: [**Job Number 101456**]
ICD9 Codes: 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1258
} | Medical Text: Admission Date: [**2184-4-26**] Discharge Date: [**2184-5-5**]
Date of Birth: [**2121-1-4**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Macrobid / Cipro / Erythromycin Base / Bactrim
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
SOB/claudication
Major Surgical or Invasive Procedure:
[**4-27**] CABG x 2 (LIMA to LAD , SVG to OM)
History of Present Illness:
63 yo female with known CAD/MI, claudication, PVD, s/p
mult.peripheral and coronary interventions, presents for cath
and peripheral angiography. Cath showed 70% LM, 80% OM 1, RCA
stent patent. LE angio revealed patent left fem-opo bypass graft
and previous PTA site widely patent. Carotid US in [**3-8**] showed
[**Country **] < 40%, left nl.echo [**3-7**] EF >55%. Referred for CABG to Dr.
[**Last Name (STitle) **].
Past Medical History:
CAD ( RCA stents)
MI
PVD with peripheral interventions)
s/p left fem-[**Doctor Last Name **] BPG
PNA
carotid dz /TIA [**2180**]
hyperlipidemia
IBS
fibromyalgia
asthma
GERD
?DM
OA
gout
melanoma left heel
s/p right carpal tunnel, left knee, right thumb, discectomy,
hemorrhoid, L [**Last Name (LF) **], [**First Name3 (LF) 3098**] ligation surgeries
Social History:
not working
lives with husband
no ETOH or recr. drugs
quit smoking 14 years ago
Family History:
father died of heart problems at 59
Physical Exam:
5'1" 78.9 kg
HR 73 RR 18 121/54
alert and oriented, well- nourished
skin/HEENT unremarkable
neck supple
CTAB
RRR, no murmur
soft, NT, ND, + BS
warm, well-perfused extrems, no edema
1+ bilat. fem/PT/radials/ left PT
dopplerable right PT
Pertinent Results:
[**2184-5-5**] 06:38AM BLOOD WBC-11.1* RBC-3.29* Hgb-9.4* Hct-27.4*
MCV-83 MCH-28.5 MCHC-34.1 RDW-15.2 Plt Ct-319
[**2184-4-26**] 09:55AM BLOOD WBC-6.3 RBC-4.18* Hgb-11.4* Hct-33.2*
MCV-79* MCH-27.4 MCHC-34.4 RDW-15.2 Plt Ct-209
[**2184-4-26**] 09:55AM BLOOD Neuts-55.4 Lymphs-34.0 Monos-7.6 Eos-2.5
Baso-0.4
[**2184-5-5**] 06:38AM BLOOD Plt Ct-319
[**2184-5-5**] 06:38AM BLOOD UreaN-17 Creat-1.2* K-4.0
[**2184-5-4**] 03:40PM BLOOD ALT-48* AST-22 LD(LDH)-259* AlkPhos-193*
Amylase-38 TotBili-0.4
[**2184-5-4**] 03:40PM BLOOD Lipase-28
[**2184-5-4**] 03:40PM BLOOD Albumin-3.2*
[**2184-4-27**] 12:50PM BLOOD HCV Ab-NEGATIVE
Brief Hospital Course:
Admitted on [**4-26**] for cath and referred for CABG. Underwent CABG
x2 with Dr. [**Last Name (STitle) **] on [**4-27**]. Transferred to the CSRU in stable
condition on insulin and propofol drips. On nitroglycerin drip
on POD #1, had a short run of VT overnight and was extubated.
Chest tubes removed, off all drips, and transferred to the floor
on POD #2 to begin increasing her activity level. Foley,pacing
wires removed on POD #3, and gentle diuresis continued.
Developed sternal drainage on POD #5 and vanco/levofloxacin
started. Wound cultures were negative and drainage became
minimal. CLeared for discharge to home with VNA on POD #8. Will
have keflex for one week and return for wound check at one week.
Medications on Admission:
atrovent 2 puffs QID
pulmocort 2 puffs [**Hospital1 **]
singulair 10 mg daily
plavix 75 mg daily
metoprolol 50 mg [**Hospital1 **]
diovan/HCTZ 160/12.5 mg daily
nexium 40 mg daily
lorazepam 0.5 mg QHS prn
quinine sulfate 260 mg qHS prn
ASA 325 mg daily
lipitor 20 mg daily
lisinopril 5 mg daily
detrol LA 4 mg daily
restasis EMU 0.05% one gtt OU [**Hospital1 **]
preservision 1 tab [**Hospital1 **]
theratears nutrition 4 tabs daily
theratears eye drops
occuvit [**Hospital1 **]
Vit. E 200 IU daily
citrocal one tab daily
oscal 1000 units daily
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Budesonide 200 mcg/Inhalation Aerosol Powdr Breath Activated
Sig: One (1) Aerosol Powdr Breath Activated Inhalation [**Hospital1 **] ().
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2
hours) as needed.
Disp:*35 Tablet(s)* Refills:*0*
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 2 weeks.
Disp:*28 Packet(s)* Refills:*0*
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
13. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
Disp:*270 Tablet(s)* Refills:*0*
14. Keflex 500 mg Tablet Sig: One (1) Tablet PO four times a day
for 1 weeks.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
home health
Discharge Diagnosis:
s/p cabg x2
Coronary Artery Disease s/p PTCA
lipids
HTN
DM2
PVD
TIA
GERD
Fibromyalgia
Asthma
L ft melanoma
R carpal tunnel
disc surgery
hemoorhoidectomy
Discharge Condition:
Good.
Discharge Instructions:
Please take all medications as prescribed.
Call with fever, redness or draiange from incision or weight
gain more than 2 pounds in one day or five in one week.
Do not do any lifting > 10 lbs for 4 weeks.
Do not drive for 4 weeks.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 12817**] Follow-up
appointment should be in 2 weeks for general assessment, LFT
check (on statin), and review of medications.
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 1112**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Phone:[**Telephone/Fax (1) 920**]
Date/Time:[**2184-7-19**] 1:45
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2184-7-19**]
10:00
Wound check on [**Wardname 836**] in one week
Completed by:[**2184-5-27**]
ICD9 Codes: 4240, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1259
} | Medical Text: Admission Date: [**2154-10-21**] Discharge Date: [**2154-10-27**]
Date of Birth: [**2104-8-29**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
SOB, Pleural Effusions, PNA, pericardial effusion, concern for
tamponade
Major Surgical or Invasive Procedure:
pericardial window, thoracentesis with chest tube
History of Present Illness:
Ms [**Known lastname 35028**] is a 50yoF with PMH significant for depression,
though negative for cardiac risk factors including CHF or CAD.
She was transferred to CCU on [**2154-10-21**] with concern for
pericardial tamponade.
She originally presented to [**Hospital3 **] with 2 weeks of
progressive productive cough, fever, SOB, and DOE despite 2
courses of PO abx (z-pack started [**10-3**]; levaquin started
[**10-16**])for outpatient treatment of PNA, and was found to have a
leukocytosis to 13.7, and a large pericardial effusion, B/L
pleural effusions and LLL opacity on CT scan.
Vitals in ED showed T101.8F, RR 20's-low 30's; winded with any
activity or with talking. Sats high 90's on 4l NC. Of note, she
has had a 50lb intentional weight loss over the last year with
strict diet modification. Prior to this episode, no F/C/NS. She
does also complain of some epigastric discomfort ([**2-21**], dull,
worse with cough). She mentions that she had a few short
episodes of palpitations on exertion in the last weeks prior to
her admission. She denies chest pain, lightheadedness or
dizziness. No sick contacts. Of note she took a cruise to the
Bahamas in late [**Month (only) **] for 1 week. Goes to Caribbean for 1
week every year, otherwise no TB exposure history.
.
ED course: WBC 13.7, chem7 normal. Cardiology was consulted and
bedside echo suggestive of pericardial effusion. Blood cultures
taken. Given PO Azithromycin and IV Ceftriaxone. Given Tylenol
1gm
.
When getting to the CCU, the patient is in NAD, though quite
anxious. Afebrile, hemodynamically stable, mildly tachypnic.
Pulsus paradoxus is 12mmHg.
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies exertional buttock or calf
pain. All of the other review of systems were negative except
per above.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: negative for DM, HTN, HLD
2. CARDIAC HISTORY: none
3. OTHER PAST MEDICAL HISTORY:
- Depression / paranoia
- cellulitis in lower extremity x2 2-3 years ago
- breast biopsy several years ago (2 sisters with breast cancer
diagnosed at 35 and 40)
Social History:
owner of a uniform supply store. Lives with husband, who is a
paramedic. No recent sick contacts. Travels to Caribbean for 1
week of vacation every year.
- Tobacco history: none
- ETOH: rare, social
- Illicit drugs: none
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
Two sisters have breast cancer, one diagnosed at about age 35,
the other around age 40. Pt has had a breast biopsy several
years ago and states that the results were not concerning. She
says she gets yearly mammograms.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T99.4; P98; BP115/73; RR25; O2 sat 96% 4L NC; Pulsus
paradoxus 12mmHg
GENERAL: Middle-aged woman in NAD, obese, comfortable and
appropriate though quite anxious
HEENT: NC/AT, PERRL, EOMI OP Clear, MMM
Chest: decreased breath sounds LLL up to mid-lung, otherwise
CTAB
Cardiovascular: borderline tachycardia, NL S1 and S2 with normal
splitting of S2, no JVP appreciated although exam inhibited [**2-13**]
body habitus
ABDOMEN: Soft, mildly tender in epigastric region, non-distended
GU/Flank: No costovertebral angle tenderness
Musc/Extr/Back: No joint pain, no cyanosis, clubbing or edema
Skin: No rashs, Warm and dry
Neuro: Speech fluent, A+Ox3
Psych: Normal mentation, Normal mood.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
DISCHARGE PHYSICAL EXAMINATION:
VS: T98.5; P98.1; BP108/71; RR21; O2 sat 96% ra, pulsus
paradoxus 8mmHg
GENERAL: Middle-aged woman in NAD, obese, comfortable and
appropriate
HEENT: NC/AT, PERRL, EOMI OP Clear, MMM
Chest: decreased breath sounds in left base
Cardiovascular: borderline tachycardia, NL S1 and S2 with normal
splitting of S2, JVP 8cm
ABDOMEN: Soft,non-tender, non-distended, no HSM, BS+
GU/Flank: No costovertebral angle tenderness
Musc/Extr/Back: No joint pain, no cyanosis, clubbing or edema
Skin: No rashs, Warm and dry
Neuro: Speech fluent, A+Ox3
Psych: Normal mentation, Normal mood.
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:
[**2154-10-21**] 12:31AM BLOOD WBC-13.7* RBC-4.37 Hgb-12.1 Hct-36.4
MCV-83 MCH-27.6 MCHC-33.1 RDW-12.9 Plt Ct-443*
[**2154-10-21**] 12:31AM BLOOD Neuts-82.5* Lymphs-11.8* Monos-4.5
Eos-0.8 Baso-0.4
[**2154-10-21**] 08:07AM BLOOD PT-14.8* PTT-27.4 INR(PT)-1.3*
[**2154-10-21**] 12:31AM BLOOD Glucose-136* UreaN-14 Creat-0.6 Na-136
K-4.1 Cl-99 HCO3-24 AnGap-17
[**2154-10-21**] 12:54AM BLOOD Lactate-1.2
.
RELEVANT LABS:
[**2154-10-21**] 02:10PM PLEURAL WBC-7250* RBC-[**Numeric Identifier 36798**]* Polys-75*
Lymphs-15* Monos-4* Meso-3* Macro-3*
[**2154-10-21**] 02:10PM PLEURAL TotProt-3.5 Glucose-127 LD(LDH)-470
Albumin-2.0
[**2154-10-21**] 02:16PM OTHER BODY FLUID WBC-[**Numeric Identifier **]* RBC-[**Numeric Identifier 91055**]*
Polys-84* Lymphs-6* Monos-4* Macro-6*
[**2154-10-21**] 02:16PM OTHER BODY FLUID TotProt-4.9 Glucose-91
LD(LDH)-[**2100**] Albumin-2.4
.
DISCHARGE LABS:
[**2154-10-27**] 04:39
White Blood Cells 8.2 Hemoglobin 11.0* Hematocrit 33.3 MCV 83
MCH 27.4 MCHC 33.0 31 - 35 %
RDW 13.9
Platelet Count 391 150 - 440 K/uL
Glucose 142 Urea Nitrogen 9 Creatinine 0.5 Sodium 139 Potassium
4.1 Chloride 102 Bicarbonate 31 Calcium, Total 9.0 Phosphate 3.2
Magnesium 1.8
IMAGING:
TTE [**2154-10-21**]:
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%).
PERICARDIUM: Moderate to large pericardial effusion. RV
diastolic collapse, c/w impaired fillling/tamponade physiology.
CONCLUSIONS: Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). There is a
moderate to large sized pericardial effusion. There is right
ventricular diastolic collapse, consistent with impaired
fillling/tamponade physiology.
.
TTE [**2154-10-25**]:
LEFT VENTRICLE: Normal LV thickness, cavity size and global
systolic function (LVEF>55%)
RIGHT VENTRICLE: chamber size and free wall motion are normal.
No AR, AS. Trivial MR.
PERICARDIUM: stable small echodense pericardial effusion,
consistent with blood, inflammation or other cellular elements.
.
Chest x-ray PA/lat [**2154-10-21**]:
1. Enlarged heart consistent with history of pericardial
effusion.
2. Extensive opacification of the left lung suspicious for
pneumonia. The
amount of left pleural fluid may be better assessed with either
decubitus
views or CT.
MICROBIOLOGY:
Blood cultures [**2154-10-21**]: negative
.
Pleural fluid (pleural effusion left): [**2154-10-21**]
GRAM STAIN: 4+ (>10 per 1000X FIELD): PMN LEUKOCYTES
no microorganisms seen. negative cultures (aerob, anaerob).
negative acid fast smear and culture. negative fungal culture
and potassium hydroxide preparation
WBC 7250/RBC [**Numeric Identifier 36798**]/Prot 3.5/Gluc 127/LDH 470/Alb 2.0
.
Pericardial fluid (pericardial effusion):[**2154-10-21**]
GRAM STAIN: 3+ (5-10 per 1000X FIELD): PMN LEUKOCYTES
no microroganisms seen.negative cultures (aerob, anaerob).
negative acid fast smear and culture. negative fungal culture.
WBC [**Numeric Identifier **]/RBC [**Numeric Identifier 91055**]/4.9/Gluc 91/LDH [**2100**]/Alb 2.4
.
Sputum: [**2154-10-21**]
GRAM STAIN: <10 PMNs and <10 epithelial cells/100X field. no
microorganisms
negative culture.
.
Urine culture [**2154-10-21**]: <10,000 organisms/ml
.
MRSA screen [**2154-10-21**]: negative for Staph aureus (Skin, Axillae,
Breast) and neg nasal swab for MRSA
.
PATHOLOGY:
Pericardial biopsy: [**2154-10-21**]
GRAM STAIN: 2+ (1-5 per 1000X FIELD): PMN LEUKOCYTES.
no microorganisms seen.negative cultures (aerob, anaerob).
negative acid fast smear and culture. negative fungal culture
and potassium hydroxide preparation
.
CYTOLOGY:
Pericardial fluid [**2154-10-22**]: NEGATIVE FOR MALIGNANT CELLS.
Predominantly neutrophils and histiocytes.
.
Pleural fluid [**2154-10-22**]: NEGATIVE FOR MALIGNANT CELLS. Reactive
mesothelial cells, histiocytes, lymphocytes, and neutrophils.
Brief Hospital Course:
Ms [**Known lastname 35028**] is a 50yoF with PMH significant for depression, who
was transferred from [**Hospital3 **] with a large pericardial
effusion, bilateral pleural effusions and a LLL opacity, with a
hospital course complicated by atrial fibrillation with rapid
ventricular response.
.
# Pericardial effusion with cardiac tamponade physiology:
On admission to CCU, an ECHO confirmed a moderate-to-large
pericardial effusion, without echocardiographic signs of
tamponade at that time. Initial EKG on admission showed NSR with
low voltages across all leads without signs for pericarditis.
Repeated measurements of pulsus paradoxus were approximately
12mmHg. She was referred to CT Surgery, and underwent
pericardial window on [**2154-10-21**], during which 1 chest tube on
the left and 1 pericardial drain were placed. She was
transferred still intubated, [**2-13**] bronchospasm/coughing in the
OR, in addition to SVT (10 seconds) and desaturation to SatO2
75%. She was extubated several hours after intervention
uneventfully. Analysis of the pericardial fluid revealed
exudative character, narrowing differential to infectious vs.
malignant vs. rheumatic etiology (despite no prior personal h/o
malignancy or rheumatologic symptoms, although does have a
strong family history of breast ca and a breast biopsy in the
past). Tissue analysis of the pericardium showed fibrinous and
organizing pericarditis. There was no evidence of malignancy in
this sample. Further no significant acute inflammation was
identified. Pericardial fluid cytology was negative for
malignant cells. Sputum, pericardial fluid, blood cultures and
PPD were negative. F/u TTE on [**10-22**] revealed decreased RV
function with septal bowing, likely secondary to constrictive
physioogy from organizing effusion. She was continued on empiric
broad-spectrum antibiotics (Vanc/Cefepime) for total treatment
of 10 days. The pericardial drain was discontinued on [**2154-10-24**]
after 214ml total output and minimal (<20ml) output over
previous 24hours. F/u TTE on [**10-25**] showed normal LV function
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There is a stable small echodense pericardial
effusion, consistent with blood, inflammation or other cellular
elements. At time of discharge, measurement of pulsus paradoxus
was within normal limits, and pt denied any chest
pain/discomfort, difficulty breathing or any positional
dyspnea/orthopnea related to presenting chief complaint.
.
# LLL PNA complicated by parapneumonic effusion:
CT chest at [**Hospital3 **] identified a LLL opacity thought to
be c/w consolidation vs. mass. Of note, pt had previously
completed outpatient course of levofloxacin and azithromycin
without improvment in symptoms (fevers, SOB) before this
presentation. On transfer, she was considered to have PNA with
resistant organisms vs. post-obstructive PNA vs. malignancy, and
was treated with 10-day course of vanc/cefepime with adequate
improvement of symptoms, resolving leukocytosis and no fever. As
mentioned, a chest tube was placed on the left, which drained a
total output of 1420mL of exudative fluid, negative for
organisms or malignant cells. Sputum, blood and pleural fluid
culture were negative for organisms. PPD was negative. Chest
tube was discontinued on [**2154-10-25**]. At time of discharge, pt
denied fevers/chills, night sweats, cough, and difficulty
breathing. She will need repeat chest CT 4-6 weeks after
discharge to evaluate for resolution of effusion and
consolidation. Furthermore, in outpatient setting PCP should be
sure she is up to date on all recommended malignacy screening
tests, with particular attention to breast cancer given strong
family history.
.
# Afib with RVR:
On hospital day 3 ([**2154-10-23**]), pt was noted to have several
short (<5 minutes) episodes of Afib with RVR (up to
180-200bpm)with spontaneous resolution. These episodes recorded
on telemetry were accompanied by subjective palpitations that
the pt related to previous chest sensations during exertion
during the preceding weeks at home. Etiology of this dysrhythmia
was thought multifactorial, [**2-13**]: irritation of the atrium by
effusion, pericardial drain and PICC line. The PICC line was
subsequently pulled back 2cm, and this coincided with decreased
frequency of these episodes. Pt was started on metoprolol
tartrate 12.5mg [**Hospital1 **], and experienced no additional rhythm
disturbance thereafter. She continued to be in NSR with a rate
in the 70's-80's. She was started on aspirin 325mg daily, given
CHADS2-score of 0. On discharge, the plan included monitoring
for outpatient events with Kings of Hearts monitor.
.
CHRONIC ISSUES:
# Depression: Documented history of this problem. The patient's
home abilify 2mg PO qPM was continued during this admission.
.
TRANSITIONAL ISSUES:
# Pt will need to schedule follow-up visits with PCP [**Last Name (NamePattern4) **] 2 weeks
and cardiology in 1 month.
# Recommend age-appropriate malignancy screening to rule out
other malignant etiologies.
# Pt will require [**Doctor Last Name **] of Hearts monitoring upon discharge to
evaluate for more episodes of paroxysmal atrial fibrillation,
with twice daily rhythm checks (with teaching).
# Pt will need repeat CT scan in [**4-17**] weeks to evaluate for
resolution of LLL consolidation.
# Pt will need repeat Echocardiogram in 4 weeks to evaluate for
progression/resolution of pericardial effusion
# Pt was started on Aspirin 325mg daily, metoprolol 12.5mg PO
daily, and was sent home with a PICC in place for 2.5 more days
of vancomycin and cefepime with VNA.
Medications on Admission:
- Abilify 2mg PO qHS
- Levofloxacin,
- Promethazine-codeine
- Multivitamin
- Calcium-magnesium
- Potassium
Discharge Medications:
1. vancomycin 500 mg Recon Soln Sig: Three (3) Recon Soln
Intravenous Q 8H (Every 8 Hours) for 4 days.
Disp:*11 Recon Soln(s)* Refills:*0*
2. aripiprazole 2 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
3. cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q8H (every 8 hours) for 4 days.
Disp:*11 Recon Soln(s)* Refills:*0*
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. multivitamin Tablet Sig: One (1) Tablet PO once a day.
7. benzonatate 100 mg Capsule Sig: [**1-13**] Capsules PO three times a
day as needed for cough.
Disp:*90 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Community VNA of [**Location (un) 6981**]
Discharge Diagnosis:
Pericardial effusion
Pleural effusion
Hospital Acquired Pneumonia
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Ms. [**Known lastname 35028**],
It was a pleasure taking care of you during your hospital stay
at [**Hospital1 69**]. You were admitted
because you had fluid accumulating around your heart. You were
also found to have pneumonia and fluid accumulating around your
lungs.
You were taken to surgery to remove the fluid around your heart
and lungs and a drain was placed around your heart. This drain
was then removed. The fluid accumulation is most likely
secondary to your pneumonia. You will remain on 4 more days of
IV antibiotics after discharge.
While in the hospital, you also developed several episodes of a
fast irregular rhythm called atrial fibrillation. We are
prescribing you metoprolol to help control the heart rate and a
full-dose aspirin to help prevent any blood clots from the
rhythm.
We made the following changes to your medications:
- ADDED Metoprolol
- ADDED Aspirin
- ADDED Vancomycin
- ADDED Cefepime
- ADDED Benzonatate
- STOPPED Levofloxacin
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Telephone/Fax (1) 91056**] to make a
follow-up appointment within the next week.
We would also like you to see one of our cardiologists for
follow-up. Please call ([**Telephone/Fax (1) 2037**] to make an appointment for
4-6 weeks from your discharge. You can make the appointment
with Dr. [**Last Name (STitle) **] if you would like.
ICD9 Codes: 486, 5119, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1260
} | Medical Text: Admission Date: [**2171-4-17**] Discharge Date: [**2171-4-22**]
Date of Birth: [**2091-1-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hand pain
hypotension
Major Surgical or Invasive Procedure:
hemodialysis line removal
History of Present Illness:
The patient is an 80 y.o. man with pmh significant for CAD, HTN,
ESRD on peritoneal dialysis, presenting with fevers and
hypotension. The patient reports being in his usual state of
health until yesterday, when he developed acute onset of chills
and rigors. Two hours later he noticed intense pain at his right
thumb cmc joint. This joint became ertythemetous and then pain
and erythema progressed to his right index finger. That evening
his Peritoneal dialysis nurse visited and reported his
peritoneal diasylate appeared normal to her and not infected.
The patient went to bed and then awoke because his pain
continued to worsen. He went to [**Hospital3 635**] hospital where his
temperature was 101.8, SBP was in the 90's, which is his
baseline, HR in 110's. He was given vancomycin and ceftriaxone
for cellutlitis and transferred to [**Hospital1 18**] to be seen by hand
specialists.
.
In the ED, initial vs were: T 98.6 P 112 BP 85/47 R21 O2 sat 96%
RA. he was given 500cc of NS when his blood pressure dropped to
57/44 and he became hypoxic to 80% on 2L NC. He was asymptomatic
during this hypotensive episode. He had a Left IJ placed and
started on levophed. His BP increased to 104/67. Hand films were
done and showed degenerative changes of the second and fifth DIP
joints, no fractures, and no bone destruction. Probable soft
tissue swelling around the wrist. Plastics evaluated the patient
and felt he had a hand cellulitis. They recommend splinting and
elevation and antibiotics. They will continue to follow. .
.
Of Note, the patient has been on dialysis for 4 years. he was on
HD for 3months, then switched to peritoneal dialysis for 3
years. He switched back to HD after having a peritoneal
infection. he transitioned back to HD for 1 year and then
switched back to PD 1 week ago. he switched to PD because it is
better for his lifestyle.
.
Review of sytems:
The patient denies dyspnea, cough, chest pain, abdominal pain,
diahrrea.
He reported one episode of emesis prior to coming to the capecod
ED.
he also reports the occurrence of "water blisters" on his lower
legs which began 1 month ago. He became anuric 1 month ago, and
since then has been retaining fluid. he reports these Bullae
have drained only clear fluid and have not appeared infected.
Past Medical History:
- MI s/p PCI [**2151**], angioplasty X1
- ESRD on HD/PD
- hypertension
- gout
.
- Endovascular AAA repair [**6-/2170**]
- tunneled HD line and peritoneal dialysis line
- bilateral inguinal herniorrhaphy about 10 yrs ago
Social History:
denies tobacco
reports [**1-12**] alcoholic beverages per week.
denies illicit drug use
lives at home with wife, needs some help in getting dressed but
is otherwise able to perform ADL's
Family History:
Father died at a young age of an industrial accident.
Mother died at 92 of natural causes.
Physical Exam:
Vitals: T:97.9 BP:91/66 P:109 R: 18 O2: 100% on NRB
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,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, distended, PD catheter in place to
left of umbilicus, catheter site is non-erythemetous, and
without drainage.
GU: foley in place
Ext: right hand with erythema and tenderness over CMC. erythema
and tenderness along entire right index finger. pain at wrist
joint with active extension but not with flexion. Tenderness
with palpation over the wrist but not with palpation over flexor
tendons in forearm.
Lower extremities with 1+ pitting edema. 1 open draining
blister on right lower leg, one open and healing blister on
right knee, a 2X2cm bullae is locatedover left lower shin, 1
open blister draining clear fluid is located over right lower
shin with surrounding erythema, two other open blisters draining
clear fluid.
Pertinent Results:
[**2171-4-17**] 09:00AM BLOOD WBC-8.1 RBC-3.86* Hgb-12.1* Hct-37.3*
MCV-97 MCH-31.5 MCHC-32.5 RDW-17.8* Plt Ct-293
[**2171-4-21**] 06:03AM BLOOD WBC-7.7 RBC-3.88* Hgb-12.3* Hct-37.1*
MCV-96 MCH-31.8 MCHC-33.3 RDW-17.0* Plt Ct-280
[**2171-4-17**] 09:00AM BLOOD Neuts-82.8* Lymphs-10.5* Monos-4.1
Eos-2.5 Baso-0.3
[**2171-4-19**] 04:53AM BLOOD PT-13.8* PTT-30.1 INR(PT)-1.2*
[**2171-4-17**] 09:00AM BLOOD Glucose-95 UreaN-97* Creat-9.2* Na-131*
K-6.6* Cl-89* HCO3-23 AnGap-26*
[**2171-4-21**] 06:03AM BLOOD Glucose-156* UreaN-82* Creat-8.7* Na-130*
K-4.4 Cl-89* HCO3-25 AnGap-20
[**2171-4-17**] 04:35PM BLOOD Calcium-7.0* Phos-6.0* Mg-1.9
[**2171-4-21**] 06:03AM BLOOD Calcium-7.6* Phos-7.2* Mg-2.0
[**2171-4-19**] 04:53AM BLOOD Albumin-2.7* Calcium-7.7* Phos-8.1*
Mg-1.9
[**2171-4-18**] 05:55AM BLOOD Vanco-12.7
[**2171-4-19**] 04:53AM BLOOD Vanco-21.4*
[**2171-4-20**] 06:18AM BLOOD Vanco-16.5
[**2171-4-21**] 06:03AM BLOOD Vanco-15.0
[**2171-4-17**] 09:59PM Peritoneal Diasylate WBC-37* RBC-20* Polys-14*
Lymphs-34* Monos-48* Eos-4*
[**2171-4-21**] 06:03AM cortisol 15.4
[**2171-4-17**] 9:00 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
STAPH AUREUS COAG +. FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
[**2171-4-17**] 9:59 pm DIALYSIS FLUID PERITONEAL DIALYSATE.
GRAM STAIN (Final [**2171-4-17**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2171-4-20**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
.
[**2171-4-19**] 5:30 pm CATHETER TIP-IV Source: RIJ hemodialysis
line.
WOUND CULTURE (Preliminary):
STAPH AUREUS COAG +. >15 colonies.
[**2171-4-20**] 6:18 am BLOOD CULTURE
Blood Culture, Routine (Pending):
EKG:
Sinus tachycardia. Right bundle-branch block. Axis appears
rightward but is difficult to assess. Early precordial QRS
transition. Right precordial lead ST-T wave changes may be
primary. Findings are non-specific. Clinical
correlation is suggested. No previous tracing available for
comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
101 180 136 374/445 53 90 16
.
Three views of the right hand and wrist. No fracture identified.
There are
degenerative changes particularly in the second and fifth DIP
joints with the latter having an apparent flexion deformity. No
bone destruction or
chondrocalcinosis. Probable soft tissue swelling about the
wrist. Assessment
is limited by lack of localizing and limited clinical history.
.
CXR:
SINGLE PORTABLE RADIOGRAPH OF CHEST: A right approach duo-lumen
central
venous catheter has the tips terminating respectively in the
distal SVC and right atrium. An endovascular stent projects over
the mid abdomen.
Evaluation of the cardiac silhouette is limited by low lung
volumes. There is relative elevation of the left hemidiaphragm,
of unknown chronicity.
Atherosclerotic calcification is noted in the aortic arch. There
are
retrocardiac opacities which could represent atelectasis
although underlying infection cannot be excluded. Additionally,
there is linear scarring in the left lung base. Mild blunting of
the right costophrenic angle could represent scarring versus a
tiny effusion. There is no pneumothorax or pulmonary edema.
IMPRESSION:
1. Retrocardiac opacities probably represent atelectasis, though
underlying infection cannot be entirely excluded. If clinical
concern lingers for possible pneumonia, PA and lateral
radiograph could be obtained. Mild blunting of the right
costophrenic angle could represent scarring versus a tiny
effusion.
2. Elevated left hemidiaphragm.
.
ECHO [**2171-4-18**]:
The left atrium is moderately dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses and cavity
size are normal. There is severe regional left ventricular
systolic dysfunction with dyskinesis of the inferior wall,
akinesis of the inferolateral wall and severe hypokinesis of the
lateral wall. [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] There is no ventricular septal defect. The right
ventricular cavity is dilated with depressed free wall
contractility. The aortic valve leaflets are mildly thickened
(?#). There is mild aortic valve stenosis (valve area
1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Severe focal LV systolic dysfunction, consistent
with prior ischemia/infarction. Mild aortic stenosis. Moderate
mitral regurgitation and pulmonary hypertension
.
STUDY: AP chest [**2171-4-21**].
HISTORY: 80-year-old man with shortness of breath.
FINDINGS: Comparison is made to previous study from [**2171-4-17**].
There has been removal of the right-sided subclavian catheters.
There remains a left IJ central venous catheter with distal lead
tip at the junction of brachiocephalic vein and SVC. There is
elevation of the left hemidiaphragm.
There is some atelectasis at the left base. There is mild
prominence of the pulmonary interstitial markings. Small
right-sided pleural effusion is also seen. Overall, the
parenchymal findings are stable.
Brief Hospital Course:
Assessment and Plan:
80M with pmh significant for ESRD on peritoneal dialysis,
presenting with acute onset of fevers, chills, rigors, and right
thumb and finger pain and erythema.
.
#Hand Inflammation: The patient was initially placed on broad
spectrum antibiotics, including vancomycin, ceftriaxone, and
clindamycin, out of concern that this may be a septic arthritis.
Plastic surgery evaluated the patient and did not feel that
this was septic arthritis, and instead felt this was more
consistent with gout. His ceftriaxone and clindamycin were
therefore discontinued on Hospital Day #2. His Vancomycin was
continued because a blood culture from [**Hospital3 **] Hospital on [**4-17**]
grew gram positive Cocci. He was given a dose of toradol on [**4-18**]
with mild improvement of his pain. On [**4-20**] he was given a dose
of colchicine .6mg, again with mild improvement, and on [**4-21**] he
was given a second dose of colchicine.
.
#MSSA Bacteremia: The patient was given a dose of vancomycin in
the ED and maintained a therapeutic trough throughout his
hospitalization. On [**4-17**] blood cutltures were positive for coag
pos staph, and on [**4-20**] blood cultures came back speciated as
MSSA. he was therefore started on nafcillin. ID consult was
obtained and they recommended nafcillin 2g IV q4h. They also
recommended a hand CT to rule out pockets of infection or joint
infection, in addition to abdominal CT to ensure his AAA graft
is not seeded by infection, and an ultrasound of his old HD line
pocket to rule out clot as a source of infection. His
peritoneal diasylate fluid was cultured and was negative for
infection. His HD line was removed by interventional radiology
and the cath tip was found to grow coag + staph, with cultures
pending.
.
#Hypotension: The patient reports his baseline systolic blood
pressure ranges between 85-95. He experienced a sudden drop in
blood pressure to 60/30 upon arrival to the [**Hospital1 18**] ED. He
received NS 500cc bolus and was started on levophed. He
reported he was asymptomatic during this episode. Upon arrival
to the ICU he was bolused an addiitonal liter of NS. He was
maintained on levophed throughout the course of hospitalization,
and attempts at weaning this pressor resulted in decreased blood
pressures to 60's/30's. The cause of his hypotension is thought
secondary to sepsis with minor contribution of early, aggressive
ultrafiltration of peritoneal dialysis. He was given a 500cc
bolus the morning of [**4-21**]. The day of transfer to [**Hospital **]
hospital he experienced a 9 beat run of NSVT with transient drop
in his blood pressure. Lytes were normal and CXR was obtained
which showed mild prominence of interstitiial markings and new
samll right pleural effusion. He does have a history of an
ischemic cardiomyopathy. His blood pressure shortly normalized.
His am cortisol on the day of transfer was 15.3, with a low
suspicion of adrenal insufficiency. Per report, his baseline
systolic blood pressure is usually in the 80s, which should be
taken into account with moves to ween from pressors.
.
#End Stage Renal Disease: The patient continued with peritoneal
dialysis dwelling for 4 hours cycled six times daily, starting
on 2.5% 2.5 Liter bags. On [**4-20**] his diasylate was changed to
alternated between 1.5% and 2.5%, and the dwelling time was
decreased to 3 hours with 6 exchanges in 24 hours. On [**4-21**] the
number of exchanges was recommended to decrease to 5 times
daily. Sevelamer was continued at 2400mg TID with meals. On
[**4-20**] his phosphate remained elevated and aluminum hydroxide 20ml
TID was added, and recommended to continue for three days,
ending on [**2171-4-22**]. He was given Epoeitin Alfa 3000 units SC on
[**4-17**] and [**4-19**].
.
#Leg Blisters: numerous blisters draining serous fluid were
found on his legs, thought secondary to edema. He was evaluated
by wound care who recommended:
cleanse wounds with commercial wound cleanser. Pat dry. Apply
Xeroform dressing over each wound (antibacterial). Cover with
4x4's and wrap with Kerlix, secure with paper tape. Change
dressings daily.
.
#CAD: aspirin 325, simvastatin 40mg were continued
.
#Hypertension: his enalapril was held.
.
FEN: renal and heart healthy diet
.
Prophylaxis: Subcutaneous heparin
.
Access: LIJ
.
Code: Full
.
Communication: Patient and wife [**Name (NI) **] [**Telephone/Fax (1) 86796**].
[**Name2 (NI) **]hter [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
Medications on Admission:
clobilotasol foam DAILY PRN itch
diflorasone ointment [**Hospital1 **] PRN itch
enalapril 1.25 mg QHS
miralax 1 cap DAILY
simvastatin 40 mg DAILY
claritin DAILY
rhinocort 1 puff each nostril DAILIY
colchicine 0.6 mg DAILY PRN gout
aspirin 325 mg DAILY
nephrocaps DAILY
zemplar
epogen
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Epoetin Alfa 3,000 unit/mL Solution Sig: One (1) injection
Injection QMOWEFR (Monday -Wednesday-Friday).
8. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
9. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) gram
Intravenous Q4H (every 4 hours).
10. Aluminum Hydroxide Gel 600 mg/5 mL Suspension Sig: Twenty
(20) ML PO TID W/MEALS (3 TIMES A DAY WITH MEALS) for 2 days:
Will receive last dose on [**4-22**].
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
12. Sevelamer Carbonate 800 mg Tablet Sig: Three (3) Tablet PO
TID W/MEALS (3 TIMES A DAY WITH MEALS).
13. Norepinephrine Bitartrate 1 mg/mL Solution Sig: 0.03-0.25
mcg/kg/min Intravenous Titrate to MAP > 65.
14. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for Cough.
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Gout
MSSA Bacteremia
Hypotension
Chronic kidney Disease requiring Peritoneal dialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with hand pain and low blood pressure. You
were found to have a blood-stream infection and were given
antibiotics. The hand surgeons evaluated you and believed your
hand pain was secondary to gout. You were given the
anti-inflammatories toradol and colchicine with mild improvement
of your pain.
You are being transferred to [**Hospital3 **] hospital to be closer to
your family.
Followup Instructions:
It is recommended that you undergo several studies upon arrival
to [**Hospital3 635**] hospital.
1.Hand CT to look for pockets of infection
2.Ultrasound of HD line pocket
3.CT abdomen to ensure no sources of infection at the AAA graft
site
4.TEE if these studies are negative
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
ICD9 Codes: 5856, 7907, 4280, 4589, 4168, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1261
} | Medical Text: Admission Date: [**2188-9-25**] Discharge Date: [**2188-10-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
sent from living facility for delusions
Major Surgical or Invasive Procedure:
none
History of Present Illness:
89 yo man with CAD, prostate ca s/p suprapubic catheter placed
[**11/2187**], and anemia, presents from nursing home with 2 days of
delusional thinking. Per the patient, one of the nurses accused
him of calling her a bad name, and out of anger she was trying
to give him harmful medicaitons. He reports that he was "lucky
to have survived." Rest home records indicate that the patient
was referring to a man named "shadow" who was trying to poison
him. Records also indicate that the patient was caught with an
empty bottle of Kahlua recently.
.
Of note he was sent to [**Hospital 882**] Hospital on [**2188-9-19**] for
hypotension (BP 86/50s), vomiting, and diaphoreseis, but had
negative workup and sent home.
.
In the ED, vs= T 98, BP 115/59, HR 72, RR 15, 97%ra. He was
noted to have moderate leuks on UA, so infectious cause of
delirium/psychosis was thought to be likely. He was given Cipro.
Also, he had troponin of 0.05 with new TWI in V2-V6, but no
chest pain. He was given Aspirin 325 and Metoprolol 50mg (home
dose). CXR negative for acute process. Admitted for UTI and
ROMI.
.
ROS: Denies recent fevers or chills, nausea or vomiting, chest
pain or shortness of breath. Does report pelvic pain, is unsure
how long it has been going on.
Past Medical History:
CAD
Hyperlipidemia
Osteoporosis
Restless Leg Syndrome
Glaucoma
Prostate cancer s/p prostatectomy
COPD
Anemia
Urinary Incontinence s/p suprapubic tube placement in [**11-18**]
Fall with resultant rib fractures (x4) [**7-/2188**]
Focal outpouching of the infrarenal aorta (radiographic
diagnosis)
Delirium on previous hospital admissions, most recently [**7-/2188**],
resolved
Calcification in the wall of the gallbladder
Intra and extrahepatic biliary ductal dilation
Multiple 3-4 mm right upper [**Year (4 digits) 3630**] pulmonary nodules
Sigmoid diverticulosis
Social History:
Lives at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] House Rest Home [**Street Address(1) 77252**]. Formerly
was a salesman for motels and gift shops. Divorced, with one son
and two grandchildren in [**Name (NI) 620**]. Denies any smoking history.
Denies alcohol although was found with small bottle of Kaluha at
his NH.
Family History:
Noncontributory.
Physical Exam:
VS: T 98, BP 187/77, P 65, Resp 16, O2Sat 100% RA
GEN: NAD, conversant
HEENT: PERRL, mucus membranes moist, no elevated JVP
LUNGS: No increased WOB, lungs CTAB
HEART: RRR, early systolic murmur
ABDOMEN: soft, nontender, nondistended. suprapubic catheter in
place, erythema ~1 cm surrounding, also opaque white discharge
from site, tender when probed
BACK: No CVA tenderness.
EXTREMITIES: No edema, strong distal pulses
NEURO: alert and oriented x 3 but with persistent paranoid
delusions, [**6-16**] upper and lower extremity strength
Pertinent Results:
Admission Labs:
.
[**2188-9-25**] 06:30PM GLUCOSE-105 UREA N-40* CREAT-1.1 SODIUM-140
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-25 ANION GAP-14
[**2188-9-25**] 07:20PM WBC-6.5 RBC-3.53* HGB-10.1* HCT-30.4* MCV-86
MCH-28.6 MCHC-33.2 RDW-14.3
[**2188-9-25**] 07:20PM NEUTS-67.8 LYMPHS-22.0 MONOS-4.6 EOS-4.8*
BASOS-0.7
.
Cardiac Enzymes:
.
[**2188-9-25**] 06:30PM CK-MB-9
[**2188-9-25**] 06:30PM cTropnT-0.05*
[**2188-9-26**] 02:30AM BLOOD CK-MB-8 cTropnT-0.05*
[**2188-9-26**] 10:50AM BLOOD CK-MB-8 cTropnT-0.04*
.
Urine
[**2188-9-25**] 07:05PM URINE RBC-[**7-22**]* WBC-[**4-16**] Bacteri-MOD Yeast-NONE
Epi-0-2
.
Other
[**2188-9-27**] 06:22PM BLOOD TSH-4.6*
.
[**2188-9-25**] EKG:
Sinus rhythm. Left anterior fascicular block. Consider left
ventricular
hypertrophy by voltage in leads I and III. Early R wave
progression.
ST segment elevation in leads V1-V2 with T wave inversion in
leads V2-V6.
Other ST-T wave abnormalities. Since the previous tracing of
[**2188-7-19**]
ST-T wave abnormalities are new. However, ST segment elevations
were seen in leads V1-V2 on prior tracings. Clinical correlation
is suggested.
QTc 445.
[**2188-9-28**] EKG: QTc 487
[**2188-9-29**] EKG: QTc 466
.
[**2188-9-29**] TTE:
The left atrium is normal in size. There is mild
(non-obstructive) focal hypertrophy of the basal septum. 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. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The left ventricular inflow pattern suggests impaired
relaxation. There is no pericardial effusion.
Brief Hospital Course:
89 y.o. man with h/o CAD, suprapubic catheter, here with likely
catheter infection and new ischemic EKG changes.
.
Pelvic pain: On presentation, the patient complained of new pain
at the site of his suprapubic catheter. He later complained of
penile and perineal pain. UA showed bacteria and WBC. He was
persistenly afebrile, with no elevated WBC count, and no CVA
tenderness. He was treated with ciprofloxacin. Urology was
consulted. They changed the suprapubic catheter and commented
that the bacteria represented normal colonizers of a bladder
with an indwelling catheter and were unlikely to be pathologic
and did not require treatment beyond 24 hours past the time of
catheter change. Ciprofloxacin was discontinued accordingly. A
PSA was sent for routine post-prostatectomy screening and was
found to be undetectable.
.
CAD: EKG showed ischemic changes new from previous tracing
06/[**2188**]. Troponins were mildly positive at .05. Records from
[**Hospital 882**] hospital were obtained, showing that EKG at the current
admission was unchanged from an ED visit there [**2188-9-19**] when the
patient was noted to be hypotensive. The most likely cause of
the EKG changes was deduced to be an ischemic event around the
time of that ED visit. Given the patient's multiple medical
comorbidities and the fact that he was asymptomatic, no stress
test was performed. Troponins were flat. Medical management of
CAD was optimized, including continuation of ACEI, BB, increase
of statin (LDL 136) and addition of ASA.
.
Pulseless arrest and ICU course: Pt was transfered to the MICU
after being found unresponsive and pulseless on the floor. On
the day of transfer, the pt was expressing increasing
frustration with his care and wanted to go home. He packed up
his belongings as if to go home, but his primary team was able
to convince him to stay. Due to his agitation, he received an
extra dose of 2.5mg Zydis Zyprexa (he takes 2.5mg at bedtime
nightly). About 1.5 hours later, a CODE BLUE was called when the
pt was found unresponsive by his RN. The primary team was first
to respond, and noted that he was pulseless, diaphoretic, and
hypoxic on arrival. Compressions were initiated, and the pt
immediately responded. CPR was stopped, and evaluation revealed
normal laboratories from the morning, FSBS 171, and ECG with new
QTc prolongation compared to admission. The patient was treated
with Magnesium 2g, and was transferred to the ICU for closer
monitoring of his QTc. The most likely cause of the arrest was
thought to be long-QT-induced arrhythmia secondary to the
combination of ciprofloxacin and olanzapine, although there was
no telemetry documentation of any abnormal rhythm.
.
On arrival to the ICU, the pt was significantly agitated. He was
responding to voice, but unable to speak coherently. Labs were
drawn and he was settled in, after which he complained of vague
mild abdominal "soreness" that had resolved. ROS was otherwise
negative at the time. KUB was unremarkable.
.
He recovered quickly and was returned to the floor in stable
condition. He was monitored on telemetry for the remainder of
his stay without further events.
.
Hypertension: The patient was initially hypertensive to the
180's with HR 50-70. His home blood pressure medications were
restarted, but he continued to be hypertensive. Amlodipine was
added to his outpatient regimen, with good control.
.
Dementia: The patient was initially alert, oriented, coherent,
and calm with a fixed delusion regarding a nursing staff member
at his living facility. He later became agitated and confused
and required redirection and zyprexa. After the pulseless
arrest in the ICU, he was initially incoherent and
uncooperative. No further antipsychotic medications were
administered. On transition back to the general medical [**Hospital1 **],
he continued to be intermittently agitated, often threatening to
leave the hospital, often confused about the place and time, and
requiring frequent redirection. Antipsychotic medications were
avoided. Head CT from prior admission was notable for evidence
of microvascular ischemia, prominent ventricles, and a single
focus of likely chronic blood product in the L frontal [**Hospital1 3630**].
TSH was slightly elevated. Electrolytes and B12 were WNL. The
psychiatry consult service saw the patient and advised that a
further dementia workup including formal neuropsychiatric
testing, laboratory testing, and consideration of head MRI be
pursued after his mental status had returned to baseline several
months after his hospital stay.
.
Glaucoma: Outpatient eye drops were continued.
.
Anemia: Hct remained at baseline 27-30. Iron studies were
consistent with iron deficiency (iron 40 mg, TIBC 348). Iron
supplementation was begun.
Medications on Admission:
Metoprolol 50 po BID
HCTZ 25mg po Daily
Prilosec 20mg po Daily
Vit B12 1000mcg tablet daily
Lisinopril 20 mg daily
Ocuvite 1 tablet daily
Nabumentone 500mg po BID
Simvastatin 20 mg daily
Brimonidine 0.2% eye drops, 1 drop both eyes TID
Travoprost 0.004%, 1 drop both eyes [**Hospital1 **]
Vitamin C 500mg po Daily
Actonel 35mg po QWeek (Wednesday)
Colace 100 mg [**Hospital1 **]
Senna 2 tablet [**Name (NI) **]
MOM 30cc po [**Name (NI) **]
Hemorrhoidal supp, 1 pr prn
Lidocaine ointment, apply to penis prn
Capcacin cream to both knees prn
Zyprexa 2.5mg po [**Name (NI) **]
Lidocaine patch to R flank, 12 hours on, 12 hours off PRN
Acetaminophen 1000mg q8h
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
primary: urinary tract infection, delirium
secondary: coronary artery disease, osteoporosis, glaucoma,
prostate cancer
Discharge Condition:
stable, with dementia and fixed delusions
Discharge Instructions:
You were admitted to the hospital because you were confused and
had pain in your urinary tract. Your catheter was changed and
you were treated with antibiotics.
The following medications were added:
Amlodipine 5 mg daily
Aspirin 81 mg daily
The following medications were changed:
Simvastatin was increased to 40 mg daily
The following medications were stopped:
Zyprexa was stopped.
Please do not take Zyprexa.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2188-10-6**] 4:00
Primary care as per [**Hospital 671**] [**Hospital 4094**] Hospital.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2188-10-2**]
ICD9 Codes: 5990, 4275, 5849, 2930, 4019, 2724, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1262
} | Medical Text: Admission Date: [**2176-9-26**] Discharge Date: [**2176-10-4**]
Date of Birth: Sex: M
Service: ORTHOPEDIC
The patient was initially on the Service of Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 1022**] of
Orthopedics.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 14782**] is a 50 year old
male with a past history significant for hepatitis C,
depression, childhood asthma, chronic low back pain status
post fall to the low back three months prior to admission,
anxiety, history of suicide attempt times two with last in
[**2176-7-10**], status post penile implant, and status post
left rotator cuff in [**2173**]. The patient was admitted to the
hospital under the Orthopedics Service and taken to the
Operating Room on [**2176-9-26**], where the patient underwent
uncomplicated L5-S1 decompression/fusion with right ICBG
placement for noted lumbar spondyloses.
The patient initially tolerated the procedure well without
complication. The patient was transferred to the Floor on
[**2176-9-27**]. The patient was noted to exhibit increasing
confusion. The patient's epidural catheter was discontinued
on postoperative day number one and the patient was started
on PCA pain control.
On [**2176-9-28**], postoperative day number two, the Orthopedics
Service notes the patient increasingly confused and now
agitated. Psychiatry is consulted. Conclusions of
Psychiatry consult are the following: History and
presentation of agitation, somnolence and disorientation
consistent with delirium, although patient has denied recent
alcohol use, his past history would strongly suggest alcohol
withdrawal. Psychiatry Service suggests alcohol withdrawal
prophylaxis with Ativan, continuation with one-to-one sitter
for patient's safety.
On [**2176-9-29**], the patient was noted to be increasingly
agitated, fever of 100.5 F., is noted; tachycardia to 110
beats per minute noted. Orthopedics Service continuing with
alcohol withdrawal prophylaxis, Ativan and normal saline drip
for decreased sodium and chloride in the likely setting of
volume depletion.
On [**2176-9-30**], Orthopedics Service is called to see patient
for increasing tachypnea, tachycardia and general agitation.
A fever is noted at 101.3 F.; heart rate between 110s and
120s. EKG is notable for sinus tachycardia. A portable
chest x-ray is notable for poor inspiration. Left lateral
lung parenchymal margin not captured; patchy asymmetric
vascular congestion, greatest in right middle lobe. Right
upper lobe and left lower lobe with hilar fullness. Cannot
rule out right middle lobe infiltrate with normal cardiac
silhouette.
On [**2176-9-30**], postoperative day number four, a Medical
consultation is obtained for the above symptomatology.
Recommendations are to discontinue intravenous fluid in
likely setting of volume overload, position the patient
upright, cycle CK and troponin to rule out myocardial
infarction in the setting of congestive heart failure. Begin
Levaquin 500 intravenously q. day as treatment for likely
pneumonic process. Recommending CT angiogram to rule out
pulmonary embolism in the setting of immobility and recent
surgery.
On [**2176-9-30**], the Medical Service accepted the patient from
the Orthopedic Service for further treatment for complicating
issues.
On [**2176-9-30**], while in the service of the Medical Team, the
patient underwent CT angio of the chest to rule out pulmonary
embolism which was noted as negative. Mental status change
continued in the setting of delirium; alcohol withdrawal was
suspected. Haldol for p.r.n. agitation was continued while
QTC interval was monitored. Antibiotic regimen was changed
from Levaquin to Ceftriaxone and Flagyl for possible
aspiration pneumonia coverage.
On [**2176-10-1**], postoperative day number five, medical
cross-coverage was called to see the patient for increasing
respiratory rate from 34 to 50 per minute and [**Doctor Last Name 688**] mental
status, now notable to be unresponsive to sternal rub or
painful stimuli. On physical examination, it was noted the
patient's pupils were fixed and dilated with only minimal to
sluggish responsiveness.
Chest x-ray was noted for increasing right middle lobe
infiltrate and right middle lobe opacity. On [**2176-10-1**], in
the morning, at around 09:15, an Anesthesia Code was called.
Anesthesia Team responded to the bed of Mr. [**Known lastname 14782**] and noted
unresponsiveness and agonal breathing. The patient was
intubated successfully with the use of Atonomate 10 mg,
succinyl choline 100 mg. A MAC 3 blade was used without
complications and an 8.0 endotracheal tube was used. Good
breath sounds were noted bilaterally and a right femoral vein
line was inserted at that time.
On [**2176-10-1**], postoperative day number five, the patient was
transferred to the Service of the Medical Intensive Care
Unit-[**Location (un) **] Team. Initial thoughts on accepting the patient
Mr. [**Known lastname 14782**] by the Medical Intensive Care Unit Team: From a
respiratory standpoint the patient demonstrated a large
pneumonic process on chest x-ray with [**Doctor Last Name 688**] mental status
necessitating intubation. The plan was for pressure support,
ventilation, and treatment with Ceftriaxone, Levofloxacin,
Flagyl and aggressive pulmonary toilet.
From a neurological standpoint, differential included alcohol
withdrawal versus metabolic versus infectious, although the
patient had denied alcohol use since [**2176-2-8**]. From a
neurological standpoint, head CT scan the prior evening on
[**2176-9-30**], was noted as negative for acute process.
On [**2176-10-1**], the patient was procedurized with a right
radial arterial line and a left subclavian Cordis
PA-catheter, both without complications. Initial readings of
PA-pressure are 25/10, wedge was 5. The patient was noted to
have a fever of 108.0??????F. Aggressive use of ice packs and
cooling blankets were utilized. Surgery was consulted which,
on [**2176-10-1**], placed a right chest tube, #36 French, without
complication with infusion of one liter of cold sterile
water.
On [**2176-10-2**], the patient was noted to be hyperthermic to a
temperature maximum of 108.0 F., despite cooling blankets, OT
lavage and placement of chest tube. Dantrolene was given,
100 mg intravenously times one for fear of malignant
hyperthermia secondary to succinyl choline versus Haldol use.
Arterial blood gas notable for severe acidosis. Started on a
bicarbonate drip. The patient was noted to be persistently
hypotensive despite aggressive fluid resuscitation and
continuing use of Neo-Synephrine, Levophed and vasopressin
drips.
Acute renal failure was noted to be worsening on [**2176-10-2**].
The Renal Service was consulted which noted a rise in CK to
initially 13,500. Renal dysfunction thought secondary to
hypoperfusion/rhabdomyolysis. Urine output was noted to be
minimal. As such, Renal Service proceeded with CVVH
treatments via left femoral Quinton placement without
complications.
On [**2176-10-3**], it was noted that the patient's CPK levels
were 49,305, consistent with a picture of rhabdomyolysis.
BUN and creatinine indicating worsening renal function.
Lactate worsening to 11.3. The patient was started on CVA
with citrate anti-coagulation on [**2176-10-3**]. Temperature
maximum noted on [**2176-10-3**], was 102.0??????F.
On [**2176-10-3**], postoperative day number seven, in the Medical
Intensive Care Unit, the patient's white count was noted to
be 33.1 despite aggressive antibiotic therapy including
Levofloxacin, Flagyl, Ceftriaxone and Vancomycin for question
of central nervous system process.
On [**2176-10-4**], at 01:15 a.m., Medical Intensive Care Unit
cross cover intern was called to see patient for lack of
respirations. On examination, the patient did not respond to
verbal or noxious stimuli. Pupils were fixed and dilated.
There were no peripheral pulses. Auscultation of the chest
for two minutes revealed no breath sounds and no heart
sounds. The patient was pronounced dead at 12:55 a.m. on
[**2176-10-4**].
DR.[**First Name (STitle) **],[**First Name3 (LF) 734**] 12-944
Dictated By:[**Last Name (NamePattern1) 14783**]
MEDQUIST36
D: [**2177-5-9**] 14:54
T: [**2177-5-9**] 17:33
JOB#: [**Job Number 14784**]
ICD9 Codes: 5185, 5070, 0389, 2930, 5849, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1263
} | Medical Text: Admission Date: [**2148-4-29**] Discharge Date: [**2148-5-17**]
Date of Birth: [**2102-3-28**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
atraumatic subarachnoid hemorrhage
Major Surgical or Invasive Procedure:
[**4-29**]: Bedside placement of External Ventricular Drain, emergent
craniotomy for aneurysm clipping
[**4-30**]: Angiogram
History of Present Illness:
46M s/p syncopal event; found down; agitated and moving all
extremities per report; taken to OSH where he was intubated and
CT head showed diffuse SAH, he was then transferred to [**Hospital1 18**] for
definitive treatment.
Past Medical History:
Hypertension
Social History:
question of drug use
Family History:
history of neice with [**Name2 (NI) 82223**] aneurysm
Physical Exam:
On Admission:
BP: 165/103 HR: 47 R: 20 O2Sats: 100%
Intubated, sedated and paralyzed (meds halted but still in
effect
Pupils equally pinpoint, non reactive;
No corneal reflex; No motor response to stimulation;
On Discharge:
Alert, oriented to person and place. Misses date. Able to follow
brief, simple commands. Moves all extremities with full strength
and power
Pertinent Results:
Labs on admission:
[**2148-4-29**] 06:45PM [**Month/Day/Year 3143**] WBC-10.7 RBC-6.25* Hgb-14.4 Hct-44.2
MCV-71* MCH-23.0* MCHC-32.6 RDW-16.1* Plt Ct-103*
[**2148-4-29**] 06:45PM [**Month/Day/Year 3143**] Neuts-86.0* Lymphs-10.0* Monos-2.9
Eos-0.8 Baso-0.3
[**2148-4-29**] 06:45PM [**Month/Day/Year 3143**] PT-14.7* PTT-26.2 INR(PT)-1.3*
[**2148-4-29**] 06:45PM [**Month/Day/Year 3143**] Glucose-110* UreaN-12 Creat-1.3* Na-140
K-4.4 Cl-105 HCO3-25 AnGap-14
[**2148-4-30**] 10:40AM [**Month/Day/Year 3143**] Calcium-8.6 Phos-3.0 Mg-2.0
Imaging:
CT/A of Heat [**4-30**]:
HEAD CT: On pre-contrast images, there is extensive subarachnoid
hemorrhage, particularly in the right sylvian fissure as well as
prepontine and perimesencephalic regions. No evidence for
hydrocephalus. No shift of normally midline structures.
[**Doctor Last Name **]-white matter differentiation is grossly preserved, and
there is no evidence for acute territorial infarction. Patient
is intubated, and there is opacification of the ethmoid air
cells and right maxillary sinus. Osseous structures appear
intact. Mastoid air cells are well aerated.
CT ANGIOGRAM: There is a 7 x 5 mm saccular aneurysm arising at
the branch
point of M1 and M2 in the right MCA. This saccular aneurysm has
an irregular contour. Flow was seen distally within the right
MCA branches. There is tortuosity to the basilar artery, which
may represent a fusiform aneurysm. In addition, in the area of
the left PCOM near the choroidal artery is potentially a 2-mm
infundibular dilation or aneurysm; however, an infundibular
aneurysm arising off the left anterior choroidal artery cannot
be excluded. No other areas of vascular narrowing or aneurysm
were identified.
IMPRESSION:
1. Extensive subarachnoid hemorrhage in the area of the right
sylvian fissure as well as in the prepontine and
perimesencephalic spaces. No hydrocephalus, and no shift of
midline.
2. 7 x 4 mm saccular aneurysm of the right MCA at the M2
bifurcation.
3. Tortuosity of the basilar artery and fusiform aneurysm cannot
be excluded.
4. Possible 2 mm infundibular dilation or aneurysm at the left
PCOM, however, an infundibular aneurysm at the left anterior
choroidal artery at this site cannot be excluded. Recommend
correlation with angiography performed on [**2148-4-30**], at 7:13
a.m.
5. Opacification of the right maxillary sinus and bilateral
ethmoid air
cells, likely related to patient's intubated status.
CTA/Perfusion Study [**5-3**]:
increased hypodensity in right temporal/parietal lobe concering
for ischemia, but with large peneumbral territory in the right
inferior MCA territory on perfusion maps. paucity of vessels in
region of inferior branch right MCA concerning for spasm or
occlusion. remaning intracranial vessels patent. 10mm leftward
midline shift with early subfalcine and uncal herniation.
decreased size of lateral ventricles. decreased right
subarachnoid hemorrhage.
Final Report
HISTORY: 46-year-old man with subarachnoid hemorrhage. Perform
CTA brain
with perfusion to evaluate for infarction, vasospasm or other
interval change.
CTA HEAD WITH PERFUSION: Contiguous axial imaging was performed
through the brain without contrast. An axial MDCT perfusion was
performed. Subsequently rapid helical axial MDCT imaging was
performed from the aortic arch through the brain after
uneventful administration of intravenous contrast. Images were
processed on a separate workstation with display of mean transit
time, relative cerebral [**Name2 (NI) **] volume, and cerebral [**Name2 (NI) **] flow
maps for the CT perfusion study, and curved reformations,
volume-rendered images, and maximum- intensity projection images
for the CTA.
COMPARISON: Carotid and cerebral angiogram [**2148-4-30**], CT head
[**2148-4-30**], CTA head [**2148-4-29**].
CT HEAD: Compared to prior study, there has been significant
further interval progression of large territory of hypodensity
in the right temporoparietal lobe. This area is concerning for
progression of cytotoxic edema, related to infarction. There is
decreased volume of hyperdense subarachnoid hemorrhage seen
along the right cerebral convexity. There is an 8-mm thick
hypodense subdural collection layering along the right frontal
convexity (2:19) causing mild sulcal effacement, as before.
Compared to the prior study, there is new 8-mm leftward shift of
normally-midline structures, with subfalcine herniation and
probable early uncal herniation (2:13). The lateral ventricles
have been further effaced since the prior study. A
ventriculostomy catheter remains present in the region of the
third ventricle, and an aneurysm clip is seen in the region of
the bifurcation of the right MCA. Evidence of prior right
temporal craniotomy with overlying soft tissue swelling is
present. There has been significant interval resorption of
previous pneumocephalus. Mucosal thickening is seen in bilateral
frontal, ethmoid, and sphenoid sinuses, which may be related to
patient's prior intubation and supine positioning.
CT PERFUSION: Perfusion maps demonstrate a large territory of
increased mean transit time and with largely corresponding zone
of increased cerebral [**Year (4 digits) **] volume, particularly in the inferior
division of the right MCA vascular territorial distribution,
highly concerning for tissue at risk for infarction. Focally
decreased [**Year (4 digits) **] volume seen in the distribution of the right MCA
corresponds to region of subarachnoid hemorrhage seen on non-
contrast CT study.
CT ANGIOGRAM: The study is limited by patient-motion artifact.
Corresponding to the conventional angiogram, there is marked
paucity of arterial vascular flow corresponding to the inferior
division of the right MCA, whereas flow is seen within its
superior division. No flow into the clipped right MCA
bifurcation aneurysm, and no new aneurysm is seen. Compared to
the prior CT angiogram, the vessels of both the anterior and
posterior circulation appear somewhat smaller in caliber and
demonstrate slight mural irregularity, diffusely (some of which
may relate to patient- motion artifact); the findings are
suspicious for new vasospasm, in this context. The basilar
artery remains highly irregular and lobulated in contour, with
likely fusiform aneurysm which appears stable since the prior
study. Again demonstrated are "triplex" ACA and fetal origin of
the right PCA, both normal variants.
IMPRESSION:
1. Enlarging hypodense territory in the left temporoparietal
lobe which
likely represents further cytotoxic edema corresponding to a
region of
ischemia with "tissue-at-risk" seen on CT perfusion study.
2. Paucity of vascularity in the territory of the inferior
division of the
right MCA, corresponding to the angiographic finding of three
days earlier, which may related to occlusion of the inferior
division.
3. Increased leftward shift of midline structures with early
subfalcine and uncal herniation. Further effacement of the
lateral ventricles with stable position of ventriculostomy
catheter.
4. Decreased volume of subarachnoid hemorrhage in the right
temporoparietal lobe.
5. Apparent caliber change with irregularity of the vessels of
both the
anterior and posterior circulation, some of which may be
technical. However, the findings remains suspicious for diffuse
cerebral vasospasm, in this context.
6. Likely fusiform aneurysm of the basilar artery, as before.
CTA [**5-14**]:
IMPRESSION:
1. Stable irregularity to the right M1 and M2 segments
consistent with
persistent areas of mild spasm.
2. There is focal fusiform dilation of the right M2 segment just
distal to
the aneurysm clip, which may be the result of spasm in this
area.
3. Unchanged appearance to fusiform aneurysm of the basilar,
more prominent in the mid basilar section.
4. Stable small left PCOM aneurysm.
5. Evolution of infarction involving the right temporal lobe.
6. Stable post-surgical changes involving the right craniotomy
with MCA
aneurysm clipping. Small volume right frontal extra-axial fluid
collection.
7. Overall improvement in appearance of prior subarachnoid
hemorrhage with no new areas of hemorrhage present.
Brief Hospital Course:
Pt was admitted to the hospital for eval of SAH. He was found
down at home after doing the dishes. Pt famiy reports question
of ilicit drug use prior to event. Pt was originally brought to
an OSH and then transfered to [**Hospital1 18**].
On hospital day number one the pt underwent a cerebral angiogram
and a Right MCA aneurysm was noted. He was started on Keppra,
mannitol and nimodipine. He was then taken to the OR for open
clipping of the same and a external ventricular drain was
placed. Post-operative Angiogram was positive for cerebral
vasospasm and was treated aggressively with medical management
(triple-H therapy).
He was extubated on [**5-3**] and was following commands. His
cervical collar was maintained in the early hospital course
because he was unreliable to assist in clearing his c-spine.
His mannitol was weaned to off on [**5-6**] and his HHH therapy
continued.
On [**5-8**] he underwent a CTA to eval for vasospasm and the results
were negative for vasospasm, but an evolving right MCA territory
infarction was noted along with
improved leftward shift of midline structures, with mild
subfalcine
herniation, but no evidence of uncal herniation, slight
improvement in the
caliber of the lateral ventricles.
[**5-9**], Patient became more lethargic and less verbally
interactive, under the assumption that the patient was in
vasospasm at this time, levophed was started and new goal for
sbp to 180s was set. With this new goal and elevated systolics,
patient became more alert and interactive. the ventricular
drain was also clamped on this day, a CT scan the following
morning did not show any evolving hydrocephalus, so the EVD was
discontinued.
The patient has remained afebrile since [**5-12**] all cultures have
shown no growth to date.
The patient remains in a hard cervical, refusing a full exam. On
[**5-15**], patient was transfered to floor and monitored on telemetry
for tachycardia. He was seen on c-spine CT to have a rotational
subluxation of his C1/2 and was told to remain in C-collar. He
denied point tenderness and Dr. [**Last Name (STitle) 548**] reviewed scan and examined
patient and felt it was appropriate to remove c-collar.
He was seen by physical and occupational therapy who determined
that he would be an appropriate rehab candidate, and discharged
on XXXXXXXXXXXXXXXXX.
Medications on Admission:
None
Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4
hours) for 5 days.
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
5. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipatoin.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Atraumatic subarachnoid hemorrhage
Right MCA aneurysm
Discharge Condition:
Neurologically Stable
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 have been
removed(on or about [**5-19**]).
?????? 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.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**6-21**] days(from your date of
surgery-on or about [**5-19**]) for removal of your sutures and a wound
check. This can be done at rehab, or an appointment can be made
with the Nurse Practitioner. Please make this appointment by
calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our
office, please make arrangements for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
Completed by:[**2148-5-17**]
ICD9 Codes: 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1264
} | Medical Text: Admission Date: [**2101-4-21**] Discharge Date: [**2101-4-29**]
Date of Birth: [**2031-11-15**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7729**]
Chief Complaint:
Tongue Cancer
Major Surgical or Invasive Procedure:
[**2101-4-21**]: left hemiglossectomy, bilateral neck dissection, and
split thickness skin graft
History of Present Illness:
Mr. [**Known lastname 3065**] is a 69-year-old gentleman with a history of cT1N0M0
moderately differentiated invasive squamous cell carcinoma of
the tongue. Given the extent of pain that he is in, he cannot
allow for a full digital exam and it is very difficult to see
between his tongue and jaw, so the tumor visibly
approaches the midline. No pathologic nodes were identified on
CT scan. It is recommended that he undergo primary surgical
excision, and after discussion of the risks and benefits of the
procedure, the patient and his family have decided to pursue
this treatment plan.
Past Medical History:
COPD
atrial fibrillation
diastolic congestive heart failure
chronic kidney disease
hypertension,
glaucoma
hyperlipidemia
history of DVT.
PAST SURGICAL HISTORY:
Status post IVC filter in [**2084**]
bilateral cataract surgery.
Social History:
Mr. [**Known lastname 3065**] is originally from [**Country 15800**].
He is married and lives with his wife in [**Name (NI) 2312**]. He
previously
worked as an economist, retired approximately five years ago.
He
has five adult children.
Tobacco: none.
Alcohol: Previously consumed alcohol, but quit approximately 25
years ago.
Family History:
His father had a history of throat cancer.
Physical Exam:
Stable vital signs, on room air.
NAD, breathing quietly and comfortably.
NGT in place.
Intraoral surgical site with skin graft healing well with 100%
take.
Neck soft and flat with minimal stable superior flap edema.
Minimal bibasilar crackles bilaterally.
Left leg skin graft donor site healing well with dry Xeroform in
place.
Pertinent Results:
[**2101-4-27**] 05:25AM BLOOD WBC-7.9 RBC-3.15* Hgb-10.2* Hct-31.1*
MCV-99* MCH-32.4* MCHC-32.9 RDW-13.3 Plt Ct-148*
[**2101-4-28**] 05:15AM BLOOD PT-20.8* INR(PT)-2.0*
[**2101-4-27**] 05:25AM BLOOD UreaN-13 Creat-0.9 Na-141 K-4.3 Cl-106
HCO3-27 AnGap-12
[**2101-4-25**] 04:50AM BLOOD Glucose-180* UreaN-17 Creat-1.2 Na-145
K-3.2* Cl-111* HCO3-28 AnGap-9
[**2101-4-22**] 09:30PM BLOOD proBNP-1431*
[**2101-4-22**] 09:30PM BLOOD TSH-1.9
Brief Hospital Course:
Mr. [**Known lastname 3065**] was admitted to [**Hospital1 18**] on [**2101-4-21**] to undergo a left
hemiglossectomy, bilateral neck dissection, and split thickness
skin graft reconstruction. He tolerated the procedure well;
please see the separately dictated operative report for details
of the procedure. Given the extent of resection, he was kept
intubated overnight and was successfully extubated the next
morning. He received a short course of post-operative steroids.
He was then transferred to the surgical floor on [**Hospital Ward Name 1950**] 7.
The remainder of his hospital course by system:
###HEENT: He was transferred to the floor with 2 JP drains in
his neck and an intraoral bolster in place over the skin graft.
The drains were removed as they met criteria on POD#3 and 4.
The bolster was removed on POD#5 and the skin graft showed 100%
take. His neck incision healed well, although he developed some
mild superior flap edema on POD#[**4-24**]. The staples were removed
from his neck incision on POD#8, and the incision was healing
well without evidence of dehiscence.
###Neuro: He initially received IV morphine for pain control
and was subsequently transitioned to oxycodone liquid PT on
POD#2. By the time of discharge, he was receiving only standing
acetaminophen every 6 hours for pain; this will be changed to a
PRN medication at the time of discharge. He also had a few
minor intermittent episodes of confusion or forgetfulness
consistent with delirium, but he was easily redirectable by his
staff and family.
###CV: He was tachycardic postoperatively, and after his heart
rate did not respond to adequate IV fluid boluses (as measured
by an appropriate urine output), a medicine consult was obtained
given his history of DVT/PE and cardiomyopathy. An EKG showed
sinus tachycardia, and a PE-protocol CT was performed. This was
negative for embolus but did show a right lower lobe pneumonia.
Troponins were negative x3. His tachycardia resolved over the
next few days. His antihypertensives were initially held, as he
had some mild hypotension to the 80's and 90's. This resolved
with the tachycardia, and by POD#7, his home antihypertensive
regimen was resumed with adequate blood pressure control.
###Pulm: He was diagnosed with a right lower lobe pneumonia
after the PE-protocol CT on POD#1. He remained stable on room
air for his entire hospital course, although he did have a
productive cough for the first few days. Sputum culture
eventually grew Citrobacter koseri and Enterobacter aerogenes,
both sensitive to fluoroquinolones; commensal respiratory flora
was absent. He received standing nebulizer treatments for a few
days with good effect and resolution of his cough.
###GI: Tube feeds were started on POD#1 after extubation. They
were quickly advanced to goal and he tolerated them well without
nausea. After the bolster was removed on POD#5, he was evaluated
by Speech and Swallow for possible initiation of an oral diet.
They recommended clear liquids given that although he showed no
signs of aspiration, he had difficulty with oral manipulation of
food boluses given the exten of his surgical resection. They
also recommended a video swallow evaluation, which was done on
POD#7. This showed a normal pharyngeal swallow but again,
difficulty with oral preparation. It was decided that he would
continue with tube feeds for nutrition while he continued to
work on his swallow ability with the therapists. He was
discharged on tube feeds and an oral full liquid diet. The NG
tube can be removed if he can take adequate POs. The patient
did not wish to consider a G tube at this time, although the
possibility was discussed.
###GU: A Foley was placed intraoperatively, and this was
continued post-operatively for aid in fluid management. It was
removed on POD#3 when his tachycardia had stabilized. He was
subsequently able to void independently. His creatinine
remained stable at his preoperative baseline (1.2-1.4).
###Heme: His post-operative hematocrit dropped to 31, where it
remained stable. He did not receive any blood transfusions. On
POD#3, it was noted that he had asymmetric edema of his upper
extremities, and ultrasound examination revealed a DVT in his
left arm. He had restarted his coumadin on POD#3 but after
identification of the clot, he was also started on a lovenox
bridge. His INR was therapeutic on POD#6 and the lovenox was
stopped.
###ID: He was started on Ancef post-operatively for prophylaxis
while the bolster was in place. This was changed to IV
ciprofloxacin for the right lower lobe pneumonia which was then
changed to Zosyn and azithromycin the next day to cover for
ventilator-associated pneumonia seen on PE-CT. After 48 hours,
he was changed to oral levofloxacin. He completed a 7-day
course of antibiotics with normalization of his leukocytosis.
###Endocrine: The patient's blood glucose was controlled with a
regular insulin sliding scale, which he tolerated well. A TSH
was checked for the tachycardia workup and was normal.
By POD#8, the patient was deemed ready for discharge to a rehab
facility. He and his family agreed with the plan and were eager
to move forward with his care.
His CT scan showed incidental findings of left axillary
lymphadenopathy and small pulmonary nodules. The
lymphadenopathy should be addressed at outpatient follow up with
hematology/oncology. His PCP should follow up the pulmonary
nodules. He will require chemoradiation therapy, and will
follow up with radiation oncology as well as hematology/oncology
as an outpatient.
Medications on Admission:
ACETAZOLAMIDE - (Prescribed by Other Provider) - 250 mg Tablet
-
1 (One) Tablet(s) by mouth every eight (8) hours
ALBUTEROL SULFATE - (Prescribed by Other Provider) - Dosage
uncertain
FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1
(One) Tablet(s) by mouth once a day as needed for as needed for
SOB
LISINOPRIL - (Prescribed by Other Provider) - 20 mg Tablet - 1
(One) Tablet(s) by mouth once a day
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 (One) Capsule(s) by mouth once a day
OXYCODONE - 5 mg Tablet - [**12-20**] Tablet(s) by mouth every 6 hours
as
needed for as needed for pain
SIMVASTATIN - (Prescribed by Other Provider) - 10 mg Tablet - 2
(Two) Tablet(s) by mouth at bedtime
WARFARIN - 5 mg Tablet - 1-1.5 Tablet(s) by mouth once a day 7.5
mg on Tues and Fridays; 5mg on the remaining days
Medications - OTC
ACETAMINOPHEN - (Prescribed by Other Provider) - 650 mg/20.3 mL
Solution - 650/20.3ml mg by mouth every six (6) hours
DOCUSATE SODIUM [COLACE] - 100 mg Capsule - 1 Capsule(s) by
mouth
twice a day
FERROUS GLUCONATE - (Prescribed by Other Provider) - 325 mg
Tablet - 1 (One) Tablet(s) by mouth
LIDOCAINE - (Prescribed by Other Provider) - Dosage uncertain
OMEGA-3S-DHA-EPA-FISH OIL [OMEGA 3] - (Prescribed by Other
Provider) - Dosage uncertain
SENNOSIDES [SENNA] - 8.6 mg Capsule - 1 Capsule(s) by mouth at
bedtime
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
3. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
4. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
5. acetaminophen 650 mg/20.3 mL Solution Sig: Twenty (20) ml PO
Q6H (every 6 hours) as needed for pain.
6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) ml PO BID (2
times a day).
8. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day): OU.
9. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day): OU.
10. bimatoprost 0.03 % Drops Sig: One (1) Drop Ophthalmic QHS
(once a day (at bedtime)): OU.
11. Bromday 0.09 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily): OD.
12. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
tongue cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Oral care: rinse mouth with saline after eating. Gentle cleaning
with sponge followed by suctioning with Yankauer if patient has
trouble with secretions.
Wound care: trim the dried edges of the Xeroform on the left leg
as needed to keep them from getting caught on clothing - this
will eventually fall off on its own. The incision line of the
neck can be covered with a thin layer of Vaseline if it is
getting crusted or itchy.
Followup Instructions:
Dr. [**Last Name (STitle) 1837**] [**2101-5-10**] 2pm
Follow up with PCP [**Name Initial (PRE) 176**] 1 week of discharge
ICD9 Codes: 486, 4254, 2760, 496, 4280, 5859, 2724, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1265
} | Medical Text: Admission Date: [**2185-10-3**] Discharge Date: [**2185-10-7**]
Date of Birth: [**2111-7-21**] Sex: M
Service: MEDICINE
Allergies:
Diltiazem
Attending:[**First Name3 (LF) 19193**]
Chief Complaint:
fever/vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 74yo M with h/o CAD s/p MI and PCI to LAD [**2179**],
hypertension,
type II diabetes mellitus, aortic stenosis, paroxysmal atrial
fibrillation on coumadin, ankylosing spondylitis, peripheral
[**Year (4 digits) 1106**]
disease s/p left popliteal-posterior tibial bypass [**2183-10-29**],
non-healing left foot ulcer for multiple years who presents w/
c/o fever and vomiting beginning the morning of presentation.
Patient was on way to PCP's office when began to feel maialase,
fevers, and chills. Patient began to feel nauseus and began
vomiting. Was sent from PCP's office to the ED. In the ED,
patient had a fever of 102. Patient increased SOB over the last
few weeks, and endorses a slight worsening of baseline cough,
producing a white mucous. He has a 50+ years smoking history,
but denies history of COPD. He denies diahrea, and had well
formed BM this morning. Denies dysuria. He currently feels much
improved when hitting the floor.
Past Medical History:
peripheral [**Month/Day/Year 1106**] disease with h/o nonhealing left foot ulcer
hypertension
coronary artery disease s/p MI, s/p LAD stent [**7-/2180**]
-- stress [**5-/2181**] with mild reversible apical defect, EF 59%
congestive heart failure
aortic stenosis
type II diabetes mellitus; on insulin
tobacco use
hyperlipidemia
paroxysmal atrial fibrillation
ankylosing spondylitis
Social History:
lives with his wife
works as a tax lawyer
[**Name (NI) **]: 1ppw x 50yrs
EtOH: rare
Illicits: none
Family History:
mother d. CAD in 60s
father d. MI in 70s
Physical Exam:
T 98.8 HR 98 BP 134/52 RR 18 97% on 3L
Gen: comfortable, well appearing, NAD
HEENT: PERRL, anicteric, MMM, OP clear
Neck: supple, no LAD, JVP nondistended
CV: RRR with occasional PVC, no m/r/g
Resp: slight crackles in LLL, otherwise CTA
Abd: +BS, soft, NT, ND, no masses, no HSM, large rightsided
scar.
Ext: No LE edema, left ankles wrapped in bandange with ampuated
big toe, 1+ right DP
Skin: erythematous papules with excoriation on B arms
Neuro: A&Ox3, CN II-XII intact, strength 5/5 throughout,
sensation intact grossly
Pertinent Results:
[**2185-10-3**] 11:20AM [**Month/Day/Year 3143**] WBC-14.8*# RBC-4.49* Hgb-14.9 Hct-43.3
MCV-96 MCH-33.1* MCHC-34.4 RDW-14.9 Plt Ct-205
[**2185-10-3**] 11:20AM [**Month/Day/Year 3143**] Neuts-82* Bands-8* Lymphs-8* Monos-1*
Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0
[**2185-10-3**] 11:20AM [**Month/Day/Year 3143**] PT-17.6* PTT-25.9 INR(PT)-1.6*
[**2185-10-3**] 12:20PM [**Month/Day/Year 3143**] Glucose-118* UreaN-26* Creat-1.0 Na-141
K-4.2 Cl-104 HCO3-30 AnGap-11
[**2185-10-3**] 12:20PM [**Month/Day/Year 3143**] ALT-19 AST-22 CK(CPK)-143 AlkPhos-75
Amylase-355* TotBili-1.0
[**2185-10-3**] 12:20PM [**Month/Day/Year 3143**] CK-MB-5 cTropnT-<0.01
[**2185-10-3**] 12:20PM [**Month/Day/Year 3143**] Lipase-22
[**2185-10-3**] 12:20PM [**Month/Day/Year 3143**] Albumin-4.1 Calcium-9.1 Phos-2.1* Mg-1.9
[**2185-10-3**] 11:28AM [**Month/Day/Year 3143**] Lactate-2.6*
.
PA AND LATERAL CHEST RADIOGRAPHS: Allowing for marked kyphosis,
the cardiomediastinal silhouette is stable and within normal
limits. There is an elevated right hemidiaphragm with a small
amount of adjacent atelectasis. No areas of consolidation are
visualized. No effusions are appreciated. There is no evidence
of CHF. Patient positioning limits evaluation of the lung
apices.
There are no suspicious lytic or sclerotic osseous lesions.
IMPRESSION: No acute cardiopulmonary process.
.
COMPARISON: Abdominal angiogram [**2177-5-12**].
Multiple clips are within the right upper quadrant and a single
clip is overlying the right lower quadrant. There are several
loops of air-filled small bowel with no evidence of obstruction.
The descending colon is filled with stool, however, not
distended.
IMPRESSION: No evidence of obstruction.
.
ECHO:
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size. There is
mild regional left ventricular systolic dysfunction with basal
and mid-inferior hypokinesis (c/w RCA disease). The remaining
segments contract normally (LVEF = 50%). 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 number of aortic valve leaflets cannot be
determined. There is no aortic valve stenosis. No 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 no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
mild regional systolic dysfunction, c/w CAD. No significant
aortic valve disease seen.
Compared with the prior study (images reviewed) of [**2180-1-12**],
the findings are similar.
Brief Hospital Course:
Pt is a 74yo M with h/o CAD s/p MI and PCI to LAD [**2179**],
hypertension, type II diabetes mellitus, aortic stenosis,
paroxysmal atrial fibrillation on coumadin, non-healing left
foot ulcer for multiple years, who presents w/ c/o fever,
malaise, DOE and 1 episode of vomiting at presentation. U/A
indicating UTI as possible source of infection. Pt developed
a-fib with [**Hospital 26875**] transferred to MICU for rate control. He
converted to sinus within a few hours of arrival to the MICU
with rapid improvement in BP to baseline. Digoxin was
discontinued, and Metoprolol was increased to 25 TID. He was
doing well at discharge.
.
HOSPITAL COURSE BY PROBLEM:
# Fever/Leukocytosis: Source likely urinary. Pt had initial O2
requirement and SOB at presentation. CXR showed no
consolidation. Pt is a chronic smoker w/ chronic cough, no h/o
asthma or documented COPD and he does not use inhalers at home.
Azithromycin was stopped given no pulmonary source. L foot ulcer
is stable with no e/o infection. Pt denies any symptoms to
suggest abdominal/GU source, vomiting on presentation resolved.
Patient was started on ciprofloxacin 10 day course. Although
patient is on coumadin and had increasing INR, pt was reluctant
to change antibiotics. [**Hospital **] cx were negative and white count
remained stable.
.
# CAD: s/p MI in '[**79**] and stenting. CK peak 700, MB peak of 12,
trop peak 0.04 [**10-4**], but pt is chest pain free, no EKG changes.
Rise may have been [**12-24**] cardiac demand in setting of infection.
Pt had episode of chest pressure in setting of a-fib with RVR,
CE remained flat and symptoms resolved w/ rate control.
Continue daily ASA, lipitor, BB, but will hold [**Last Name (un) **] in setting of
lowish BPs. Echo was obtained which showed mild symmetric left
ventricular hypertrophy with mild regional systolic dysfunction,
c/w CAD. No significant aortic valve disease seen, EF 50%.
.
# HTN: patient on metoprolol and [**Last Name (un) **] as outpt. [**Last Name (un) **] held in
setting of lower [**Last Name (un) **] pressures while in-house, furosemide also
held. Will defer to PMD to restart medications as indicated.
.
# anemia: Hct drop since admission, BL 40s, may be dilutional
and pt has had lower Hct in setting of infection in past. No
clear source for bleeding. Hct was stable throughout this
admission.
.
# PAF: Patient in NSR on presentation. Supratherapeutic INR
while on ciprofloxacin. Pt was transferred to MICU for rapid
rate and had some chest pressure. Rate controlled with
metoprolol increased to 25mg TID. Patient was stable on
discharge. His coumadin dose was decreased while he is taking
ciprofloxacin. Antibiotic was not changed given good response
and patient's apprehension towards change. Patient's coumadin
dose will be adjusted per his PCP.
.
# DM: Continued outpatient NPH + ISS regimen.
.
# BPH: continued outpatient flomax.
.
# contact: wife [**Name (NI) 1328**] [**Telephone/Fax (1) 27101**]
Medications on Admission:
Lipitor 10mg daily
Lasix 40mg daily
Insulin NPH Human Recomb 26U am / 40 U pm + HISS
metaprolol 25mg [**Hospital1 **]
Tamsulosin 0.4mg daily
Valsartan 10 mg daily
Warfarin 7.5mg daily
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Insulin Regular Human 100 unit/mL Cartridge Sig: sliding
scale sliding scale Injection four times a day: dose as
indicated.
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at [**Hospital1 21013**]).
6. Ciprofloxacin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 9 days: to finish [**10-15**].
Disp:*36 Tablet(s)* Refills:*0*
7. Warfarin 2 mg Tablet Sig: One (1) Tablet PO at [**Month/Year (2) 21013**]:
please adjust dose with your primary care physician.
8. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: Seventy
Five (75) mg PO once a day: please provide correct tablet size
for 75mg dose daily.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
9. Outpatient Lab Work
please draw pt/ptt/inr on monday and follow-up result with your
primary care physician to adjust your warfarin dose. You may
call his office.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Primary Diagnosis:
Urinary tract infection
Atrial tachycardia and paroxysmal atrial fibrillation
Secondary Diagnosis:
Coronary Artery Disease
Peripheral [**Location (un) 1106**] disease
Chronic foot ulcer
Diabetes
Tobacco Use
Ankylosing Spondylitis
?congestive heart failure
Discharge Condition:
Good; T 97.4/98.0 BP 130/64
Discharge Instructions:
You were admitted with a fever and were found to have a urinary
tract infection. Your fever improved with Ciprofloxacin
antibioitics. You will finish a 10-day course of oral
antibiotics on [**10-15**]. Please finish all of your medications.
.
You also had a rapid heart rate which may have started because
of your infection. You were transferred to the ICU and they
were able to stabilize your rate with medications. Your
metoprolol was changed from 25mg twice a day to three times a
day and you can take Toprol XL 75mg daily for ease of dosing.
Please discuss this with your cardiologist.
.
Your coumadin levels (INR) have been high because you are taking
ciprofloxacin. We recommend taking 2mg at night until you have
a lab draw. Please have your INR drawn on Monday and follow-up
with your primary care physician. [**Name10 (NameIs) 2172**] medication will need to
be adjusted and will likely change once you are off of the
antibiotics.
.
Your Valsartan was held given some low [**Name10 (NameIs) **] pressures. You
pressures were stable on discharge. Please discuss restarting
the Valsartan with your primary care physician and do not take
it for now.
.
Your breathing was stable at discharge and you did not require
any oxygen. We advise you to quit smoking, as smoking
cigarettes will cause problems for your lungs and will make
breathing more difficult. Your cough appears to be chronic and
there was no concern for a pneumonia. We again advise you to
quit smoking.
.
If you develop any concerning symptoms such as persistent
fevers, chest pain, shortness of breath, please call your
physician or go to the emergency department.
Followup Instructions:
Please see your physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on Tuesday at 1:15pm.
Please have your PT/PTT/INR drawn prior to your appointment, and
if possible, on Monday.
.
Please arrange to see your cardiologist 1-2 weeks after your
discharge
.
Provider [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2185-10-11**]
1:30
ICD9 Codes: 5990, 4280, 2859, 412, 3051, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1266
} | Medical Text: Admission Date: [**2194-12-1**] Discharge Date: [**2194-12-5**]
Date of Birth: [**2157-2-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4232**]
Chief Complaint:
overdose
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
He presented to the ED reported that he was s/p ingestion (right
prior to coming into the ED) of 12 400mg seroquels and 11 900mg
pills of trileptals. However the patient only had 600mg
trileptal pills available to him and none on his person despite
bringing in a bag of his meds.
.
In the ED, vital signs on arrival were 96.0 116 149/94 16 98%.
In the ED the patient was originally asking questions
appropriately but became increasingly somnolent. The patient was
vomiting large amounts in the ED. He was given etomidate 20mg
and succ 120mg and intubated. He received was then put on
propofol. CXR showed low lung volume, ET tube terminates at 4.9
cm above carina, NG tube terminating at appropriate location,
mild pulm vasc congestion, bibasilar opacities likely infection
vs aspiration. He received 2.5L of NS and zofran 4mg IV x1 in
the ED.
.
The pt's exam was notable for mydriasis with pupils dilated to
5mm, roving eye movements, diaphoretic, slurred speech, [**5-6**]
beats of clonus, psychomotor depression, wheezy after
intubation, mottling of the hands, poor cap refill. There was no
evidence rigidity or fevers. His EKG at 18:20 was notable for
sinus tachycardia to 117 and Qtc of 387 with QRS of 80 and then
repeat EKG at 18:50 was sinus tachycardia to 104 and Qtc of 331
with QRS 86. FS was normal at 134. CBC was unremarkable.
Electrolytes were normal. Serum tox screen was pending at the
time of transfer. Unable to place foley to get urine tox. Vitals
prior to transfer were Hr 93, BP 135/84 RR 15 100%.
.
On arrival to the ICU were 100% on AC TV 550 RR14 PEEP 5 Fio2
100%, HR 94 BP 154/96. He was awake on 60mcg/kg/min and
responding to commands. EKG was concerning for 1mm ST elevations
in v5, v6, old ST elevation in II, old j point elevation in
v2/v3. His QRS remained narrow and his QTC was 383.
Past Medical History:
Past Psych Hx:
- dx of bipolar II with psychotic features in the past- symptoms
unclear that led to that diagnosis at this time.
- cognitive d/o NOS by neuropsychological testing [**12-9**] (prior
to
TBI)
- h/o prior psychiatric hospitalizations, with "8 or 9" suicide
attempts by overdose
- h/o assaultive behavior: stabbed a friend with a penknife many
years ago (in secondary school)
PMH:
Klinefelter's, Raynaud's, Systemic sclerosis (extent uncertain,
recent dx), hypercholesterolemia, s/p pedestrian vs. car
accident in [**1-8**] with TBI
Social History:
Per OMR: Mr. [**Known lastname 67595**] reported in previous psych notes that he has
h/o etoh abiue. Between the ages of 19 and 21 he reported
drinking 2 pints of scotch or vodka per day. [**2193-10-1**] 3 to 6
times per week, drinking a six pack of beer at each use." He
also reported a history of marijuana use. The period of
heaviest usage was between the ages of 19 and 21. He stopped
using marijuana because of its side effects such as paranoia.
[**Year (4 digits) **] h/o of IVDU and cocain in past notes but urine and serum
tox positive for methadone in [**11-9**]. H/o stabbing friend with
[**Name2 (NI) **]. After graduating high school, he worked for one year as a
prep cook, he then works at a farm, and later at [**Company 25282**]
pharmacy.
.
Family History:
His father and two aunts (paternal and maternal) have a history
of depression. This maternal aunt also has a history of alcohol
abuse.
Physical Exam:
On admission:
VS: T96.4 BP 154/96 RR18 95% on AC TV 550 RR14 PEEP 5 Fio2 100%
GEN: awake and arousable, able to squeeze hands and follow
commands
HEENT: Pupils dilated to 5 and reactive to 3, EOMI grossly,
anicteric, MMM, op, intubated
RESP: CTA b/l with good air movement throughout anteriorly
CV: RRR nl s1/s2 no m/r/g
ABD: +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: + poor cap refill in right hand and doppler but not
palpable right radial pulse, left radial pulse +1
NEURO: Pupils responsive to light bilaterally 5mm -> 3mm. Able
to squeeze hands when initially awake. 10+ beats of clonus
bilaterally in feet.
On discharge:
VS: 96.0 140/P 79 16 94% RA
GEN: NAD, AOx3, awake and alert
HEENT: anicteric, MMM, op clear, CN II-XII grossly intact
RESP: CTAB, no crackles or wheezes
CV: RRR nl s1/s2 no m/r/g
ABD: +b/s, soft, nt, nd, no hsm
EXT: wwp, no c/c/e, + poor cap refill in right hand and doppler
but not palpable right radial pulse, left radial pulse +1
Pertinent Results:
[**2194-12-1**] 10:42PM GLUCOSE-153* UREA N-13 CREAT-0.8 SODIUM-140
POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-30 ANION GAP-13
[**2194-12-1**] 10:42PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2194-12-1**] 10:09PM TYPE-ART PO2-250* PCO2-53* PH-7.33* TOTAL
CO2-29 BASE XS-1 -ASSIST/CON INTUBATED-INTUBATED
[**2194-12-1**] 06:35PM GLUCOSE-127* UREA N-14 CREAT-0.8 SODIUM-141
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-28 ANION GAP-17
CXR [**12-1**]:
IMPRESSION:
1. Endotracheal and nasogastric tubes in appropriate position.
2. Low lung volumes. Possible mild pulmonary vascular
congestion. Bibasilar opacities could be due to pneumonia and/or
aspiration
Tib/fib xray [**12-4**]:
Patient is status post internal fixation of the right tibia.
There is no
evidence of hardware fracture or loosening. Again identified is
an oblique
fracture of the mid shaft of the tibia with mature bridging bone
along the
lateral aspect of the tibial fracture and no significant callus
formation
along the medial aspect of the tibial fracture, unchanged. The
proximal
fibular fracture line is still seen, unchanged. There is diffuse
osteopenia.
No new fractures are identified.
IMPRESSION:
No significant change when compared to prior exam.
Brief Hospital Course:
P: 37 yo male with h/o raynauds, HL, suicide attempt, and etoh
abuse who presents with suicide attempt likely with trileptal
and seroquel but also the potential for other medications being
involved given was incorrect about doses when speaking with ED
doctors. EKG also notable for new 1mm ST elevation in v5 and v6.
.
Overdose: Pt reported over dose with seroquel and trileptal on
arrival to the ED although he was incorrect about the doses of
the medications and brought a seroquel bottle but not a
trilpetal bottle with him to the ED. The additional medications
he brought with him included: sertraline, lexapro, abilify,
trazodone, nifedipine, naltrexone, and lipitor. Tox screen was
notably negative for ASA, EtOH, Acetminophen, Benzo,
Barbituates, and Tricyclics. Both Seroquel and Trileptal can
cause CNS depression and are unlikely to cause aggitation. QRS
and QTc were normal.
Toxicology saw the patient and on the basis of possible
trileptal and seroquel overdose recommended to avoid
antipsychotics for acute aggitation and instead using benzos,
serial EKGs q4-6 hours to monitor for prolonged QTc, and
monitoring electrolytes as Tripelptal can cause mild
hyponatremia. All EKGs and electrolytes remained normal.
.
Respiratory acidosis and ? Aspiration PNA: Pt intubated for
airway protection in the setting of decreased mental status and
in the setting of large volume emesis and likely aspiration. ABG
with respiratory acidosis 7.33/53/250 with component of acute on
chronic co2 retention. Bicarb was 28. She was started on ARDS
net ventilation, and FiO2 was quickly decreased. CXR on the
second hospital day showed L consolidation and effusion,
consistent with aspiration.
.
Depression with suicidality: All psychiatric medications were
held given concern for overdose while in MICU. On awakening,
patient wrote that he wanted to kill himself. Psychiatry was
consulted. Patient was transferred to medical floor after being
extubated for observation and then was deemed medically clear
for transfer to inpatient psych floor.
.
ST elevations: 1mm in II (old) and 1mm in v5 and v6, old j point
elevation in v2 and v3. There is no reason that the meds he took
should cause ST elevations unless cocaine involved. Cocaine
screen was negative. Cardiac ischemia was thought very
unlikely.
.
Etoh abuse history: He was initially on a midazolam gtt and CIWA
after extubation, showed no signs or symptoms of withdrawal, was
taken off CIWA on medical floor. He was given thiamine, folate,
MVI.
.
Mottling on arms in ED and delayed cap refill: Pt with baseline
Raynaud's disease. On admission he had palpable radial pulse on
left and a dopplerable pulse with delayed cap refill on the
right.
.
HL: Lipitor continued
.
Bipolar II: Held home psych meds until transfer to medical
floor. Restarted seroquel, trazodone and sertraline at
outpatient doses, restarted trileptal at 300 mg [**Hospital1 **] per psych
recs. Patient will be transferred to an inpatient psych unit for
further management.
.
Urinary obstruction, unable to place foley: Pt with 800 cc
urinary retention and difficult foley placement. Urology was
consulted, found a stricture, and placed foley. They recommended
instilling 400 cc into the bladder prior, which was done and he
was able to void.
.
S/p tib/fib fracture: Stable since [**Month (only) 1096**] of last year, got
inpatient Xray which was initially scheduled as outpatient,
showed no significant change in fibula fracture. Per ortho, he
should be non weight bearing on the R leg and will follow up as
needed.
Medications on Admission:
Sertraline 100mg 2.5 tabs qam
lexapro 20 mg daily
abilify 5mg [**Hospital1 **]
trazodone 100mg qhs
nifedipine 60mg daily
naltrexone 50mg daily
lisinopril 20mg daily
lipitor 10mg daily
seroqeul 25mg 1 tab TID prn agitation
seroquel 300mg qhs
protonix 40mg daily
ducosate 100mg [**Hospital1 **]
calcium + vit D
-trileptal (had in med list but no bottle here)
Discharge Medications:
1. sertraline 50 mg Tablet Sig: Five (5) Tablet PO DAILY
(Daily). Tablet(s)
2. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. quetiapine 100 mg Tablet Sig: Four (4) Tablet PO QHS (once a
day (at bedtime)).
6. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
7. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
Bipolar disorder II
Secondary:
hyperlipidemia
Raynaud's disease
systemic sclerosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital for an overdose of your
medications, for this you were in the intensive care unit and
intubated, but your breathing function recovered. After
discharge, you will be transferred to an inpatient psychiatry
unit for further management of your bipolar disorder and your
medications.
Changes to your medications:
Start taking trileptal 300 mg twice a day (decreased dose)
Followup Instructions:
You will be transferred to an inpatient psychiatry unit for
further management of your bipolar disorder.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**]
Completed by:[**2194-12-5**]
ICD9 Codes: 5070, 2762, 5119, 2720, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1267
} | Medical Text: Admission Date: [**2180-10-7**] Discharge Date: [**2180-10-11**]
Date of Birth: [**2133-1-12**] Sex: F
Service: OMED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9871**]
Chief Complaint:
Severe back pain
Major Surgical or Invasive Procedure:
Removal of portacath
Femoral line
Pressor support
History of Present Illness:
47F with breast cancer metastatic to bone, breast, and lung,
status post multiple rounds of chemotherapy complicated by
herceptin-induced cardiomyopathy with Serratia
hypotension/sepsis. Patient presented to the Emergency
department with severe back pain unlike previous back pain due
to metastatic lesions, refractory to Vicodin. As patient was
being worked up in ED for spinal cord compression, patient
became extremely hypotensive to systolic blood pressures to
70s-80s. Patient was administered 4 liters of IV fluid bolus and
was transferred to the [**Hospital Unit Name 153**] where she was maintained on Levophed
and Vasopressin with SBP in 100s (MAPs 58-83). Patient was felt
to be in bacterial sepsis and empirically started on vancomycin
and ceftriaxone which was later changed to ceftazidime and
ciprofloxacin when blood cultures were positive for gram
negative rods X [**3-1**].
Patient denies previous history of sepsis, has never been on
TPN, has no history of urinary tract infections, and has had
this porta cath since [**2179-4-27**]. In addition, patient complains
of history of loss of right hand dexterity over the last year,
with tingling in the fingertips of both hands, which she feels
started when she began taking Decadron. Otherwise, she denies
any asymmetric weakness or paresthesias.
Past Medical History:
1) Pulmonary embolism [**2180-6-27**], anticoagulated on Coumadin
(target INR [**2-29**])
2) Breast Cancer
3) Hypertension
4) Depression
5) S/P tonsilectomy
6) Cardiomyopathy due to Herceptin toxicity - Ejection fraction
<20%
Social History:
Patient lives at home with husband and three children, aged 22,
19, and 16.
- Denies tobacco use
- Drinks alcohol only occasionally
Family History:
Uncle: Liver cancer
Aunt: [**Name (NI) **] Tumor
Uncle: Congestive [**Name (NI) 3495**] Failure/Coronary artery disease
Father: alive and well
Mother: multiple cerebrovascular accidents
Physical Exam:
VS. T99F P85 BP110/52 (MAP71) RR20 95%
General: Pleasant, mildly obese woman in no acute distress
HEENT: NCAT. PERRL, EOMI, OMM, no lesions, no thrush.
Neck: supple, no cervical lymphadenopathy, no JVD.
CV: normal S1, S2, regular rate and rhythm, no murmurs, rubs, or
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales or
rhonchi.
Abdomen: Bowel sounds present, nontender, nondistended, no
rebound or guarding.
Extremities: no pitting edema
Neuro: Alert and oriented X 3
- CNII-XII intact
- Strength 5/5 all extremities except right
- Reflexes 1+ throughout, symmetric, Negative for clonus.
- Sensation light touch intact throughout.
Pertinent Results:
[**2180-10-7**] 11:00PM GLUCOSE-195* UREA N-11 CREAT-0.3* SODIUM-134
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-20* ANION GAP-13
[**2180-10-7**] 11:00PM CALCIUM-8.1* PHOSPHATE-1.9* MAGNESIUM-2.5
IRON-69
[**2180-10-7**] 11:00PM calTIBC-225* FERRITIN-1437* TRF-173*
[**2180-10-7**] 11:00PM HCT-27.7*
[**2180-10-7**] 11:00PM PT-15.1* PTT-33.2 INR(PT)-1.4
[**2180-10-7**] 11:08AM PO2-98 PCO2-32* PH-7.43 TOTAL CO2-22 BASE
XS--1
[**2180-10-7**] 11:08AM K+-3.5
[**2180-10-7**] 11:08AM freeCa-1.05*
[**2180-10-7**] 11:00AM GLUCOSE-102 UREA N-15 CREAT-0.5 SODIUM-135
POTASSIUM-3.5 CHLORIDE-104 TOTAL CO2-21* ANION GAP-14
[**2180-10-7**] 11:00AM ALT(SGPT)-39 AST(SGOT)-29 ALK PHOS-40
AMYLASE-48 TOT BILI-1.1
[**2180-10-7**] 11:00AM LIPASE-29
[**2180-10-7**] 11:00AM ALBUMIN-3.1* CALCIUM-7.0* PHOSPHATE-2.8#
MAGNESIUM-1.2*
[**2180-10-7**] 09:43AM LACTATE-2.4*
[**2180-10-7**] 05:13AM LACTATE-3.3*
[**2180-10-7**] 04:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-6.0 LEUK-NEG
[**2180-10-7**] 04:50AM URINE RBC-0 WBC-0 BACTERIA-RARE YEAST-NONE
EPI-0
[**2180-10-7**] 02:20AM GLUCOSE-92 UREA N-20 CREAT-0.5 SODIUM-138
POTASSIUM-3.0* CHLORIDE-105 TOTAL CO2-22 ANION GAP-14
[**2180-10-7**] 02:20AM WBC-3.1*# RBC-3.41* HGB-10.6* HCT-30.5*
MCV-90 MCH-31.3 MCHC-34.9 RDW-16.7*
[**2180-10-7**] 02:20AM NEUTS-61 BANDS-16* LYMPHS-19 MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-3* MYELOS-0
[**2180-10-7**] 02:20AM HYPOCHROM-1+ ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL OVALOCYT-OCCASIONAL
[**2180-10-7**] 02:20AM PLT COUNT-81*
[**2180-10-7**] 02:20AM PT-24.3* PTT-150* INR(PT)-3.7
------------------
[**2180-10-7**] 4:35 am BLOOD CULTURE
**FINAL REPORT [**2180-10-9**]**
AEROBIC BOTTLE (Final [**2180-10-9**]):
REPORTED BY PHONE TO [**Last Name (LF) **] , [**First Name3 (LF) **] AT 10PM [**2180-10-7**].
SERRATIA MARCESCENS. FINAL SENSITIVITIES.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy..
Therefore, isolates that are initially susceptible may
become
resistant within three to four days after initiation of
therapy.
For serious infections, repeat culture and sensitivity
testing may
therefore be warranted if third generation
cephalosporins were
used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
SERRATIA MARCESCENS
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
GENTAMICIN------------ <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC BOTTLE (Final [**2180-10-9**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], @ 10PM [**2180-10-7**].
SERRATIA MARCESCENS.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC
BOTTLE.
[**2180-10-7**] 4:50 am URINE
**FINAL REPORT [**2180-10-8**]**
URINE CULTURE (Final [**2180-10-8**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Radiology Reports:
MRI Spine:
1. Findings indicative of metastatic focus in L2 vertebra
described by the recent bone scan of [**2180-8-2**].
2. Heterogeneous marrow signal in L1 vertebra indicative of
previous history of metastasis to this area.
3. No acute compression fracture or area of new pathologic
fracture.
4. No evidence of high grade thecal sac compression, or
compression of the distal spinal cord.
---
Chest X-Ray:
FINDINGS: Lung volumes are low. The heart size and pulmonary
vasculature are within normal limits. A Port-A-Cath device has
its tip in the central most SVC. There are no pleural effusions.
The previously identified right lower lobe mass lesion is again
identified and unchanged. There is overall no significant change
from the previous exam. The lungs are clear without evidence of
consolidation.
IMPRESSION: No radiographic evidence for pneumonia.
Brief Hospital Course:
47F with metastatic breast cancer and herceptin-induced
cardiomyopathy, now with Serratia hypotension/sepsis.
1) Sepsis: Patient had porta-cath removed by general surgery on
hospital day 2, and was weaned off pressors by hospital day 3.
Wound culture and gram stain yielded no organisms. Tip culture
was not performed. By hospital day 4, blood cultures speciated
Serratia with a high possibility of developing resistance to
third generation cephalosporins, and so antibiotics were changed
to ciprofloxacin and cefepime, and vancomycin was discontinued.
Patient continued to be hemodynamically stable without pressor
support, was afebrile, in no acute pain and was felt to be
stable for the floor on hospital day 4.
Infectious disease was briefly consulted with regard to the
organism and treatment course. Consultants advised that single
therapy with a third generation cephalosporin should be avoided
given the theoretical possibility of inducible beta-lactamase.
Therefore, it was recommended that patient be initiated on a
course of oral levofloxacin to continue treatment as outpatient.
Patient continued to be hemodynamically stable and afebrile and
was discharged home with a course of oral levofloxacin and to
return to clinic a week following discharge.
2) Anticoagulation: Patient had had a history of pulmonary
embolism in [**2180-6-27**] for which she is chronically
anticoagulated. However, patient's coumadin was held in order
to allow removal of the portacath. Following stabilization in
the [**Hospital Unit Name 153**] on day 3, coumadin therapy was reinitiated.
Consideration was given to decreasing patient's dose of coumadin
given her antibiotic therapy, however, at the time of discharge,
patient's INR was 1.6, and it was felt that patient would likely
reach therapeutic range during the week before returning to
clinic. Patient was instructed to follow up with oncology for
continued monitoring of anticoagulation.
3) Breast Cancer: Given patient's acute clinical instability,
chemotherapy (scheduled weekly carboplatin) was deferred.
Patient was to return to clinic for evaluation for chemotherapy
a week following discharge.
At the time of discharge, patient was in excellent clinical
condition with only complaints of mild back pain (which she
attributed to the hospital bed). She was instructed to continue
taking levofloxacin for 10 days following discharge, to continue
taking all of her outpatient medications except for
antihypertensives, and to follow up with her oncologist a week
following discharge.
Medications on Admission:
1) Vicodin
2) Protonix
3) Lisinopril
4) Effexor
5) Warfarin,
6) Toprol
7) Lasix
8) Ativan
9) Decadron
Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO at bedtime as
needed for insomnia.
2. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
4. Effexor 75 mg Tablet Sig: 1.5 Tablets PO once a day.
5. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. Dexamethasone 6 mg Tablet Sig: One (1) Tablet PO once a day.
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO once a day.
8. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day: For constipation while taking vicodin.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Bacterial sepsis
Breast Cancer
Discharge Condition:
Good
Discharge Instructions:
1) Continue taking the following medications:
- Levofloxacin (antibiotic) 500mg by mouth daily for 10 days.
- Coumadin 5mg by mouth once daily
- Effexor 112.5mg by mouth once daily
- Decadron 6mg once daily
- Protonix 40mg once daily
- Lorazepam 0.5-1mg as needed for agitation or sleep
- Vicodin 1-2 tablets every 4-6hours for pain
- Docusate 100mg twice a day (stool softener)
Do not take Toprol or Lisinopril until you see Dr. [**Last Name (STitle) 2036**]
2) Call your doctor or come to the emergency room if you start
having severe pain, fever, chills, shortness of breath, or chest
pain.
Followup Instructions:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], RN Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2180-10-18**] 9:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3260**], [**MD Number(3) 3670**]: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2180-10-19**] 9:00
Provider: [**Name Initial (NameIs) 4426**] 19 Date/Time:[**2180-10-18**] 9:00
ICD9 Codes: 4280, 2761, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1268
} | Medical Text: Admission Date: [**2193-5-6**] Discharge Date: [**2193-5-7**]
Date of Birth: [**2128-4-22**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
unresponsiveness
Major Surgical or Invasive Procedure:
mechanical ventilation
History of Present Illness:
65yo M h/o HTN, DM, CAD s/p CABG [**2189**], Afib on coumadin who went
to church in his usual state of health this morning but was
found down Sunday evening at 8:30pm by his wife, unresponsive
with mild shaking of his body. The patient was taken to an OSH
where a large right ICH was found with extension into the
ventricles with associated left midline shift and subfalcine
herniation.
At [**Location (un) 620**], he received vitamin K, 2 units of FFP and mannitol.
In our ED, he received dilantin 1g IV x 1, mannitol 250mg bolus
x 2, profilnine 2 vials.
Past Medical History:
hypertension
diabetes
coronary artery disease s/p CABG 3yrs ago on coumadin
mild chronic obstructive pulmonary disease
Social History:
lives at home with wife; occ smoker, nonETOH drinker
Family History:
noncontributory
Physical Exam:
T:97 BP: 157/93/ HR:116 R 16 O2Sats 98%
Gen: unresponsive, intubated and sedated.
HEENT: Pupils: equally round at 6mm, nonreactive; + corneal
reaction bilat; No doll eye movement; EOMs full
Neck: supple
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft.
Neuro:
Mental status: nonresponsive, intubated and sedated.
Cranial Nerves:
I: Not tested
II: Pupils equally round equally round at 6mm, nonreactive.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. No withdrawal of extremities to noxious bilaterally.
Sensation: no grimace to noxious stimuli.
Reflexes: diminished bilaterally.
Toes upgoing bilaterally
Pertinent Results:
Labs:
[**2193-5-6**]
CBC: WBC-21.0* RBC-4.55* Hgb-14.1 Hct-41.3 MCV-91 MCH-31.0
MCHC-34.2 RDW-14.9 Plt Ct-200
Diff: Neuts-92.2* Bands-0 Lymphs-4.6* Monos-2.6 Eos-0.3 Baso-0.2
Coags: PT-18.9* PTT-23.5 INR(PT)-1.8*
Chem: Glucose-200* UreaN-25* Creat-1.0 Na-139 K-4.4 Cl-102
HCO3-26 AnGap-15 Calcium-9.8 Phos-4.3 Mg-2.5
STox: ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
ABGs:
[**2193-5-7**] 03:47AM pO2-75* pCO2-61* pH-7.31* calTCO2-32* Base XS-1
[**2193-5-7**] 06:08AM pO2-75* pCO2-38 pH-7.45 calTCO2-27 Base XS-2
Other:
CK-MB-5 CK(CPK)-113 cTropnT-0.01
[**2193-5-7**] Coags: PT-15.8* PTT-27.7 INR(PT)-1.4*
Ucx negative
Bcx, sputum cx NGTD
Imaging:
CT OSH [**2193-5-5**]: large right intraparenchymal hemorrhage, tracking
into ventricles, with leftward MLS 17mm and subfalcine
herniation; possible brain stem hemorrhage as well.
Brief Hospital Course:
65yo man with PMH significant for HTN who presents with large
intracerebral hemorrhage with intraventricular extension
admitted with signs of herniation. His neurologic exam on
admission was notable for coma with loss of pupillary and
oculocephalic reflexes, with preserved corneal and gag reflexes.
Options were discussed with the family and it was determined (in
conjunction with the neurosurgery service) that surgical
intervention was not desired. He was admitted to the neurology
ICU. The patient's ICU course was complicated by probable
development of DI, with urine output of one liter over one hour.
He received treatment with DDAVP and fluid replacement. In the
meantime, deliberations continued among the family about goals
of care and whether to initiate comfort measures. Family
meetings involving the patient's wife, sons, as well as other
relatives and friends, took place involving the house staff,
social worker, and nurse.
On [**2193-5-7**] in the morning, Mr. [**Known lastname 73345**] was noted to have a
rapidly falling blood pressure. He was started on multiple
pressors but was not able to regain a viable blood pressure.
Within approximately 30 minutes, he had a cardiac arrest and
died. His son was at the bedside. The rest of the family was
called. His wife declined autopsy.
Medications on Admission:
Diltiazem 30 QID
Lipitor 40
Isordil 30
Coumadin 7.5mg daily
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Intracerebral hemorrhage with intraventricular extension
Likely brain herniation
Cardiac arrest
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
ICD9 Codes: 431, 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1269
} | Medical Text: Admission Date: [**2191-11-10**] Discharge Date: [**2191-11-19**]
Date of Birth: [**2118-4-25**] Sex: M
Service: Cardiothoracic Surgery
CHIEF COMPLAINT: Patient admitted to [**Hospital6 649**] post cardiac catheterization and pre-coronary
artery bypass grafting.
HISTORY OF PRESENT ILLNESS: 73-year-old man with known
coronary artery disease and hypertension as well as diabetes
who was transferred to [**Hospital6 256**]
from an outside hospital for cardiac catheterization as well
as presumed primary PTCA intervention.
The patient was in his usual state of health until two to
three days ago when he began experiencing indigestion which
spread to both arms and increased in intensity, associated
with diaphoresis and shortness of breath. He presented to
the outside hospital and was found to have ST elevations in
2, 3 and F. He was given Nitroglycerin, heparin and Morphine
as well as 2B3A infusion and transferred to [**Hospital6 1760**] for cardiac catheterization.
Please see catheterization report for full details and
summary. At catheterization, the patient was found to have
80% left main disease, the left anterior descending artery
with a 70% and the circumflex with a 70% lesion. He had a
PTCA of the first obtuse marginal with a good result. Post
intervention EKG showed ST depression and lessening of his ST
elevation. He was then transferred to the CCU for further
care.
PAST MEDICAL HISTORY: 1. Diabetes mellitus, type 2.
2. Hypertension. 3. Hernia repair x2. 4. Cerebrovascular
accident. 5. Right total knee replacement.
MEDICATIONS PRIOR TO ADMISSION: Hydrochlorothiazide,
aspirin, Glucophage, Losartan and Neurontin.
ALLERGIES: Percocet and Valium, both of which cause itching.
SOCIAL HISTORY: Lives at home by himself. He has a wife who
lives in [**Hospital3 **]. He denies alcohol use. Is a
current smoker.
PHYSICAL EXAMINATION:
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2191-11-18**] 10:14
T: [**2191-11-18**] 10:46
JOB#: [**Job Number 44601**]
ICD9 Codes: 5180, 2762, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1270
} | Medical Text: Admission Date: [**2149-11-6**] Discharge Date: [**2149-11-14**]
Date of Birth: [**2097-6-20**] Sex: F
Service: MEDICINE
Allergies:
Bactrim Ds / Cellcept
Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
Septic Shock
Major Surgical or Invasive Procedure:
Central Line Placement
Hemodialysis
History of Present Illness:
Ms. [**Known lastname 6357**] is a 52 year old woman w/ ESRD from SLE s/p
cadaveric renal transplant in [**2146**] which was complicated by FSGS
and transplant failure [**8-6**] now on hemodialysis who was
recently treated for CMV viremia in the setting of C. difficle
colitis, admitted with fever and hypotension from rehab.
History per patient supplemented with I.D.: The [**Month (only) **]
admission was complicated by CMV viremia and C. diff colitis.
She was discharged on IV ganciclovir (120mg IV daily), which was
to continue until she had two negative CMV virals loads
separated by one week's time. She finished IV ganciclovir
treatment course and was transitioned to oral valganciclovir
suppression. Suppression therapy was discontinued on [**10-10**] due
to neutropenia (wbc 1.8, plt 59). Per [**Name (NI) **], pt had an interim
hospitalization of a few days for septic shock in mid-[**Month (only) 359**],
requiring pressors, details of which are unclear, which pt did
not clearly confirm or deny.
On [**10-27**] pt began having fevers. A CMV viral load was rechecked
(970) and repeat VL of 4059 on [**11-2**]. It is unclear when
ganciclovir was restarted, but by [**11-2**], she was on ganciclovir
with HD dosing. She began to complain of dizzines and visual
disturbances. Then, still with fevers, she became hypotensive on
[**11-6**] without a localizing source of infection. She complained
of some mild abdominal pain. She was transferred to [**Hospital1 **] for
further management. In the ED, she had a temp to 100.3, bp 85/48
so levophed was started and she was transferred to the MICU.
Past Medical History:
-ESRD s/p cadaveric renal transplant in [**2146**] complicated by FSGS
and transplant failure [**8-6**] now on HD
-SLE, followed by Dr.[**Last Name (STitle) **] in Rheumatology
-Paroxysmal atrial fibrillation
-NSVT
-Hypertension
-Hyperthyroidism
-s/p bilateral knee surgeries and R ACL repair
Social History:
Single, lives with sister's family in [**Location (un) 686**]. Denies
tobacco, ETOH, and drugs.
Family History:
Mother and brother both with diabetes and [**Name (NI) 2091**], both deceased.
Physical Exam:
V/S: T 98 BP 117/63 HR 87 RR 17 02sat 98% on room air
GEN: AAOx3, NAD, Pleasant
HEENT: Moon facies, no oral ulcers, MMM, supple, no LAD, no JVP
CARDIAC: rrr, no m/r/g, referred fistula bruit at LUSB
LUNGS: CTAB a/p
ABDOMEN: bowel sounds present, soft, obese, nontender,
nondistended; mass in RLQ; no HSM.
EXT: Warm, well-perfused. Dp pulses difficult to palpate through
lower extremity and pedal edema. No cyanosis or clubbing.
Striated UE bilaterally with loose adipose. Left upper extremity
with raises, scarred fistula tract. Left hand with swan neck
deformities.
NEURO: cn 2-12 intact, [**4-1**] upper arm (prox + dist) strength, [**1-2**]
LE strength, bilaterally
DERM: no rashes
Pertinent Results:
[**2149-11-6**] 01:51PM BLOOD WBC-9.3# RBC-3.41* Hgb-9.6* Hct-32.1*#
MCV-94 MCH-28.0 MCHC-29.7* RDW-17.8* Plt Ct-119*
[**2149-11-6**] 01:51PM BLOOD Neuts-76* Bands-7* Lymphs-3* Monos-9
Eos-0 Baso-0 Atyps-0 Metas-4* Myelos-1*
[**2149-11-6**] 01:51PM BLOOD PT-14.0* PTT-29.7 INR(PT)-1.2*
[**2149-11-6**] 01:51PM BLOOD Glucose-124* UreaN-12 Creat-4.9* Na-142
K-4.6 Cl-108 HCO3-24 AnGap-15
[**2149-11-6**] 01:51PM BLOOD ALT-11 AST-16 LD(LDH)-336* CK(CPK)-10*
AlkPhos-58 TotBili-0.2
[**2149-11-6**] 01:51PM BLOOD Albumin-2.4* Calcium-7.8* Phos-2.6*
Mg-1.5*
[**2149-11-12**] CBC WBC-2.9 RBC-2.77 Hgb-8.2 Hct-27.0 MCV-98 MCH-29.4
MCHC-30.2 RDW-17.9 Plt Ct-126
[**2149-11-12**] PT-12.4 PTT-29.0 INR(PT)-1.0
[**2149-11-11**] K-2.8
[**2149-11-12**] Glucose-79 UreaN-19 Creat-4.7 Na-144 K-3.9 Cl-107
HCO3-30 AnGap-11
MICROBIOLOGY
1) CMV Viral Load (Final [**2149-11-8**]):
CMV DNA not detected
2) DIRECT INFLUENZA A ANTIGEN TEST (Final [**2149-11-7**]):
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2149-11-7**]):
Negative for Influenza B.
3) [**11-8**] and 13: Feces negative for C.difficile toxin A & B
by EIA.
4) CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2149-11-11**]):
Feces negative for C.difficile toxin A & B by EIA.
5) Stool culture negative for Campylobacter, Shigella,
Salmonella, Enteric gram negative rods, viruses (Final [**2149-11-13**])
6) BK virus PCR pending
RADIOLOGY
CXR
The cardiac, mediastinal, and hilar contours are unremarkable.
Except for right perihilar linear opacity, likely representing
atelectasis, the lungs are clear without focal consolidation. No
pleural effusion or pneumothorax is seen. The osseous structures
demonstrate no acute skeletal abnormalities.
KUB
There is no evidence of free air. There is no evidence of
obstruction. There is no evidence of gas within the bowel wall.
CT ABD and PELVIS
1. Uncomplicated sigmoid diverticulitis. No evidence of abscess
formation or perforation.
2. Dilated main pancreatic duct worsened since [**2147-9-28**].
This might represent a segmental main duct IPMN (intraductal
papillary mucinous neoplasm). Consultation with the Pancreas
Center at [**Hospital1 18**] is recommended for further workup.
3. Unchanged right anterior abdominal wall seroma.
4. Transplanted kidney shows decreased enhancement consistent
with history of evolving transplant failure. There is slightly
increased perinephric stranding, but no evidence of abscess or
acute infection.
Repeat CXR:
Compared to AP single view CXR on [**2149-11-6**]. Previously
identified right internal jugular approach central venous line
remains in unchanged position terminating overlying the SVC 2 cm
below the carina. No pneumothorax is present. The pulmonary
vasculature is not congested and the heart size has not
increased. New, however, is a density occupying the left lower
lobe basal portion and obliterating the diaphragmatic contours,
most likely representing a new retrocardiac atelectasis, not
identified on the next previous study of [**11-6**]. In the
right mid lung field, a plate atelectasis is seen, but appears
as before. No other new abnormalities are seen.
IMPRESSION: Development of sizeable left lower lobe atelectasis
in
retrocardiac position.
RENAL U/S [**2149-11-11**]:
FINDINGS: The transplant kidney is again seen in the right lower
quadrant and it measures 12.1 cm in length. There is no
hydronephrosis and no perinephric fluid collection is
identified. No cyst or stone or solid mass is seen in the
transplant kidney.
Within the superficial tissues a heterogeneous mass is again
identified previously presumed to be a hematoma. This structure
is unchanged in size and appearance from the prior ultrasound of
[**2149-7-30**] measuring about 11 cm in its widest diameter.
DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images
were obtained. Note is made that the Doppler images were limited
by the patient's body habitus. Appropriate venous flow is seen
within the main renal vein. Limited views of the main renal
artery demonstrate appropriate acceleration times. Mildly
elevated resistive indices are seen in the intraparenchymal
arteries.
IMPRESSION:
1. Somewhat limited Doppler exam demonstrating essentially
appropriate transplant vasculature.
2. No hydronephrosis or collections identified.
3. Similar size and appearance of the subcutaneous hematoma in
the right lower quadrant.
ECHO [**2149-11-12**]:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The estimated cardiac
index is normal(>=2.5L/min/m2). Right ventricular chamber size
and free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets(3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion. Compared with the prior study (images reviewed) of
[**2149-8-6**], the severity of mitral regurgitation is reduced (but
was only mild on review of the prior study).
Brief Hospital Course:
#Septic shock - Admitted to the MICU and treated with
vasopressor therapy, stress-dose steroids, and empiric PO
vancomycin, IV vancomycin, IV zosyn and IV gancyclovir. CT
abd/pelvis showed uncomplicated sigmoid diverticulitis. All
other culture data and infectious workup (including c. diff
toxin negative x 3) was unrevealing as to another source of
infection. Due to asymptomatic relative hypotension after
transfer to the medical floor, midodrine was started with
improvement in blood pressure. Metoprolol was discontinued due
to hypotension.
.
#Pancytopenia - Counts remained stable off of zosyn. Tacrolimus
was decreased to 2 mg [**Hospital1 **].
.
#Renal transplant c/b graft FSGS and ESRD on HD - Continued
usual schedule of HD TuThSa. Prednisone tapered from stress-dose
to 10 mg daily. Tacrolimus dose decreased as above.
.
#CMV viremia: Will continue IV ganciclovir pending CMV viral
load results (sent [**11-14**]).
#Hyperglycemia: Attributed to corticosteroid therapy.
Well-controlled on basal and sliding scale insulin.
.
#Paroxysmal atrial fibrillation: In sinus rhythm on discharge.
CHADS2 score of 1 so continued aspirin 325 mg.
#Anemia of chronic kidney disease: Continued erythropoeitin and
zemplar with HD.
Medications on Admission:
1. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain: not to exceed 4g tylenol per
day.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
5. Petrolatum Ointment Sig: One (1) Appl Topical TID (3
times a day) as needed for for dry skin.
6. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for constipation.
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
8. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
9. Insulin Glargine 100 unit/mL Cartridge Sig: Two (2) units
Subcutaneous at bedtime.
10. Insulin Lispro 100 unit/mL Cartridge Sig: as per sliding
scale as per sliding scale Subcutaneous qACHS.
14. Prednisone 5 mg Tablet DAILY
15. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H 16.
Ganciclovir 110 mg IV Q24H Start: In am
Give after HD on dialysis days
17. Atovaquone 750 mg/5 mL Suspension Sig: Two (2) PO DAILY
(Daily).
18. Tacrolimus 4.5 mg [**Hospital1 **]
Lactobacillus
ASA 325
Nephrocaps
Erythropoetin 15,000U QHD
Magnesium Oxide 200mg [**Hospital1 **]
.
MEDICATIONS ON TRANSFER:
Ganciclovir 110 mg IV QHD Day 1= [**11-2**]
Vancomycin 1000 mg IV HD PROTOCOL Day 1 = [**11-6**]
Piperacillin-Tazobactam 2.25 g IV Q 12H Day 1 = [**11-7**]
Tacrolimus 4.5 mg PO Q12H
Hydrocortisone Na Succ. 100 mg IV Q8H
Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose
Order
Aspirin 325 mg PO/NG DAILY
Nephrocaps 1 CAP PO DAILY
Atovaquone Suspension 1500 mg PO/NG DAILY
Pantoprazole 40 mg PO Q24H
Heparin 5000 UNIT SC TID
Discharge Medications:
1. Atovaquone 750 mg/5 mL Suspension Sig: Ten (10) mL PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 2 days: through [**11-16**].
Disp:*2 Tablet(s)* Refills:*0*
7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 2 days: through [**11-16**].
Disp:*6 Tablet(s)* Refills:*0*
8. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
9. Ganciclovir Sodium 500 mg Recon Soln Sig: One Hundred-Ten
(110) mg Intravenous QHD (each hemodialysis): Please continue
ganciclovir 110 mg IV QHD until instructed to discontinue this
medication by the patient's infectious disease physicians (after
CMV viral load sent [**11-14**] returns negative). .
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) unit
Injection TID (3 times a day).
11. transportation
please provide transportation to and from appointments
12. Insulin Glargine 100 unit/mL Cartridge Sig: Two (2) units
Subcutaneous at bedtime.
13. NPH Insulin Human Recomb 100 unit/mL Cartridge Sig: Four (4)
units Subcutaneous QAM.
14. Humalog 100 unit/mL Cartridge Sig: ASDIR units Subcutaneous
QACHS: per attached sliding scale.
15. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Ondansetron 4 mg IV Q8H:PRN nausea
17. Epogen 10,000 unit/mL Solution Sig: [**Numeric Identifier 3301**] ([**Numeric Identifier 3301**]) units
Injection QHD.
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: [**11-29**]
Tablet, Delayed Release (E.C.)s PO once a day as needed for
constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital-[**Location (un) 86**]
Discharge Diagnosis:
Septic shock
CMV viremia
Acute uncomplicated diverticulitis
End-stage renal disease on hemodialysis
Status post deceased donor kidney transplant
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
You were admitted with fever and low blood pressure, most likely
due to an infection in your large intestine called
diverticulitis. Your infection was partially treated with
antibiotics. Please continue taking the antibiotics as
prescribed through Sunday, [**11-16**].
The following medication changes were recommended:
1) Started ciprofloxacin, an antibiotic.
2) Started flagyl, another antibiotic.
3) Started midodrine, a medication to raise your blood pressure.
4) Stopped metoprolol due to low blood pressure.
5) Tacrolimus decreased to 2 mg twice daily.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2149-11-24**] 3:00
PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 3393**] as needed
Follow up with nephrologists as
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2149-12-18**] 9:40
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]
Completed by:[**2149-11-15**]
ICD9 Codes: 0389, 5856, 4271, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1271
} | Medical Text: Admission Date: [**2136-9-19**] Discharge Date: [**2136-9-26**]
Date of Birth: [**2054-4-3**] Sex: M
Service: NEUROSURGERY
Allergies:
Levaquin / Norvasc
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Carotid stenosis
Major Surgical or Invasive Procedure:
Cerebral angiogram with Left ICA stenting
History of Present Illness:
In early [**Month (only) **] Mr. [**Known lastname 48291**] felt lightheaded and had an episode of
dysarthric speech. He complained of facial numbness and was
admitted in the hospital
for three days where he was noted to have expressive aphasia.
He had CT scans which did not reveal any significant hemorrhage
or infarct. Subsequently, carotid ultrasound identified right
internal carotid artery occlusion and ICA stenosis of greater
than 70%. This was also confirmed on CTA.
He has an asymptomatic left high-grade stenosis with
contralateral occlusion. Dr. [**First Name (STitle) **] discussed the case with Dr.
[**Last Name (STitle) 112163**] and they decided that he
would be a good candidate in which a left carotid
revascularization should be attempted. Given the contralateral
occlusion, Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) **] of Vascular surgery
felt that it is safer to proceed with a carotid stenting.
Past Medical History:
He has had a recent pacemaker implantation for intermittent
high-grade AV block. This was done in late [**2136-5-1**]. Otherwise,
his past medical history is significant for coronary artery
disease with an anterior septal infarct in [**2116**], symptomatic
bradycardia, carotid artery disease, hypertension, dyslipidemia,
GERD, sleep apnea treated with nasal CPAP, polio.
Social History:
He and his wife live in [**Name (NI) 28159**]. They have three children.
He is very involved in radio broadcasting and in fact setup the
broadcasting station of [**First Name4 (NamePattern1) 805**] [**Last Name (NamePattern1) 1688**].
Family History:
NC
Physical Exam:
Pre-op:On examination, his blood pressure was 130/60. He was
awake,
alert, oriented x3. His speech was fluent. He is oriented to
person, place, and date. Pupils were equal and reactive to
light. Extraocular movements are full. His facial sensation is
normal. His facial movements were symmetric. Hearing was
diminished bilaterally. Palate elevation is symmetric.
Shoulder
shrug with good strength bilaterally. Tongue was in the midline
with no fasciculations. Motor strength was [**5-5**] in the right
upper and lower extremity. Left upper extremity strength was
0-1/5 secondary to his poliomyelitis. Left lower extremity was
[**5-5**]. There was no pronator drift. Reflexes were [**3-4**] except the
left upper extremity where no reflexes were elicited. There was
no clonus, no Hoffmann's.
At discharge: He is intermittently lethargic. His lethagry is
using when he has his CPAP in place. When awake he is oriented,
PERRL, face symmetric. LUE 0/5. LLE and RUE, RLE have full
strength. He has a Foley catheter that is required until
[**2136-10-3**]. They is some intermittent bleeding around the cathter.
Pertinent Results:
[**2136-9-19**]: cerebral angiogram: Pre-lim report
Left common carotid artery arteriogram shows filling of the left
Preliminary Report common carotid artery and the right internal
carotid artery. There is stenosis of the left internal carotid
artery with an 80% stenosis approximately 2 cm from the
bifurcation. There is a long stretch of atherosclerotic disease
with significant calcific plaque.
Left internal carotid artery arteriogram shows filling of the
left internal carotid artery, left middle cerebral artery and
left anterior cerebral artery with cross-fill into the right
hemisphere. There is no evidence of reportintracranial stenosis
or aneurysms.
Left common carotid artery arteriogram status post stenting
shows that the stenosis in the left common carotid artery is now
resolved. There is still theromatous ulcers outside the walls of
the stent; however, there is no significant stenosis in the
internal carotid artery.
EKG [**2136-9-20**]
Sinus rhythm with atrial sensing and ventricular pacing.
Compared to the
previous tracing of [**2136-9-12**] atrial pacing is no longer present.
CXR [**2136-9-22**]
Bilateral carotid stenosis and poliomyelitis with
residual left upper extremity redness, admitted for 24 hours
monitoring after left carotid stent.
Portable AP radiograph of the chest was compared to prior study
obtained a day earlier.
Heart size and mediastinum are stable. Bibasal, left more than
right
atelectasis and left pleural effusion are unchanged, except for
minimal
questionable progression on the left. No pneumothorax is seen
[**2136-9-25**] LENS
No evidence of deep vein thrombosis in the either leg.
Brief Hospital Course:
Mr. [**Known lastname 48291**] presented to [**Hospital1 18**] for elective stenting of his left
ICA. The procedure was performed under general anesthesia. In
the interventional suite a Foley catheter was placed at the
start of the case, placement of the catheter was followed by
blood tinged urine was seen flowing at first and then more
bloody urine during the case with administration of heparin.
The procedure was uncomplicated and at once complete patient was
extubated and transferred to the Trauma Intensive Care unit.
The hematuria continued and his urine output decreased. Urology
was consulted and given high suspicion for false passage in
urethra, the decision made to proceed directly to flexible
cystoscopy. A 17 Fr Olympus flexible cystoscope was inserted
into the urethra and marked false pass was noted posterior to
the true lumen at the level just distal to the external
sphincter. According to urology. presumably the initial insult
was the surgical defect at the bladder neck consistent with his
history of prior TURP. A 16 Fr Council tip Foley catheter was
placed. Urology recommended keeping the Foley catheter in place
for at least 14 days, 3 day course of fluoroquinolone, and using
2 cath-secure devices to keep Foley securely in place
Patient's urine started to clear by the following day and his
hematocrit stayed stable. On [**9-20**] patient developed two episodes
of coffee ground emesis, an NG tube was placed that put out
800cc of coffee ground gastric fluid was suctioned out. Patient
was intubated for a upper GI endoscopy. A GI consult was
obtained, he was placed on a Protonix drip and a scope was
scheduled for [**9-21**].
Endoscopy showed gastritis. He was extubated and transferred to
the stepdown unit for sleep apnea and occasional desats. He was
requiring oxygen but the same degree as at home. He was seeing
PT. They recommended rehab. He had screening LENS on [**9-25**] for
prolonged bedrest and there was no DVT. He had a moderate
amounts of blood at the meatus and urology was re consulted.
They felt that this would self resolve. He was otherwise stable
and transferred to the floor status. He was transferred to rehab
on [**2136-9-26**].
Medications on Admission:
ASA 81mg
Plavix 75 mg
Simvastatin 80 QHS
Ventolin INH
Lisinopril 20mg QD
Zetia 10mg QD
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing/sob
3. Aspirin 325 mg PO DAILY
4. Bisacodyl 10 mg PO/PR DAILY
5. Clopidogrel 75 mg PO DAILY
6. Ezetimibe 10 mg PO DAILY
7. Heparin 5000 UNIT SC TID
8. Lisinopril 20 mg PO DAILY
9. Metoprolol Tartrate 12.5 mg PO BID
hold for HR<50 or SBP<110
10. Senna 1 TAB PO BID
11. Simvastatin 80 mg PO DAILY
12. Pantoprazole 40 mg PO Q12H
13. Sucralfate 1 gm PO QID
14. Fluconazole 200 mg PO Q24H [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 6689**] - [**Location (un) 6691**]
Discharge Diagnosis:
Cartotid stenosis
Urinary retention
Meatal hemorrhage
Hypertension
Obstructive Sleep Apnea
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Angiogram with Stent placement
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Take Plavix (Clopidogrel) 75mg once daily.
-Lopressor was added to your medication regimen for BP and heart
rate control.
?????? 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.
-A cathter was placed and there was some difficulty that led to
urology placing a cathter that needs to be left in for 2 weeks.
You can follow up with our Urology department or urology near
your home/rehab. There was some bleeding around your cathter and
the urology department felt that this was not of concern and
would resolve spontaneously.
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)
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
You were entered into the FREEDOM carotid stent registry and
this requires follow up in 30 days with Dr [**First Name (STitle) **].
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7746**], MD Phone:[**Telephone/Fax (1) 3666**]
Date/Time:[**2136-10-25**] 9:45
Please call [**Telephone/Fax (1) 4296**] if you need to change this appointment.
You will need a carotid ultrasound at this time.
You need to have urology follow up after [**Month (only) 359**] third (2 weeks
after placement of cathter). We have gotten you an appointment
with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] urology clinic for voiding trial on
[**Month (only) 359**] third at 8:30 am. If you need to cancel this
appointment, the number is 67-[**Telephone/Fax (1) **]
Completed by:[**2136-9-26**]
ICD9 Codes: 412, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1272
} | Medical Text: Admission Date: [**2111-8-30**] Discharge Date: [**2111-9-8**]
Date of Birth: [**2111-8-30**] Sex: F
Service: Neonatology
HISTORY OF PRESENT ILLNESS: Baby girl [**Known lastname 3443**] is a 2575 gram
former 34 and [**7-25**] week infant born to a 40-year-old gravida
1, para 0 (now 1) mother with prenatal screens as follows; B
positive, antibody negative, rapid plasma reagin nonreactive,
Rubella immune, and hepatitis B surface antigen negative.
Estimated delivery date was [**2111-10-6**].
The prenatal course was significant for amniocentesis due to
advanced maternal age with 46 XX, history of positive
PPD, negative chest x-ray, and mild
glucose intolerance. The infant was delivered by cesarean
section due to placenta previa following unstoppable labor.
Unknown group B strep status. There was no maternal fever.
Neonatology arrived at eight minutes of life when the infant
appeared pale with mild respiratory distress and decreased
tone. Apgar scores were 7 at one minute and 7 at five
minutes. The infant was brought to the Neonatal Intensive
Care Unit for further care.
PHYSICAL EXAMINATION ON PRESENTATION: Head circumference was
32.5 cm, length was 18.75 inches, and weight was 2575 grams.
Anterior fontanel was open and flat. Pale. Normal first
heart sounds and second heart sounds. No murmurs. Mild
respiratory distress with intermittent grunting and nasal
flaring. Mild intercostal and subcostal retractions. Course
breath sounds bilaterally. The abdomen was soft, nontender,
and nondistended. Extremity examination revealed slightly
decreased perfusion. Tone was decreased initially and
subsequently improved to normal. A patent anus. The spine
was intact.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. RESPIRATORY ISSUES: Baby girl [**Known lastname 3443**] was initially given
blow-by oxygen and subsequently placed on nasal cannula for
drifting oxygen saturations. Nasal cannula was subsequently
weaned by day of life four, and she has remained on room air
since then. No apneic or bradycardic episodes.
2. CARDIOVASCULAR SYSTEM: Baby girl [**Known lastname 3443**] had an intermittent
murmur which was no longer audible at the time of discharge.
She has been hemodynamically stable after initially
receiving one normal saline bolus for transient hypotension.
3. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: Baby girl [**Known lastname 3443**] was
started on enteral feeds after resolution of respiratory
distress. She has been tolerating Enfamil 20 p.o. ad lib
since day of life four; maintaining a minimal of 120 cc/kg
per day. Her birth weight was 2575 grams, and her weight on
the day of nursery transfer was 2320 grams; weight at
discharge 2 days later was 2380 grams.
4. GASTROINTESTINAL ISSUES: Baby girl [**Known lastname 51276**] bilirubin level
peaked at 9.8 on day of life five. No phototherapy was
initiated. Minimal jaundice was noted at discharge.
5. INFECTIOUS DISEASE ISSUES: Baby girl [**Known lastname 3443**] was started on
ampicillin and gentamicin for 48 hours of rule of sepsis.
Her blood cultures remained negative after 48 hours, and
antibiotics were discontinued at that time.
6. HEMATOLOGIC ISSUES: Baby girl [**Known lastname 51276**] initial hematocrit
was 29 and subsequently 30.1 with a reticulocyte
count of 13.8% on day of life three. No transfusion was
received during her Neonatal Intensive Care Unit course. She
is receiving supplemental iron.
7. SOCIAL ISSUES: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 51277**] of the [**Hospital1 18**] Social Work
Department has been involved with the family. She can be
reached at [**Telephone/Fax (1) 51278**]. [**First Name8 (NamePattern2) 2127**] [**Last Name (NamePattern1) 1057**] of the Asian Task Force
Against Domestic Violence can be reached at [**Telephone/Fax (1) 51279**].
CONDITION ON DISCHARGE: Baby girl [**Known lastname 3443**] has been doing well on
room air without apneic or bradycardic episodes. She has
been tolerating Enfamil 20 p.o. and gaining weight.
DISCHARGE DISPOSITION: Baby girl [**Known lastname 3443**] was discharged home
with her mother on [**2111-9-8**]. They will be staying with
friends temporarily pending permanent housing arrangements.
PRIMARY PEDIATRICIAN: Primary pediatric care will be
at [**Hospital3 **].
CARE RECOMMENDATIONS:
1. Feedings on discharge: Enfamil 20 p.o. ad lib.
2. Medications: Iron sulfate 2mg/kg/day (0.2cc of 25mg/ml
solution po qd).
3. Car seat screening was passed.
4. State newborn screening was sent.
5. Immunizations: Received hepatitis B vaccination on [**9-3**].
DISCHARGE INSTRUCTIONS/FOLLOWUP: Follow-up appointment
recommended at [**Hospital3 **] Pediatrics in two to three days
following discharge. Visiting nurse [**First Name8 (NamePattern2) 767**] [**Last Name (Titles) 86**] VNA to visit
within 1-2 days following discharge.
DISCHARGE DIAGNOSES:
1. Prematurity at 34 and 6/7 weeks.
2. Sepsis evaluation with antibiotics.
3. Anemia.
4. Respiratory distress, resolved.
5. Hyperbilirubinemia, resolved.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51280**], M.D. [**MD Number(1) 36532**]
Dictated By:[**Name8 (MD) 47634**]
MEDQUIST36
D: [**2111-9-7**] 13:46
T: [**2111-9-7**] 14:41
JOB#: [**Job Number 51281**]
ICD9 Codes: 7742, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1273
} | Medical Text: Admission Date: [**2131-3-6**] Discharge Date: [**2131-3-12**]
Date of Birth: [**2063-3-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
intubation, upper endoscopy
History of Present Illness:
This is an 68 yo M w/ h/o MI, CHF w/ EF 20%, afib, CVA from
possible embolic event, colon CA s/p resection, h/o GIB,
laryngeal cancer undergoing XRT and chemotherapy with a G-tube,
and PVD s/p bilateral CIA and EIA stents on [**2-27**], who presents
with melana over 24 hours and Hct drop from 29 to 19 over 1 day.
He was transferred from the [**Hospital **] [**Hospital **] Hospital and Rehab Center.
Per Rehab records, had loose tarry stools 6 times since
yesterday, with one large black and bloody stool this AM.
.
Patient is moderately poor historian. Reports melanic stools
since yesterday. Denies nausea/vomiting/ hematemesis/coffee
ground emesis, LH, CP, dyspnea, abdominal pain, headache. Per
daughter, he had bloody or black stools in [**2130-10-4**] after
XRT for laryngeal cancer. Per his PCP, [**Name10 (NameIs) **] was discontinued
at this time; however it was restarted in [**Month (only) 956**] when he was
diagnosed with a CVA.
.
On arrival in the ED Mr. [**Known lastname 19755**] was tachycardic and
hypotensive at 87/64; two large bore IVs were placed, and
transfusion was initiated. Mr. [**Known lastname 19755**] was admitted to the
MICU.
Past Medical History:
-s/p prior hospitalization for respiratory failure, renal
failure and altered mental status, secondary to Klebsiella
pneumoniae pneumonia (tx with Zosyn, Levofloxacin--sent out on
Amikacin, Levofloxacin)
-C. difficle colitis
-Laryngeal cancer-recurrent, undergoing chemo/radiation
s/p G tube after XRT
-Indwelling Foley
-Colon Cancer s/p resection in 8 years
-Renal Insufficiency
-Cardiomyopathy
-Multiple sclerosis X 40 y
-CVA-frontal, [**2131-1-4**] (in the setting of discontinuing
[**Year (4 digits) **] for GIB in [**Month (only) **])
-CAD, s/p MI
-CHF ([**10-9**] last EF 20-25%, 1.4-1.5 thrombus L apex, not
mobile), s/p defibrillator
-History of GIB - [**Hospital6 **], per daughter unclear
cause
peripheral neuropathy
-afib (on [**Hospital6 **])
-history of GIB - ~[**10-9**] [**Month/Year (2) **] initially discontinued, but
restarted after likely CVA
Social History:
From rehab facility.
Previous to rehab, lives with his son and daughter in law.
Smoked 2+ ppd X 50 years, quit recently. Occ EtOH, stopped
several years ago. Denies IVDU.
Family History:
NC
Physical Exam:
NAD, lying flat in bed
HEENT: anicteric, PERRL 2-->1, EOMI, OP w/ dry MM, no JVD
CV: 90's, regular, no murmurs appreciated, but distant HS
Resp: CTAB, no wheezes, no crackles
Abd: thin, G-tube in place w/ small amt of firmness adjacent to
tube, soft
Ext: 1+ LE edema, L DP barely palpable but [**Month/Year (2) 17394**], L PT
palpable and [**Month/Year (2) 17394**]
Pertinent Results:
[**2131-3-9**] 04:17AM BLOOD WBC-8.7 RBC-4.10* Hgb-13.0* Hct-36.1*
MCV-88 MCH-31.7 MCHC-36.1* RDW-16.1* Plt Ct-139*
[**2131-3-6**] 09:57PM BLOOD Hct-20.5*
[**2131-3-6**] 03:00PM BLOOD WBC-11.0 RBC-1.90*# Hgb-6.3*# Hct-19.5*#
MCV-103* MCH-33.2* MCHC-32.3 RDW-16.4* Plt Ct-242
[**2131-3-9**] 04:17AM BLOOD Plt Ct-139*
[**2131-3-8**] 02:24AM BLOOD PT-12.2 PTT-27.6 INR(PT)-1.0
[**2131-3-6**] 03:00PM BLOOD PT-15.3* PTT-26.6 INR(PT)-1.4*
[**2131-3-9**] 04:17AM BLOOD Glucose-96 UreaN-22* Creat-0.8 Na-144
K-3.5 Cl-111* HCO3-26 AnGap-11
[**2131-3-6**] 03:00PM BLOOD ALT-20 AST-22 LD(LDH)-225 AlkPhos-64
Amylase-88 TotBili-0.2
EGD: A single non-bleeding localized erosion was seen in the
second part of the duodenum adjacent to the G tube balloon. A
single acute cratered 8mm ulcer was found in the apex of the
duodenum with an adherent clot suggesting recent bleeding. A
total of 4 cc Epinephrine 1/[**Numeric Identifier 961**] injections were applied to the
base and on the clot of the ulcer for hemostasis with success.
[**Hospital1 **]-CAP Electrocautery was also applied for hemostasis
successfully. In addition, a single Hemoclip was also applied
for hemostasis successfully.
Brief Hospital Course:
A/P: 68 yo M w/ MMP including CAD, s/p MI w/ EF 20%, PVD s/p
stents on [**2-27**], colon CA, who presents w/ melena and 10 pt Hct
drop over 24 hours, while on [**Month/Year (2) **], [**Month/Year (2) **], plavix. lovenox. Pt
required 8U PRBC, 4U FFP and one bag of platelets. Give
persistant GI bleeding and falling hematocrit, Mr. [**Known lastname 19755**] [**Last Name (Titles) 8783**]t an urgent EGD. Given his history of laryngeal cancer
s/p XRT, he was electively intubated prior to the EGD. The EGD
revealed erosion at the site of the insertion of the G tube at
the second portion of the duodenum (the G tube had advanced into
the duodenum) and another erosion with a blood clot. Both
ulcers were injected with epinephrine. A clip was applied at
the base of the ulcer with clot.
.
After the EGD, Mr. [**Known lastname 71861**] hematocrit remained stable at 36
and he was extubated successfully on HD #2.
.
Per discussion with the patient's primary care physician,
[**Name10 (NameIs) **] will not be restarted. Aspirin and clopidogrel may be
reinstituted, probably ~7 days from discharge, in concert with
recommendations from Mr. [**Known lastname 71861**] primary care physician and
[**Known lastname 1106**] surgeon.
.
Surgery was consulted regarding the G-tube. They repositioned
and re-secured the G-tube. A G tube study was obtained that
demonstrated appropriate filling of the stomach and tube feeds
were restarted. After confirming with the rehabilitation center
Mr. [**Known lastname 19755**] was previously cared for at, he was restarted on
a heart healthy, diet.
.
Mr. [**Known lastname 71861**] creatinine was initially elevated above his
baseline in the setting of hypovolemia, but returned to baseline
after appropriate resuscitation with blood products.
.
Patient had 2 episodes of 14 and 18 beat VT on [**2131-3-10**]. Vital
signs were otherwise stable. We replaced his electrolytes to
keep his potassium > 4.0 and his magnesium >2.0. He will follow
up with Dr. [**Last Name (STitle) 2077**] on [**2131-3-15**].
Medications on Admission:
[**Date Range **] 81 mg PO daily
[**Date Range 197**] 7.5 mg PO daily
Plavix 75 PO daily
Lasix 20 mg IV after PRBCs
Lipitor 10 mg PO daily
Lovenox 55 mg SC q12H
MVI
Docusate
Senna
Bisacodyl
Percocet 5/325mg PO prn
miconazole nitrate 2% Q8H to rash
Discharge Medications:
1. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Lipitor 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
-Erosion in the second part of the duodenum
-Ulcer in the apex of the duodenum (injection, thermal therapy)
-Bleeding likely caused by the duodenal ulcer, which was likely
due to trauma from the G tube balloon.
Discharge Condition:
stable, hematcrit stable at 35-36 for over 36 hours
Discharge Instructions:
Please take all medications as prescribed. Please do not take
your Plavix, [**Location (un) **], or aspirin unless instructed by your
primary care doctor. These can contribute to gastrointestinal
bleeding. You have had a gastrointestinal bleed which has
stopped. You should take protonix (a new medication which helps
prevent recurrent gastrointestinal bleeding) twice daily.
.
You should return to the emergency department if you resume
bleeding again (black tarry stools, or grossly bloody stools),
if you feel lightheaded/like you might pass out, if you have
chest pain or shortness of breath, or for any other symptoms
that concern you.
Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **]
[**First Name (STitle) 2077**], [**Telephone/Fax (1) 14967**]. You have been scheduled for an appointment
on Thursday, [**3-15**] at 4:45 PM.
.
You have a follow-up with the [**Month (only) 1106**] surgeon on [**3-29**] as
follows, with the following scheduled studies:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 7721**] [**Name11 (NameIs) **] LMOB (NHB) Date/Time:[**2131-3-29**]
10:15
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 7721**] [**Name11 (NameIs) **] LMOB (NHB) Date/Time:[**2131-3-29**]
10:45
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2131-3-29**] 11:15
Completed by:[**2131-3-12**]
ICD9 Codes: 2851, 2875, 5859, 4280, 4271, 2767, 2760, 5849, 2768, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1274
} | Medical Text: Admission Date: [**2191-6-10**] Discharge Date: [**2191-6-20**]
Date of Birth: [**2136-12-24**] Sex: F
Service: MEDICINE
Allergies:
Vancomycin / Iodine; Iodine Containing / Tape / Ibuprofen /
Levofloxacin
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
CC: dyspnea
PCP: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Outpatient Cardiologist: none
Major Surgical or Invasive Procedure:
Right sided PA catheter placement
History of Present Illness:
54 yo F with PMH sarcoidosis, tracheostomy [**3-14**] upper airway
obstruction, dCHF, DM1, pulmonary HTN, CAD, morbid obesity p/w
abdominal pain radiating to the back and shortness of breath.
Given nebs/lasix 80 IV/ and 2 nitro SL. Has history of CAD, CHF
and sarcoidosis. BIBEMS 95% on NRB. BP 210/100 with EMS. She has
had 3 admissions within the last 2 months for dyspnea (thought
related to CHF/COPD) and nausea/abdominal pain likely from
gastroparesis
Ms. [**Known lastname **] was sitting at home this afternoon when she began
experiencing gradual onset SOB. She says she first noticed
dyspnea with exertion (wheeling around apartment) about a day
ago; no orthopnea/pnd. sleeps on 3 pillows for comfort. She has
noticed progressive LE edema since last discharge. She took a
few nebs at home without relief so she called 911. EMS found her
ot have SaO2 in mid 80's on room air; put her on blow-by. 80 IV
lasix, 2 sL NTG. She also complains of nausea/vomiting and sharp
epigastric intermittent pain, similar to what last brought her
to the ED. She denies any chest pain or tightness, no syncope or
palpitations.
.
Initial VS in ED: T 97.3 HR 72 BP 164/74 RR 16 SaO2 89% on RA;
respiratory distress. She was given 80mg IV lasix & 2 NTG by EMS
and is negative 1.8L. She was placed on nitro drip in ED with
improvement in her symptoms. CXR showed CHF.
Past Medical History:
Morbid obesity
Asthma
Diastolic heart failure
Diabetes mellitus Type 1 (since age 16): neuropathy,
gastroparesis, nephropathy, & retinopathy
Sarcodosis ([**2175**])
Tracheostomy - [**3-14**] upper airway obstruction, sarcoid. [**2191-5-19**]
trach changed from #6 cuffed portex to a #6 uncuffed,
nonfenestrated portex
Arthritis - wheel chair bound
Neurogenic bladder with chronic foley
Asthma
Hypertension
Pulmonary hypertension
Hyperlipidemia
CAD s/p CABG [**2179**] (SVG to OM1 and OM2, and LIMA to LAD)
last c. cath [**2187-2-28**]: widely patent vein grafts to the OM1 and
OM2, widely patent LIMA to LAD (distal 40% anastomosis lesion).
Chronic low back pain-disc disease
s/p cholecystectomy
s/p appendectomy
History of sternotomy, status post osteomyelitis in [**2179**].
Leukocytoclastic vasculitis [**3-14**] vancomycin in [**2179**].
History of pneumothorax in [**2179**].
Colon resection, status post perforation.
J-tube placement in [**2173**].
Social History:
The patient formerly lived alone and has a female partner for 25
years that visits frequently and is her HCP. She had been living
in rehab recently, but most recently discharged home w/o
services. The patient is mobile with scooter or wheelchair and
can walk short distances. Remote smoking history <1 pack per day
>30 years ago, denies EtOH or drug use.
Family History:
Father: [**Name (NI) **], Diabetes & MI in 60s
Mother's side: Family history of various cancers & heart disease
Physical Exam:
On admission -
T AF HR 80 BP 158/72 RR 18 SaO2 97% on 50%
GENERAL: obese, tachypnic, not speaking in full sentences
HEENT: Normocephalic, atraumatic. left pupil 3mm, right pupil
2mm both reactive to light, EOMI, dry mucous membranes
Neck: obese, Supple, No LAD, unable to appreciate JVP
CARDIAC: regular rhythm, no appreciable murmur; heart sounds
distant
LUNGS: decreased breath sounds at the bases, few basilar
crackles; difficult to tell given body habitus
ABDOMEN: Obese, slightly distended but soft, umbilical hernia
with, positive bowel sounds, no rebound or gurding.
EXTREMITIES: 2+ pitting edema to the knees bilaterally, trace
dp's bilaterally, cool extremities.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**2-11**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
.
Pertinent Results:
ADMISSION LABS:
[**2191-6-10**] 09:24PM BLOOD WBC-12.6* RBC-4.04* Hgb-11.9* Hct-35.5*
MCV-88 MCH-29.6 MCHC-33.6 RDW-14.9 Plt Ct-114*
[**2191-6-10**] 09:24PM BLOOD Neuts-88.8* Lymphs-6.4* Monos-2.1 Eos-2.5
Baso-0.2
[**2191-6-10**] 08:40PM BLOOD Glucose-109* UreaN-34* Creat-1.0 Na-129*
K-4.8 Cl-93* HCO3-24 AnGap-17
[**2191-6-10**] 09:45PM BLOOD Calcium-9.3 Phos-3.3 Mg-1.6
[**2191-6-11**] 05:57AM BLOOD ALT-81* AST-58* LD(LDH)-257* CK(CPK)-63
AlkPhos-200* TotBili-0.5
.
CARDIAC ENZYMES:
[**2191-6-10**] 08:40PM BLOOD CK-MB-NotDone cTropnT-<0.01 proBNP-[**2129**]*
[**2191-6-10**] 09:45PM BLOOD cTropnT-<0.01
[**2191-6-10**] 09:45PM BLOOD CK-MB-NotDone proBNP-2185*
[**2191-6-10**] 08:40PM BLOOD CK(CPK)-87
[**2191-6-12**] 01:26AM BLOOD CK(CPK)-42
.
UPRIGHT AP VIEW OF THE CHEST: The patient is status post
tracheostomy, with the tube tip in satisfactory position
approximately 4.5 cm from the carina. Bilateral hazy opacities
are seen with increased vascular markings and vascular
indistinctness, compatible with pulmonary edema. Cardiac
silhouette is difficult to assess, but appears at least mildly
enlarged. The right costophrenic angle is excluded from view.
There is likely at least small bilateral pleural effusions. No
pneumothorax. Clips are seen projecting over
the left superior mediastinum. Elevation of the right
hemidiaphragm is seen.
IMPRESSION: Findings compatible with moderate pulmonary edema
and probable small bilateral pleural effusions. The right
costophrenic angle is excluded from the study.
[**5-17**] CT torso
1. Mild dilation of ileal small bowel loops with transition
point near an umbilical hernia represents at least partial
small-bowel obstruction. Early complete obstruction is a less
likely possibility.
2. Stable extensive coronary artery atherosclerotic
calcification and post CABG changes.
3. Pulmonary artery enlargement suggestive of pulmonary artery
hypertension is unchanged since [**2191-1-3**].
4. No evidence of pneumonia.
[**8-17**] Echo
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. There is no aortic valve stenosis. No aortic
regurgitation is seen. Trivial mitral regurgitation is seen.
There is no pericardial effusion.
.
EKG: NSR at 88. borderline left axis. normal intervals. Q in
III. poor RWP and low voltages.
.
CARDIAC CATH [**2191-6-13**]
COMMENTS:
1. Resting hemodynamics demonstrated marked biventricular
diastolic
dysfunciton, with a mean PCWP of 45 mmHg and an RVEDP of 32
mmHg. There
was severe elevation of the PA pressures, with a mean PAP of 80
mmHg.
FINAL DIAGNOSIS:
1. Severe biventricular diastolic dysfunction.
2. Severe pulmonary hypertension.
Brief Hospital Course:
Ms. [**Known lastname **] is a 54 yo woman with morbid obesity, DM1 with
numerous complications, diastolic CHF, pulmonary hypertension,
sarcoid s/p trach for upper airway obstruction who presents from
home with dyspnea
# Dyspnea/diastolic heart failure: Ms. [**Known lastname **] had complicated
respiratory issues with many admissions for dyspnea felt to be
from multifactory causes: diastolic CHF, reactive airways,
pulmonary hypertension. Her current presentation and CXR seem
consistent with CHF exacerbation likely related to hypertension
and underdiuresis given progressive LE edema. She was referred
for right heart cath with mean PCWP of 45, PA systolic of 110
with PA diastolic 50. A PA catheter was placed and aggressive
diuresis was initiated. Diuresis was limited by several episodes
of hypotension requiring pressors, she appeared to be very
sensitive to quick volume shifts without time for
intravascular/extravascular equilibration. It was felt that she
needed slow gentle diuresis over prolonged period of time to
prevent hyptensive insults and she was set up wit heart failure
VNA for outpatient lasix titration and referred to see Dr. [**First Name (STitle) 437**]
in heart failure clinic.
.
# Coronary artery disease: s/p CABG [**2179**] (SVG to OM1 and OM2,
and LIMA to LAD)In [**2187-2-28**]: all grafts widely patent. She was
continued on aspirin, beta blocker & statin
.
# abdominal pain, nausea/vominting: Patient had these symptosm
for one day prior to admission that were thought c/w
gastroparesis. She was continued on reglan with reoslution of
her symptoms on hospital day #1.
.
# Hypertension: Hypertensive on admission although it was
unclear if this was a response to respiratory distress or the
inciting event. Her losartan & metoprolol were uptitrated as
tolerated. Patient then had several episodes of hypotension
erquiring pressor support that was temporally related to
diuresis. Her blood pressure seemed to be very sensitive to
volume shifts liekly due to diastolic dysfunction for
long-standing hypertension.
.
# Asthma: Unclear dx. FEV1/FVC ratio's preserved in PFTs. She
was continued on home regimen of advair + nebs. Not thought
that bronchospasm was contributing significantly to this
presentation
.
# Type I Diabetes: Long-standing history with numerous
complications including neurogenic bladder, CAD, neuropathy,
nephropathy, retinopathy. She was continued on basal lantus
insulin with sliding scale with good overall control
Medications on Admission:
1. Losartan 25 mg po saily
2. Citalopram 20 mg po daily
3. Furosemide 40 mg po daily
4. Multivitamin po daily
5. Calcium Carbonate 500 mg po tid
6. Simvastatin 10 mg po daily
7. Metoprolol Tartrate 50 mg po bid
8. Gabapentin 300 mg po bid
9. Ipratropium Bromide QID
10. Fluticasone 110 mcg/Actuation [**Hospital1 **]
11. Miconazole Nitrate 2 % TID
12. Docusate Sodium 50 mg/5 mL [**Hospital1 **]
13. Lansoprazole 30 mg po daily
14. Metoclopramide 20 mg po bid
15. Metoclopramide 10 mg po bid
16. Aspirin 81 mg po daily
17. Hydrocodone-Acetaminophen 5-500 mg q 8 hrs prn
18. Clopidogrel 75 mg po daily
19. Slow-Mag 64 mg PO twice a day.
20. Benztropine 1 mg po tid
21. Psyllium tid prn
22. Lorazepam 1 mg po QHS
23. Heparin tid.
24. Albuterol q 6 hrs
25. Acetylcysteine 20 % (200 mg/mL) Solution [**Hospital1 **]: Five (5) mL
Miscellaneous every six (6) hours as needed for secretions.
26. Insulin
27. Nystatin powder
Discharge Medications:
1. Losartan 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
2. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID
(2 times a day).
3. Citalopram 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
4. Multivitamin Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
5. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
6. Calcium Citrate 200 mg (950 mg) Tablet [**Hospital1 **]: Two (2) Tablet PO
three times a day.
7. Vitamin D 1,000 unit Tablet [**Hospital1 **]: One (1) Tablet PO once a
day.
8. Simvastatin 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
9. Gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
10. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) vial
vial Inhalation Q6H (every 6 hours).
11. Reglan 10 mg Tablet [**Hospital1 **]: Three (3) Tablet PO twice a day.
12. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Benztropine 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times
a day).
14. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) cc
Injection TID (3 times a day).
15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) vial Inhalation Q6H (every 6 hours) as
needed for dyspnea.
16. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
17. Magnesium Chloride 64 mg Tablet Sustained Release [**Last Name (STitle) **]: One
(1) Tablet Sustained Release PO twice a day.
18. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO BID
(2 times a day).
19. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO twice a
day as needed for constipation.
20. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
21. Hydrocodone-Acetaminophen 5-500 mg Tablet [**Hospital1 **]: 1-2 Tablets
PO every eight (8) hours as needed for headache.
22. Psyllium Packet [**Hospital1 **]: One (1) Packet PO TID (3 times a
day) as needed for constipation.
23. Sodium Chloride 0.9 % 0.9 % Syringe [**Hospital1 **]: Three (3) ML
Injection once a day as needed for line flush.
24. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device [**Hospital1 **]:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
25. Lorazepam 1 mg Tablet [**Hospital1 **]: 1-2 Tablets PO three times a day
as needed for anxiety.
26. Insulin Glargine 100 unit/mL Solution [**Hospital1 **]: Fifty Eight (58)
units Subcutaneous at bedtime.
27. Humalog 100 unit/mL Solution [**Hospital1 **]: per sliding scale attached
units Subcutaneous four times a day: before meals and hs.
Discharge Disposition:
Extended Care
Facility:
Radius Specialty- [**Location (un) 86**]
Discharge Diagnosis:
Acute on chronic diastolic heart failure
Discharge Condition:
Good. Hemodynamically stable and afebrile
Discharge Instructions:
You had trouble breathing at home and required intravenous
Furosemide to Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight >
3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
An appointment was made for you with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] in the
Heart Failure Clinic on [**7-25**] at 9am. His office is located
on the [**Location (un) 436**] of the [**Hospital Ward Name 23**] Clinical Center, [**Hospital Ward Name 516**] at
[**Hospital1 18**].
.
Primary Care: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 250**] Please make an
appt to see when you are out of [**Hospital 671**] Healthcare.
Rheumatology:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3310**], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2191-6-29**] 1:30
Cardiology:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2191-7-6**] 1:40
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2191-7-18**] 12:00
Completed by:[**2191-6-20**]
ICD9 Codes: 4280, 3572, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1275
} | Medical Text: Admission Date: [**2192-11-27**] Discharge Date: [**2192-12-10**]
Date of Birth: [**2117-3-14**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 4327**]
Chief Complaint:
Cardiac arrest
Major Surgical or Invasive Procedure:
Intubation in ED; Extubated in MICU
ArcticSun Cooling
Coronary Catheterization
EP study
ICD placement
History of Present Illness:
75 year old female with past medical history of CAD MIx4 s/p 3v
CABG [**2174**], who was living at [**Hospital3 2558**] after two staged
spinal surgery [**2192-11-12**] complicated by NSTEMI.
.
She had an stress dobutamine echo prior to the surgery for risk
stratification. Per report, it was normal with no clear evidence
of ischemia. She remained intubated after the second surgery out
of concern for aggressive IVF resuscitation, with peak lactate
of 3.5 intra-operatively. She experienced an NSTEMI on [**11-14**]
with TWI in lateral leads and Troponins up to 2.667. Echo at the
time showed EF 50-55%, with inferolateral wall akinesis, basal
to mid-inferior wall is akinetic. Mid anterolateral hypokinesis
and the discrete mid-laterall wall aneurysm noted on dobutamine
stress images from [**2192-11-7**] was not visualized. Cardiology
consult was obtained and it was decided to medically manage her
NSTEMI.
.
According to the report, she was found pulseless and
unresponsive [**2192-11-27**], code blue was called and patient received
6 cycyles of CPR, AED was applied and shock advised after which
SROC occurred. She was transferred to [**Hospital1 18**] for further
managment and had agonal breathing in the ED, she was intubated
and admitted to the MICU. She was found to have multiple
pulmonary emobli and a possible ileopsoas abscess. She was
treated with the post arrest cooling protocol. She was started
on heparin bridge to warfarin, and was briefly treated with
antibiotics for supposed ileopsoas abscess however suspicion for
abscess was low and abx were discontinued. She had ECHO [**11-14**]
which showed EF of 50-55%%. Head CT was negative. [**2192-12-3**] She
was extubated and transferred to the general medical floor.
.
Cardiac enzymes were trended which never increased.
.
Following transfer to the general medical floor at [**Hospital1 18**], the
working diagnosis was that arrest was precipitated by PE versus
cardiac arrhythmia. She was seen by electorphysiology who
requested transfer to Inpatient cardiology service for an EP
study and possible ICD palcement.
.
Per Ms [**Known lastname 91304**] son, she was independent prior to her surgery.
She had limited motion due to her back pain but heart has not
been a problem for her since the CABG operation. Her son recalls
use of NTG only twice over the last 10 years. She did not have
any orthopnea, PND or lower extremity edema prior to her
surgery.
.
REVIEW OF SYSTEMS
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
-Advanced DJD lumbar spine, s/p L1-S1 ALIF, T11-ilium PSIF on
[**2192-11-3**]
[**11-13**] of this year
-CAD s/p MI x 4, s/p 3V CABG [**2174**]
-Hypertension
-Hyperlipidemia
-PVD s/p Right lower extermity angioplasty [**12-10**]
-Tobacco abuse
-Aortic stenosis
-Osteoporosis
-Cataract
Social History:
Lives in nursing home in [**Location (un) **]. Smokes 10 cigarettes per day.
Drinks very rarely with no drug use. Per family, she is fairly
independent and does not drive. Husband is no longer alive. Son
is an ER physician in [**Name9 (PRE) 531**].
Family History:
Colon cancer in sister, DM in mother
Physical Exam:
Admission physical exam in ICU:
VS: 37.2, HR 71 (regular), BP 118/60, RR 22, SpO2 99% on 70%
face tent
Gen: Elderly woman in NAD but appears chronically ill in ICU
bed. Opens eyes and responds to voice, but falls asleep easily
during conversation.
HEENT: Conjunctivae injected but not icteric. MMM, OP clear.
Face symmetric. Neck supple without JVD.
CV: s1-s2 normal, regular rate and rhythm, + holosystolic murmur
RLSB and apex. no rubs or gallops appreciated.
Lungs: Diffuse rhonchi. No wheeze.
Abd: Soft, NT/ND, +NABS. No HSM. No guarding.
Extrem: Trace edema bilateral lower extremities
Neuro: Normal tone, somewhat responsive as above. Full neuro
exam limited by lethargy
.
Discharge physical exam:
VS T 98, BP 138/61, HR 60s, RR 15, O2 Sat 96% RA
GENERAL: in NAD. Oriented x3. Mood, affect appropriate. sitting
at bed side comfortably
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 5 cm above sternal angle at 45 degrees
CARDIAC: RR, normal S1, S2. No rubs or gallops. 3/6 systolic
murmur best heard at right 2nd intercostal space, radiating to
carotids, but heard all over the precordium. No S3 or S4.
LUNGS: 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. No femoral bruits. +1 pitting edema up to
tibial tuberosity on right side, with 0-+1 pitting edema up to
mid-shin on left side.
PULSES:
Right: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ DP 2+ PT 2+
Pertinent Results:
CBC:
[**2192-11-27**] 12:43PM BLOOD WBC-13.8* RBC-3.43* Hgb-10.5* Hct-31.9*
MCV-93 MCH-30.8 MCHC-33.1 RDW-15.9* Plt Ct-382
[**2192-12-10**] 06:45AM BLOOD WBC-5.9 RBC-3.04* Hgb-9.6* Hct-28.9*
MCV-95 MCH-31.5 MCHC-33.1 RDW-17.5* Plt Ct-180
.
Coagulation profile:
[**2192-12-10**] 06:45AM BLOOD PT-25.8* PTT-35.2* INR(PT)-2.5*
[**2192-12-9**] 05:59AM BLOOD PT-37.9* PTT-38.1* INR(PT)-3.8*
[**2192-11-27**] 12:43PM BLOOD PT-14.4* PTT-25.6 INR(PT)-1.2*
.
Blood chemistry:
[**2192-12-10**] 06:45AM BLOOD Glucose-96 UreaN-12 Creat-0.6 Na-141
K-3.7 Cl-106 HCO3-26 AnGap-13
[**2192-11-27**] 12:43PM BLOOD Glucose-119* UreaN-11 Creat-0.6 Na-137
K-3.7 Cl-104 HCO3-24 AnGap-13
[**2192-11-27**] 12:43PM BLOOD ALT-74* AST-67* CK(CPK)-174 AlkPhos-133*
TotBili-1.1
[**2192-11-28**] 01:22AM BLOOD ALT-52* AST-45* LD(LDH)-486* CK(CPK)-196
AlkPhos-114* TotBili-0.8
[**2192-12-10**] 06:45AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.1
[**2192-11-27**] 12:43PM BLOOD Albumin-3.0* Calcium-8.1* Phos-4.1 Mg-2.0
.
Cardiac markers:
[**2192-11-28**] 01:22AM BLOOD CK-MB-5 cTropnT-0.03*
[**2192-11-27**] 06:46PM BLOOD CK-MB-4 cTropnT-0.04*
[**2192-11-27**] 12:43PM BLOOD cTropnT-0.03*
.
Others:
[**2192-11-27**] 01:49PM BLOOD Lactate-1.6
[**2192-11-29**] 04:15AM BLOOD Lactate-1.4
[**2192-12-9**] 05:59AM BLOOD VitB12-289 Folate-5.4
[**2192-11-27**] 12:43PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-
NEG Tricycl-NEG
.
IMAGING:
[**2192-11-27**]
ECHO:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is an inferobasal and posterobasal left
ventricular aneurysm. Overall left ventricular systolic function
is moderately depressed (LVEF= 35 %) secondary to severe
hypokinesis/akinesis of the inferior septum, inferior free wall,
and posterior wall. The right ventricular free wall thickness is
normal. Right ventricular chamber size is normal. with depressed
free wall contractility. The aortic root is mildly dilated at
the sinus level. The ascending aorta is mildly dilated. There
are three aortic valve leaflets. 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. The mitral valve leaflets are mildly
thickened. There is mild bileaflet mitral valve prolapse. Mild
to moderate ([**2-5**]+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. At least moderate [2+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
.
[**2192-11-27**]
CT HEAD without contrast
FINDINGS: There is no intracranial hemorrhage, masses, edema, or
shift in
normally midline structures. There is preservation of the
white-[**Doctor Last Name 352**] matter differentiation with no evidence of acute
large vessel territorial infarct. There is mild mucosal
thickening of the ethmoidal air cells and a small air-fluid
level in the left frontal sinus. Otherwise, the paranasal and
mastoid airspaces are clear. Osseous structures and soft tissues
are
unremarkable. The cavernous carotids are heavily calcified
bilaterally while the vertebral arteries are calcified
moderately. Osseous structures and soft tissues are
unremarkable.
IMPRESSION: No acute intracranial process.
.
[**2192-11-27**]
CT Chest with and without contrast, CT abd-pelvis with contrast
IMPRESSION:
1. Large retroperitoneal abscess which involves the right
iliopsoas muscle
with extension through the abdominal wall with corresponding
soft tissue
edema.
2. Multiple pulmonary embolisms seen in the left upper lobe,
left lower lobe and right lower lobe pulmonary branches. No sign
of right heart strain.
3. Multiple bilateral anterior rib fractures (right #[**2-9**], left
#[**3-10**]), likely secondary to CPR.
4. Bilateral dependent atelectases with adjacent small pleural
effusions.
5. Endotracheal tube is seen coursing through the trachea into
the right
mainstem bronchus. Staff was notified.
6. Left adnexal mass seen, which is not age concordant and
requires
outpatient ultrasound follow-up in order to exclude malignancy.
7. Marked spinal malalignment of indeterminate acuity.
Comparison with
immediate postop imaging would be helpful if made available.
.
[**2192-12-3**]
ECHO
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with basal inferior and inferolateral akinesis to
dyskinesis (aneurysmal). The remaining segments are normal.. No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size is
normal with normal free wall contractility. The ascending aorta
is mildly dilated. The aortic arch is mildly dilated. The aortic
valve leaflets are moderately thickened. 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. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2192-11-27**],
the LV and RV appear more vigorous (may be due to increased HR).
.
[**2192-12-4**]
Coronary Catheterization
COMMENTS:
1. Coronary angiography of this right dominant sytem revealed
severe
native two vessel coronary artery diseae. The LMCA had no
significant
stenosis. The LAD had a 90% narrowing at its origin and diffuse
disease
distally up to 90% in narrowing after a high D1. The LCx system
had no
significant flow limiting disease. The RCA had a total
occlusion
proximally with filling through left to right collaterals,
mostly via
the LIMA.
2. Selective graft angiography revealed two stump occluded
venous
grafts, one to the RCA and one likely to the D1 The LIMA to LAD
was
widely patent supplying the LAD and RCA through collaterals.
Based on
graft amd native anatomy and collateral distribution, the
moderate sized
d1 is comproomised without patent graft or collaterals.
FINAL DIAGNOSIS:
1. Severe native 2 vessel coronary artery disease.
2. Occluded SVG to RCA and diagonal (presumed target); Patent
LIMA to
LAD.
.
Lower Extremity venous US:
FINDINGS: There is normal flow, augmentation and compressibility
of the
common femoral vein, superficial femoral vein and popliteal
veins bilaterally. There is normal flow and compressibility of
the peroneal and posterior tibial veins bilaterally.
IMPRESSION: No evidence of deep vein thrombosis in either lower
extremity.
.
[**2192-12-8**]
CXR
IMPRESSION:
Status post median sternotomy for CABG with overall stable
cardiac and
mediastinal contours. Interval placement of a dual lead
pacemaker with its
leads terminating over the expected location of the right atrium
and right
ventricle, respectively. There is persistent blunting of the
left
costophrenic sulcus which may represent pleural thickening
and/or a small
pleural effusion. Linear opacities at the left base may reflect
post-inflammatory scarring or subsegmental atelectasis; an early
pneumonia is less likely. No evidence of pulmonary edema. No
pneumothorax. Spinal
fixation hardware overlies the thoracic and upper lumbar spine.
.
[**2192-12-6**]
Cardiac MRI: final report pending, this is prelim report
Impression:
1.Severely increased left ventricular cavity size with thinned
and akinetic basal to mid inferior and inferolateral walls,
consistent with a previous infarct. The LVEF was mildly
depressed at 45%.
2.The aforementioned akinetic segments were not visualized in
the LGE sequences due to technical issues. No CMR evidence of
prior myocardial scarring/infarction in the other visualized
segments.
3.Normal right ventricular cavity size and systolic function.
The RVEF was normal at 56%.
4.Aortic regurgitation (not quantified). Mild pulmonic and
tricuspid regurgitation.
5.The indexed diameters of the ascending and descending thoracic
aorta were both severely increased. The main pulmonary artery
diameter index was mildly increased.
6.Mild [**Hospital1 **]-atrial enlargement.
Brief Hospital Course:
Mrs [**Known lastname **] is a 75 year old female with CAD (MI x 4, CABG) and
aortic stenosis who presents status post cardiac arrest. Patient
was resuscitated in the field and received one shock from AED
she was transferred to [**Hospital1 18**] where she was treated with the post
arrest cooling protocol with full neurologic recovery. She was
found to have bilateral pulmonary emboli on CTA chest without
evidence of right heart strain. Coronary catheterization showed
non-intervenable coronary artery disease, with the ability to
induce polymorphic Ventricular tachycardia. ICD was placed and
discharged back to rehabilitation in stable condition.
.
#Cardiac Arrest:
In the MICU, patient was managed with continuation of intubation
during cooling protocol. Cardiac enzymes were followed which
never increased. Echo revealed an ejection fraction of 35%,
which may be consistent with her cooling. Because of uncertainty
over whether pulmonary emboli fully accounted for the arrest
cardiology was consulted for concern of an ischemic insult or
arrhythmia. EEG throughout cooling protocol demonstrated
findings consistent with sleeping and no evidence of seizure
activity or neurologic deficits. After cooling protocol, patient
was extubated successfully after one attempt. Patient's
neurologic status returned to baseline soon after extubation.
Antibiotics were stopped as final read on CT abdomen
demonstrated seroma. Of note, patient had QT prolongation on
EKG, and EP was consulted for evaluation as well as ICD
placement. Once she was awake, stable and sent to the floor, she
had a coronary catheterization which showed non-intervenable
coronary vessel disease (please see pertinent results section).
Electrophysiologic study revealed inducible non-sustained VT
only, both uniform and polymorphic. It is believed that
ischemia may have contributed to her arrest. She had an ICD
placed based on EP findings. Pulmonary emboli may also have
contributed to her arrest. This is being treated with warfarin
anticoagulation.
.
#Pulmonary Embolism: She reported no shortness of breath or
chest pain during her inpatient stay. As work up for her arrest,
she had CT chest which revealed bilateral segmental and
subsegmental pulmonary emboli. She was initially placed on
heparin with bridging to warfarin. She was discharged on
warfarin of 3 mg daily with INR of 2.5 on the day of discharge.
Given recent surgery with immobilization, this is likely a
provoked pulmonary embolism. She will need to continue warfarin
to maintain INR [**3-8**] until [**2192-5-28**] (6 months of therapeutic
anticoagulation).
.
#CAD: Given her extensive cardiac history, patient was continued
on atorvastatin and aspirin throughout her inpatient stay. Her
ACEi, beta blocker and Imdur were restarted after she was stable
in the floor post ICU course.
.
#Constipation: She was constipation in the first few days of her
stay. Milk of mag and bisacodyl supp PRN were provided to help
her have good bowel movements.
.
#Back Pain: Her pain regimen at rehabilitation was continued
while in the hospital. In the last few days, oxycontin was
discontinued, but gabapentin and Tylenol were continued.
Percocet [**2-5**] tab every 4 hours was added to be used as needed.
.
.
.
Transitional issues:
1. please follow INR three times a week and adjust warfarin
accordingly She will need 6 months of anticoagulation for
pulmonary embolism, final day [**2192-5-28**].
2. please follow up cardiac MRI final report
Medications on Admission:
Medications on transfer:
Milk of Magnesia 30 mL PO/NG Q6H:PRN constipation
Acetaminophen 650 mg PO/NG Q6H
Metoprolol Tartrate 25 mg PO/NG [**Hospital1 **]
OxycoDONE (Immediate Release) 5 mg PO/NG Q4H:PRN pain
Bisacodyl 10 mg PO DAILY:PRN constipation
Aspirin 81 mg PO/NG DAILY
Oxycodone SR (OxyconTIN) 10 mg PO Q12H
Docusate Sodium 100 mg PO BID
Gabapentin 300 mg PO/NG [**Hospital1 **] at 2pm and at 9p
Gabapentin 200 mg PO/NG DAILY at 9am
Senna 1 TAB PO/NG DAILY constipation
Polyethylene Glycol 17 g PO/NG DAILY
traZODONE 50 mg PO/NG HS:PRN insomnia
Heparin IV Sliding Scale
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. enalapril maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
6. Lipitor 80 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
8. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
9. gabapentin 300 mg Capsule Sig: One (1) Capsule PO three times
a day.
10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO every other day.
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
12. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 4-6 hours as needed for pain.
13. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
14. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM: as directed by INR 3 times a week.
15. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Cardiac arrest
Pulmonary embolism
Back Pain
Recent myocardial infarction
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 Ms. [**Known lastname **],
.
It was a great pleasure taking care of you as your doctor.
.
As you know you were hospitalized for a cardiac arrest that you
experienced while at your living facility. You were
resuscitated, intubated and stabilized, and placed on
anticoagulation in lieu of finding pulmonary embolisms on
imaging.
.
During your stay, you had heart vessel catheterization which
showed narrowness in some vessels that were not intervenable.
You were evaluated by heart electricity doctors
(electrophysiologist) and they found that your heart has the
potential to develop abnormal life-threatening rhythm.
Therefore, a shocking device is placed which will shock when
such rhythms are detected by the device.
.
On discharge, you were in stable condition, alert, and oriented.
.
We made the following changes in your medication list:
-please STOP atenolol
-please STOP oxycontin
-please START aspirin 81 mg daily
-please START metoprolol 25 mg twice daily
-please START coumadin 3 mg daily. This is a blood thinner for
the clots in your lungs. The coumadin level (INR) will be
checked three times a week and according to it the doses might
be adjusted.
-please CONTINUE percocet. It contains acetamenophen. Please
make sure if you take extra acetamenophen, the total per day
does not exceed 4 grams.
-please TAKE milk of magnesia for constipation AS NEEDED for
constipation.
.
Please continue the rest of your medications the way you were
taking them at home prior to admission.
.
Please follow your appointments as illustrated below.
Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2192-12-13**] at 1:30 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2193-1-17**] at 3:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11899**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4275, 4241, 4019, 2724, 3051, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1276
} | Medical Text: Admission Date: [**2148-1-16**] Discharge Date: [**2148-1-26**]
Date of Birth: [**2080-5-29**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
s/p v-fib arrest
Major Surgical or Invasive Procedure:
central line placement, arterial line placement, s/p intubation,
cardiac catheterization, ICD placement
History of Present Illness:
67 yo M with PMH significant for HTN, DM found to be in v-fib
arrest and transferred from [**Hospital3 **] for further
management. The patient was in his car this AM and rolled into
the car ahead of him. This was witnessed by a police officer who
found him slumped over in his car. He received 1 cycle of CPR
and an AED was placed that showed VF and was shocked x1 with
conversion to sinus tach. He was only down for a few minutes.
The patient had spontaneous movement at the scene. He was
intubated by EMS in the field and given 100mg IV lidocaine. The
patient was transported to [**Hospital3 **] and given 2g Mg,
150mg IV bolus of amiodarone, followed by 1mg/hr. His CE at the
OSH were trop I 0.03, CK 129. His ECG showed sinus tachycardia.
Labs were significant WBC 11.9, UA [**6-2**] WBC, 3+ bacteria, mod
epis. CXR showed well positioned ET tube, perihilar pulm edema
and no other acute abnormality. He was given 5mg pancuronium x2
and 4mg versed prior to transfer and cooling. He has PIVx2 and
right leg I/O. He was started on Arctic Sun protocol and
transferred to [**Hospital1 18**] for further management.
Past Medical History:
[**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Report and Family)
1. CARDIAC RISK FACTORS: +Diabetes, -Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
unknown
3. OTHER PAST MEDICAL HISTORY:
- multiple eye surgeries: laser, cataract removal
Social History:
obtained through son
employed with TSA and as real estate [**Doctor Last Name 360**]. Married with 4
children
- denies ETOH, smoking or other drug use
Family History:
Father had MI in 60s. + type 2 DM
Physical Exam:
VS: T=97.3...BP=166/82...HR=120...RR=16...O2 sat=92%
CMV/ VT:550/ PEEP:12/ RR:16/ FiO2: 100%
GENERAL: intubated and sedated. With random movement of all of
his ext
HEENT: NCAT. Sclera anicteric. right pupil 4mm and left 3mm,
both sluggish, but reactive to light. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP difficult to assess given habitus.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. tachycardic, RR, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Transmitted vent sounds otherwise CTAB, no crackles, wheezes or
rhonchi.
ABDOMEN: Soft, NTND. No abdominial bruits.
EXTREMITIES: No c/c/ +1 lower ext edema. 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:
[**2148-1-16**] 05:48PM BLOOD WBC-19.1* RBC-4.43* Hgb-13.6* Hct-42.2
MCV-95 MCH-30.7 MCHC-32.3 RDW-14.8 Plt Ct-238
[**2148-1-16**] 05:48PM BLOOD PT-13.2 PTT-25.2 INR(PT)-1.1
[**2148-1-16**] 05:48PM BLOOD Glucose-373* UreaN-21* Creat-1.0 Na-136
K-3.5 Cl-100 HCO3-22 AnGap-18
[**2148-1-16**] 05:48PM BLOOD ALT-25 AST-34 LD(LDH)-275* CK(CPK)-148
AlkPhos-87 TotBili-0.6
[**2148-1-16**] 05:48PM BLOOD Albumin-3.7 Calcium-8.6 Phos-5.0* Mg-1.9
[**2148-1-16**] 05:48PM BLOOD CK-MB-8 cTropnT-0.08*
-----------------
DISCHARGE LABS:
[**2148-1-26**] 07:20AM BLOOD WBC-9.5 RBC-3.38* Hgb-10.2* Hct-30.8*
MCV-91 MCH-30.1 MCHC-33.0 RDW-14.7 Plt Ct-186
[**2148-1-24**] 07:15AM BLOOD PT-13.6* PTT-27.4 INR(PT)-1.2*
[**2148-1-26**] 07:20AM BLOOD Glucose-136* UreaN-19 Creat-0.8 Na-139
K-4.1 Cl-101 HCO3-31 AnGap-11
[**2148-1-25**] 07:20AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.2
-----------------
STUDIES:
TTE ([**2148-1-17**]): The left atrium is moderately dilated. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. There is mild to moderate regional left ventricular
systolic dysfunction with severe hypokinesis of the distal [**1-28**]
of the left ventricle. There is mild global hypokinesis of the
remaining segments (LVEF = 35-40%). No masses or thrombi are
seen in the left ventricle. Right ventricular chamber size is
normal. with mild global free wall hypokinesis. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. Mild (1+) mitral regurgitation
is seen. The estimated pulmonary artery systolic pressure is
high normal. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and mild regional and global systolic
dysfunction. Mild mitral regurgitation.
.
TTE ([**2148-1-22**]): The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size.
There is mild regional left ventricular systolic dysfunction
with focal hypokinesis of the apex without aneurysm. The
remaining segments contract normally (LVEF = 55-60 %). The
estimated cardiac index is normal (>=2.5L/min/m2). The aortic
valve leaflets (?#) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild (1+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2148-1-17**],
apical function is improved.
.
Head CT ([**2148-1-16**]): 1. No acute intracranial abnormality.
2. Air-fluid level in the sphenoid sinus and mild ethmoid
mucosal thickening. Clinical correlation recommended.
Findings were discussed with Dr. [**First Name (STitle) 50871**] [**Name (STitle) **] at 11:55 p.m. on
[**2148-1-16**].
NOTE ADDED IN ATTENDING REVIEW: There is some loss of the normal
[**Doctor Last Name 352**]-white matter differentiation, diffusely, and likely sulcal
effacement over the convexities (given the patient's age),
suggestive of diffuse cerebral edema. The ventricles and
cisterns are preserved, and there is no evidence of herniation.
As above, there is no hemorrhage or sign of vascular territorial
infarction.
.
Head CT ([**2148-1-18**]): FINDINGS: Since examination from [**2148-1-23**],
there has been little interval change. There is no increasing
hypodensity to suggest evolving infarction. The [**Doctor Last Name 352**]-white
matter differentiation is preserved with appearance of the sulci
stable since examination from [**2148-1-16**] and slightly less
conspicuous. There is stable appearance of basal ganglia
calcifications. Ventricles and sulci are normal in size and
appearance. Redemonstrated is an air-fluid level within the
right side of sphenoid sinus and mild mucosal thickening of the
bilateral ethmoid sinuses. Incompletely imaged are several oral
tubes, likely orogastric and endotracheal tube. Evidence of
prior left lens surgery.
IMPRESSION: No evolving hypodensity to suggest evolving
infarction. Stable appearance of sulci which are slightly less
conspicuous for the age-stable since examination from [**2148-1-16**].
Clinical correlation is recommended as CT is less sensitive in
the detection of cerebral edema. Other details as above.
.
CXR ([**2148-1-16**]): ET tube tip is 4.3 cm above the carina. There is
mild-to-moderate cardiomegaly. NG tube tip is out of view below
the diaphragm likely in the stomach. The side port is just
distal to the GE junction. There is diffuse alveolar opacity in
the perihilar regions and in the upper lobe. These are
consistent with pulmonary edema. There is mediastinal widening
likely due to engorgement of mediastinal vessels. There is no
pneumothorax or large pleural effusions.
.
CXR ([**2148-1-26**]): The position of the leads is unchanged since the
prior chest x-ray. One lies in the right atrium, the other in
the right ventricle. The lungs remain clear. There is no
pneumothorax.
.
Cardiac Cath ([**2148-1-24**]): COMMENTS:
1. Selective coronary angiography in this left dominant system
demonstrated two vessel disease. The LMCA had no
angiographically apaprent disease. The LAD had a proximal 50%
stenosis and a long 50% mid vessel stenosis. The Cx had a 70%
proximal stenosis as well as a 60% stenosis in the L-PDA. There
was a subtotal occlusion of a small ramus that came off of the
Cx. Both the Cx and the LAD were small diffusely diseased
vessels. The RCA was a small non-dominant vessel with an 80%
ostial stenosis as well as an 80% mid vessel stenosis.
2. Limited resting hemodynamics revealed elevated left and rigth
sided filling pressures with an RVEDP of 19 mmHg and a PCWP of
20 mmHg. There was moderate pulmonary artery hypertension with a
PASP of 53 mmHg. The cardiac index was preserved at 3.5
L/min/m2. The SVR was slightly decreased at 760 dynes-sec/dm5
and the PVR was slightly increased at 140 dynes-sec/cm5. The
central aortic pressure was 130/60 mmHg.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Moderate left and right ventricular diastolic dysfunction.
3. Moderate primary pulmonary hypertension.
Brief Hospital Course:
67 yo M with DM, HTN presents following VF-arrest s/p shock x1
with conversion to sinus tach and initiated on arctic sun
cooling protocol.
.
# VF arrest: The patient was found in VF arrest this morning.
His down time was very brief as his arrest occurred outside a
firestation and was witnessed by a police officer. He was
shocked x1 with conversion to sinus tach. At the OSH, he was
initially given 100mg IV lidocaine and amiodarone 150mg bolus,
and transferred on amiodarone 1mg/hr. He was initiated on artic
sun protocol prior to transfer. The cardiac arrest and
neurology teams followed the patient. Head CT was negative for
an bleed or other intracranial process. He was rewarmed after
18hours with full neurologic recovery. His amiodarone had to be
discontinued secondary to QT prolongation. He was transitioned
to metoprolol for rate control. The cause of his arrest is most
likely felt to be secondary to ischemic. Cardiac enzymes did
increase, but were not out of proportion of the degree of
elevation that might be attributed to the shock alone. After
waiting several days for the patient's renal function to imrpove
to baseline, he underwent cardiac catheterization which showed
diffuse two vessel disease, moderate left and right systolic
dysfunction, and moderate primary pulmonary hypertension. No
intervention was done because of diffuse disease. An ICD was
placed on [**2148-1-25**] for secondary prevention. Patient tolerated
the procedure well. He will follow up in the device clinic in
one week.
.
#. Respiratory Failure/Aspiration Pneumonia: The patient
required intubated in the field after being found unresponsive
and in VF arrest. His CXR showed pulm edema, but no other acute
abnormality. The patient developed purulent thick secretions
and was found to have MSSA in his sputum. He was treated
initally with broad spectrum antibiotics and then transitioned
to ceftriaxone to complete a 8 day course. Despite the
aspiration pneumonia and the pulmonary edema the patient was
extubated successfully after 4 days.
.
# Acute systolic heart failure: The patient's echocardiogram
showed an EF of 35-40% after the shock and resuscitation,
although repeat Echos showed improvement in ejection fraction,
and only focal hypokinesis at the apex.
.
# Diabetes Mellitus: The patient was previously on oral
hypoglycemic medications. However, he required an insulin drip
during his stay in the ICU and then was transitions to lantus
with sliding scale insulin. He was discharged home on previous
outpatient PO regimen.
.
# HTN: The patient did become hypotensive requiring pressors
during this hospitalization; however, after the rewarming
period, his blood pressure increased and he was placed on the
following anti-hypertensive regimen: Toprolol 75mg daily,
lisinopril 2.5mg daily.
.
# Acute kidney injury: The patient's Creatinine increased to 1.7
in the setting of diuresis, the initiation of an ace inhibitor
and low normal blood pressures. His [**Last Name (un) **] was attributed to poor
renal blood flow. The diuresis and ACE were discontinued. His
creatinine improved to 0.9, which was sufficiently low for
cardiac catheterization. On discharge, his creatinine was 0.8.
Medications on Admission:
lipitor 10', metformin 1000'', flovent 2puffs '', prilosec 40',
zantac 150, xalatan eye drops left eye qhs, glyburide 6mg [**Hospital1 **],
actos 45 daily.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
4. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*30 Capsule(s)* Refills:*0*
5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day.
8. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day:
Do not start taking until Saturday [**2148-1-27**] am. .
9. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a
day.
10. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
13. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 2 days.
Disp:*8 Capsule(s)* Refills:*0*
14. Outpatient Lab Work
please check CMP on [**2147-1-28**]
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Ventricular fibrillation Arrest
Non ST Elevation myocardial Infarction
Hypertension
Diabetes Mellitus
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You had ventricular fibrillation and required CPR and shocks to
revive you. You were on a ventilator and have recovered well.
Your kidneys were not working well, but have improved. You will
need to get you labs checked on Monday [**1-29**]. You had a
cardiac catheterization that showed multiple moderate blockages
in your coronary arteries. This was not amenable to bypass
surgery so we started medicines that may prevent the blockages
from getting larger. You will need to take your medicines every
day, follow a cardiac diet and control your blood sugars well to
prevent your heart disease from worsening. You received an
internal defibrillator to shock your heart if it has ventricular
fibrillation again. You cannot lift more than 5 pounds with your
left arm or lift your left arm over your head for 6 weeks.
Discuss when you should return to work with your new primary
care doctor, Dr. [**Last Name (STitle) **].
.
New Medicines:
1. Metoprolol Succinate: to control your heart rhythm and help
your heart recover.
2. Increase Aspirin to 325 mg: to prevent a heart attack
3. Increase Atorvastatin to 80 mg
4. Start Lisinopril to treat high blood pressure and help your
heart recover
5. Start Furosemide (Lasix) to prevent fluid from building up.
6. Start plavix 75mg: to prevent a future heart attack
7. Start Benzonatate to take as needed for cough.
Followup Instructions:
Primary Care:
[**First Name8 (NamePattern2) 11805**] [**Last Name (NamePattern1) **], MD with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**Hospital Ward Name 23**] Clinical
Center 6 South . Phone: [**Telephone/Fax (1) 250**] Date/Time: [**2-5**] at 2:35pm
.
Cardiology:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 62**] Date/time: [**2-27**] at
3:20pm. [**Hospital Ward Name 23**] Clinical Center [**Location (un) 436**], [**Hospital Ward Name 516**], [**Hospital1 18**],
[**Location (un) **], [**Location (un) 86**].
.
Electrophysiology:
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62**] Date/time:
[**4-12**] at 3:40pm. [**Hospital Ward Name 23**] Clinical Center [**Location (un) 436**], [**Hospital Ward Name 5074**], [**Hospital1 18**], [**Location (un) **], [**Location (un) 86**].
.
Device Clinic: [**2148-2-2**] 10:00
[**Hospital Ward Name 23**] Clinical Center [**Location (un) 436**], [**Hospital Ward Name 516**], [**Hospital1 18**], [**Location (un) **], [**Location (un) 86**].
.
[**Hospital **] clinic: Phone: [**Telephone/Fax (1) 2378**] Date/time: One [**Last Name (un) **] Place,
[**Location (un) 86**]
Dr. [**Last Name (STitle) **] will set up a referral at [**Last Name (un) **].
ICD9 Codes: 5849, 4275, 2724, 4280, 4019, 2875, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1277
} | Medical Text: Admission Date: [**2154-4-24**] Discharge Date: [**2154-5-3**]
Date of Birth: [**2075-10-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2154-4-24**] Minimally invasive mitral valve replacement with a size
27 St. [**Male First Name (un) 923**] tissue valve
History of Present Illness:
This is a 78 year old male with known mitral regurgitation for
the last several years. PMH also notable for COPD. Despite
tobacco cessation two years ago along with adjustment in Lasix
and multiple inhalers, he continues to experience worsening
shortness of breath with minimal activity. He denies chest pain,
orthopnea, PND, presyncope, syncope and pedal edema. After
extensive evaluation, he has been referred for possible mitral
valve surgery.
Past Medical History:
Chronic Systolic Heart Failure
Mitral Regurgitation
Hypertension
Abd Aortic Aneurysm
Chronic Renal Insufficiency
Peripheral arterial disease
Chronic obstructive pulmonary disease
Type II Diabetes
Dyslipidemia
?Adrenal disorder
History of GI bleed
Anemia
Kidney Stones
?History of Gallstones
Presbycusis - has hearing aides but does not wear them
s/p AAA endovascular repair at [**Hospital1 112**] in [**2148**]
s/p Cataracts - bilateral
s/p Tonsillectomy
s/p Tympanostomy Tube
Social History:
Lives alone
Occupation: Retired
Tobacco: 60 PYH, quit 2 years ago
ETOH: 1 drink/day
Family History:
non-contributory
Physical Exam:
Pulse: 89 Resp: 16 O2 sat: 96%
B/P Right: 134/64 Left: 132/83
Height: 5'9" Weight: 155 lbs
General: Well-developed male in no acute distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur 2/6 systolic
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema:trace
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: - Left: -
Pertinent Results:
[**2154-4-24**] Echo: PRE-BYPASS: The left atrium is markedly dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium or left atrial appendage. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses and cavity size
are normal. Overall left ventricular systolic function is
moderately depressed (LVEF= 30-35 %). The right ventricular
cavity is mildly dilated with moderate global free wall
hypokinesis. There are three aortic valve leaflets. The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are moderately thickened. The mitral valve
leaflets are myxomatous. The mitral valve is abnormal. Moderate
to severe (3+) mitral regurgitation is seen. There is no
pericardial effusion. Coronary sinus catheter, pulmonary vent
and venous access cannulae positioned under TEE guidance
POST CPB: 1. Bioprosthetic valve in mitralposition. Well seated
and stable. Good leaflet excursion. Trace valvular MR. 2.
Unchanged left and right ventricular function with inotropic
support. 3. Intact aorta
[**2154-5-3**] 04:35AM BLOOD WBC-11.8* RBC-3.22* Hgb-11.0* Hct-31.6*
MCV-98 MCH-34.2* MCHC-34.9 RDW-14.4 Plt Ct-258
[**2154-5-2**] 04:20AM BLOOD WBC-10.8 RBC-3.40* Hgb-11.1* Hct-33.3*
MCV-98 MCH-32.6* MCHC-33.3 RDW-14.3 Plt Ct-219
[**2154-5-3**] 04:35AM BLOOD PT-13.4 PTT-26.4 INR(PT)-1.1
[**2154-4-28**] 03:12AM BLOOD PT-13.2 PTT-27.8 INR(PT)-1.1
[**2154-5-3**] 04:35AM BLOOD Glucose-119* UreaN-33* Creat-1.4* Na-135
K-4.3 Cl-96 HCO3-29 AnGap-14
[**2154-5-2**] 04:20AM BLOOD Glucose-116* UreaN-31* Creat-1.4* Na-138
K-4.2 Cl-98 HCO3-30 AnGap-14
[**2154-5-1**] 04:40AM BLOOD Glucose-151* UreaN-31* Creat-1.5* Na-139
K-4.8 Cl-100 HCO3-29 AnGap-15
[**2154-4-30**] 04:45AM BLOOD Glucose-109* UreaN-40* Creat-1.8* Na-140
K-4.0 Cl-100 HCO3-28 AnGap-16
Brief Hospital Course:
The patient was brought to the operating room on [**2154-4-24**] where
the patient underwent minimally invasive Mitral Valve
Replacement with a 27mm tissue valve. Overall the patient
tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support.
On POD 1 the patient did have a seizure and neurology was
consulted. Dilantin was started. The patient likely had a CVA
per neurology. Beta blocker was initiated and the patient was
gently diuresed toward the preoperative weight. He developed
atrial fibrillation and amiodarone was started. He did become
drowsy after a dose of Ativan and required BIPAP at night. He
made further progress and was transferred to the telemetry floor
for further recovery on POD 4. Chest tubes and pacing wires
were discontinued without complication. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. Repeat brain MRI showed No evidence of
acute infarct, moderate-to-severe atrophy and small vessel
disease.
By the time of discharge on POD 9, the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged to [**Hospital **] Health Care
in good condition with appropriate follow up instructions.
Medications on Admission:
FORMOTEROL FUMARATE [FORADIL AEROLIZER] - (Prescribed by Other
Provider) - 12 mcg Capsule, w/Inhalation Device - 1 (One)
inhaled twice a day
FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet -
1-1.5 Tablet(s) by mouth daily every M-W-F he takes an
additional 20mg (1.5 Tablet) Tu-Th-Sat-Sun 40mg one tablet
GLIPIZIDE - (Prescribed by Other Provider) - 5 mg Tablet -
0.5(One half) Tablet(s) by mouth daily\
LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - one
Tablet(s) by mouth daily
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 25 mg
Tablet - 0.5 (One half) Tablet(s) by mouth twice a day
MOM[**Name (NI) **] [[**Name2 (NI) **] TWISTHALER] - (Prescribed by Other
Provider) - 220 mcg (60) Aerosol Powdr Breath Activated - 1
(One) twice a day
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - one Capsule(s) by mouth daily
SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet -
0.5 (One half) Tablet(s) by mouth daily
Medications - OTC
ASCORBIC ACID [VITAMIN C] - (Prescribed by Other Provider) -
1,000 mg Tablet - one Tablet(s) by mouth daily
ERGOCALCIFEROL (VITAMIN D2) [VITAMIN D] - (Prescribed by Other
Provider) - 1,000 unit Capsule - one Capsule(s) by mouth twice
daily
FERROUS SULFATE - (Prescribed by Other Provider) - 325 mg (65
mg iron) Tablet - one Tablet(s) by mouth twice daily
MAGNESIUM OXIDE [MAG-OXIDE] - (Prescribed by Other Provider) -
400 mg Tablet - 3 Tablet(s) by mouth daily
MULTIVITAMIN - (Prescribed by Other Provider) - Tablet - one
Tablet(s) by mouth daily
Discharge Medications:
1. glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruritis.
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever, pain.
7. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO BID (2 times a day).
9. magnesium oxide 400 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. ascorbic acid 500 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. phenytoin sodium extended 100 mg Capsule Sig: One (1)
Capsule PO Q 8H (Every 8 Hours).
13. metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
15. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO QID (4 times a day) as needed for
indigestion .
16. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
17. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours) as needed for constipation.
18. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
19. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed for sob/wheezing.
20. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
21. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
22. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
23. potassium chloride 10 mEq Tablet Extended Release Sig: Four
(4) Tablet Extended Release PO DAILY (Daily).
24. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: MD
to dose daily for goal INR [**2-21**] dx: a-fib/flutter.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Health Care
Discharge Diagnosis:
Mitral valve regurgitation s/p Minimally invasive mitral valve
repair
postop seizure
postop CVA
postop A Fib
Past medical history:
Chronic Systolic Heart Failure
Hypertension
Abd Aortic Aneurysm
Chronic Renal Insufficiency
Peripheral arterial disease
Chronic obstructive pulmonary disease
Type II Diabetes
Dyslipidemia
?Adrenal disorder
History of GI bleed
Anemia
Kidney Stones
?History of Gallstones
Presbycusis - has hearing aides but does not wear them
Past Surgical History:
s/p AAA endovascular repair at [**Hospital1 112**] in [**2148**]
s/p Cataracts - bilateral
s/p Tonsillectomy
s/p Tympanostomy Tube
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Right groin - healing well, no erythema or drainage
Edema - none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
Labs: PT/INR
Coumadin for atrial flutter
Goal INR [**2-21**]
First draw day after discharge [**2154-5-4**]
Then please do INR checks [**Month/Day/Year 766**], Wednesday, and Friday for 2
weeks then decrease as directed by MD
You are scheduled for the following appointments
Surgeon: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 766**] [**5-27**] @ 1:15 pm
Cardiologist: Dr.[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] NP Fri [**5-24**] @ 3:10 pm at [**Hospital1 2292**] [**Location (un) 38**] office
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 17465**] in [**2-21**] 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**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2154-5-3**]
ICD9 Codes: 4240, 5849, 9971, 2851, 496, 5859, 4280, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1278
} | Medical Text: Admission Date: [**2197-11-6**] Discharge Date: [**2197-11-24**]
Date of Birth: [**2124-12-20**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
IR lines
History of Present Illness:
72yo vasculopathic F with ESRD on HD (BL Cr [**4-11**]), bilateral
BKAs, DM2 (HbA1c 5.2), HTN, CHF (EF 50%), hx of MRSA line
infection presents from HD with fever. She completed her HD run
(wts not available in paperwork). There she was HD stable, but
per verbal report 76% RA, Bld cultures were drawn (presumptively
off of the HD line). She was given 750mg of vanco and 60mg of
gentamicin and transferred from [**Hospital1 18**].
.
In the ED, initial vs were 100.8 125 138/70 20 78%RA in triage,
and 102.2 115 94/38 14 99%3L. Patient had more bld cxs drawn.
CXR showed increased opacity on right side (chronic pulmonary
edema +/- mild pleural effusions). Pt was given tylenol and
flagyl (presumptively for asp pna).
.
Per conversation with NH staff Pt had oxygen of 96% thursday and
friday, 93% on monday. They also noted that she has had
decreased appetite, refusing supplements over the last few days,
?right arm swelling, pt had been dening SOB.
.
Of note patient has had mulitple HD lines over the years. Most
recently on [**2197-9-15**] she had an exchange for a non-functioning
HD line.
.
On the floor, she denies pain and is breathing comfortably, but
crying intermittently.
Past Medical History:
1. ESRD on HD since [**2189**]
2. Diabetes mellitus II
3. Orthostatic Hypotension on midodrine
4. Hyperlipidemia: [**4-11**] LDL of 49
5. Peripheral [**Month/Year (2) 1106**] disease
6. Diastolic CHF, LVH, EF 55% in [**7-16**]
7. Chronic upper extremities DVTs
8. CVA x2
9. Seizure d/o s/p CVA
[**99**]. h/o MRSA line sepsis/klebsiella bacteremia, coag neg staph
bacteremia
11. h/o Osteomyletis (L3-L4 vertabrae) '[**92**]
12. h/o Pelvic fx
13. h/o psoas abscess
14. Pericardial tamponade, cardiac perforation post dialysis
catheter change
PAST SURGICAL HISTORY:
1. s/p Right BKA
2. s/p emergent cardiac surgery with sternotomy and drainage in
[**7-16**].
Social History:
Lives at [**Hospital3 **] Home in [**Location (un) 583**], MA. Daughter is
next of [**Doctor First Name **]: [**First Name8 (NamePattern2) **] [**Known lastname **] [**Telephone/Fax (1) 94263**], but friend [**Name (NI) 50269**]
[**Name (NI) **] is HCP. [**Name (NI) **] tobacco, EtOH, drug use.
Family History:
Non-contributory
Physical Exam:
VS: 99.0 114 114/45 11 92%RA, 100%2L
GENERAL: elderly AA female, cachectic, laying in bed, awake,
denies pain and AOx1 (to name, not to date)
SKIN: warm and well perfused, left tunnelled line with tracking
erythema up to above subclavian where line dives deeper, back
with healed sacral decub with very minimal scab.
HEENT: AT/NC, EOMI, pupils sluggish 2 to 1.5mm bilaterally,
anicteric sclera
Neck: Dilated veins throughout neck.
CARDIAC: RRR, S1/S2, 2/6 systolic murmur at USB
LUNG: significant bibasilar crackles, fair air movement, no
wheezes
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly, significantly dilated
superficial veins
M/S: R BKA, L AKA, moves upper extremities, hands tightly
clenched
NEURO: A+O x1 (name), rarely makes eye contact, CN [**Name2 (NI) 12428**]
grossly intact, sensation to touch intact, moves all 4, but
hands are held in contracted position (able to move them).
Pertinent Results:
[**2197-11-6**] 05:30PM PT-27.5* PTT-50.5* INR(PT)-2.8*
[**2197-11-6**] 05:30PM PLT COUNT-140* LPLT-1+
[**2197-11-6**] 05:30PM WBC-9.2# RBC-3.05* HGB-10.8* HCT-32.7*
MCV-108* MCH-35.5* MCHC-33.0 RDW-14.7
[**2197-11-6**] 05:36PM LACTATE-1.7
[**2197-11-6**] 06:25PM ALT(SGPT)-63* AST(SGOT)-72* ALK PHOS-279* TOT
BILI-0.6
[**2197-11-6**] 06:25PM GLUCOSE-176* UREA N-20 CREAT-2.3*# SODIUM-143
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-34* ANION GAP-11
.
[**2197-11-24**] 07:58PM BLOOD WBC-6.7 RBC-2.68* Hgb-9.0* Hct-29.0*
MCV-108* MCH-33.6* MCHC-31.0 RDW-15.9* Plt Ct-555*
[**2197-11-24**] 07:58PM BLOOD PT-26.7* PTT-150* INR(PT)-2.7*
[**2197-11-24**] 09:50AM BLOOD PT-17.2* PTT-67.8* INR(PT)-1.6*
[**2197-11-24**] 09:50AM BLOOD Glucose-84 UreaN-22* Creat-3.7*# Na-140
K-3.7 Cl-102 HCO3-29 AnGap-13
[**2197-11-22**] 02:30AM BLOOD ALT-9 AST-17 LD(LDH)-137 AlkPhos-152*
TotBili-0.6
[**2197-11-24**] 09:50AM BLOOD Calcium-8.7 Phos-5.3* Mg-2.1
[**2197-11-24**] 09:31PM BLOOD Type-ART pO2-48* pCO2-46* pH-7.36
calTCO2-27 Base XS-0
[**2197-11-24**] 09:31PM BLOOD Lactate-4.7*
Brief Hospital Course:
A/P: 72yo vasculopathic F with ESRD on HD (BL Cr [**4-11**]), bilateral
BKAs, DM2 (HbA1c 5.2), HTN, CHF (EF 50%), hx of MRSA line
infection admitted for ongoing MRSA bacteremia and recent yeast
fungemia on dapto as well as MS for pain.
.
#. MRSA + yeast line sepsis: Patient with high grade bacteremia
and fungemia persisting on Abx. HD line removed and grew MRSA at
tip. I&D at site of HD line by surgery. On daptomycin from
[**2197-11-18**] onwards with clear cultures since that time. Therefore
new tunnelled line was placed [**2197-11-24**] by IR. Before that pt has
been on multiple abx regimens to treat her perisitent
bacteremia. TTE had been negative, but TEE was not possible in
this pt. Plan was to continue QOD dapto v vanco for 6 weeks from
last confirmed negative culture per endocarditis protocol. If pt
re-infected to consider chronically infected DVTs and move to
CMO.
.
#. Chronic upper extremity DVTs: On coumadin at home. On heparin
drip for line replacement. Concern is that these clots are
infected and serving as source for her ongoing bacteremia. [**Month (only) 116**]
need long term ABx
.
#. Pain: evidently chronic. Reason unclear. Followed closely for
localizing s/s, but nothing ever really localized. On standing
dilaudid plus breakthrough dose as well as standing tylenol per
palliative care with good effect.4
.
#. ESRD: Lytes stable on HD. Cont nephrocaps, cincalcet
.
#. Seizure d/o s/p CVA. Cont keppra.
.
#. Mental status: Per prior housestaff discussion with HCP, pt
has had subacute decline over the last year. Usually oriented to
self. Appears to be at baseline. Moaning in pain but able to
interact.
.
# Elevated LFTs: Abd exam intermittently concerning, but not
clearly [**Last Name 5283**] problem. [**Name (NI) **] of ALT 63* AST 72* AP 279* on [**11-6**].
Resolved spontaneously.
.
#. DM: RISS
.
#. Anemia: Chronic. Baseline around 29-33. Cont Folic acid and
Procrit at HD. Was using 22 as cutoff for xfusion.
.
#. Chronic orthostatic hypotension: Cont Midodrine 10mg TID
.
#. Glaucoma: Cont Timolol gtts, Lumigan gtt
.
#. Healed sacral decubitus ulcer: Chronic, noted at admission.
.
# Course the day of death: Pt had good AM, went to IR for
tunnelled line placement and returned in the evening hypotensive
and tachycardic. TAchycardia had been a problem for the past 48
hours. Was planning pRBC transfusion. Pt ultimately became
diaphoretic and increasingly tachypneic as well as tachycardic.
Trid IVF with little success. After dinner was noted to be
coughing. Sats dropping. CXR looked improved to last check. ABG
was attempted but seems to have been venous blood. Notably,
lactate was 4.7. Concern was for aspiration PNA v fluid overload
v. PE v. DIC/sepsis. Family was contact[**Name (NI) **] and informed of course
and agreed to current plan of DNR DNI. Pt became apneic and
developed PEA. Eventually pass. Family agreed to autopsy.
Medications on Admission:
Medications on Admission:
Insulin Regular Human 100 unit/mL Injection Injection RISS
** NH says Qmonday
Remeron 15 mg Tab Oral QHS
Dilaudid -- 6mg Solution(s) Four times daily 6a,11a,5p,9p
Dilaudid 6mg PRN Q4 hours
Cinacalcet 30 mg Tab Oral Daily
Ranitidine 150 mg Tab Oral Daily
Adult Aspirin 81 mg Chewable Tab Oral Daily
Keppra 500mg QD at 6pm
Coumadin -- 3.5mg Tablet(s) Once Daily
simvastatin 40mg Daily
Timolol gtts 1gtt Ou Daily
Lumigan 1gtt OU QHS
midodrine 10mg TID, hold SBP >130
Nephrocaps Daily
Folic Acid Daily
ducolax PRN
Nitro paste PRN
Albuterol 90 mcg/Actuation Aerosol Inhaler Inhalation
2 Aerosol(s) Every 4 hrs, PRN
Senna plus 2tabs Daily
Lactulose 10 gram/15 mL Oral Soln Oral 1 Solution(s) Twice Daily
tylenol prn
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
line sepsis
Discharge Condition:
death
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2197-11-27**]
ICD9 Codes: 5856, 7907, 2720, 2767, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1279
} | Medical Text: Admission Date: [**2103-9-27**] Discharge Date: [**2103-10-27**]
Service: SURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
87 M from [**Last Name (un) 1724**] w/ contained ruptured AAA, s/p RP repair w/ 20mm
graft
Major Surgical or Invasive Procedure:
1. Open surgical repair of contained ruptured abdominal aortic
aneurysm with prosethic graft
2. reduction of hiatal hernia
3. CT-guided pigtail catheter placement into the patient's left
pleural space
History of Present Illness:
The patient presented to [**Hospital3 **] Hosptial with a 6 hour
history of abdominal pain. He was found on workup to have a
contained ruptured abdominal aortic aneurysm. The patient was
emergently transferred to [**Hospital1 18**] for operative repair.
Past Medical History:
bladder CA, prostate CA, AAA, EF 65%, mild TR/mild diastolic
dysfunction
Social History:
Lives with wife. retired. [**Name2 (NI) **] in [**Country 5881**].
Family History:
non-contributory
Physical Exam:
On discharge:
98.5 62 120/62 20 95% RA FS: 102-116
Gen: nad
Neuro: alert and oriented x3
Chest: ctab
CV: RRR, no murmur
Abd: s/nd/nt/ +BS
Ext: WWP, pulses: fem/[**Doctor Last Name **]/dp = palp bilateral
PT doppler+ bilateral
Incisions sites: CD and I
Coccyx: irritated and erythematous
Pertinent Results:
Admission labs:
[**2103-9-27**] 08:18PM TYPE-ART PO2-103 PCO2-43 PH-7.35 TOTAL CO2-25
BASE XS--1
[**2103-9-27**] 08:18PM GLUCOSE-125* LACTATE-2.2* K+-4.8
[**2103-9-27**] 03:08PM UREA N-25* CREAT-1.3* SODIUM-146*
POTASSIUM-3.6 CHLORIDE-116* TOTAL CO2-24 ANION GAP-10
[**2103-9-27**] 11:56AM GLUCOSE-80 UREA N-23* CREAT-1.1 SODIUM-147*
POTASSIUM-4.0 CHLORIDE-115* TOTAL CO2-25 ANION GAP-11
[**2103-9-27**] 07:50AM WBC-5.7 RBC-3.74* HGB-11.1* HCT-33.5* MCV-90
MCH-29.7 MCHC-33.2 RDW-15.3
.
Discharge date labs:[**2103-10-27**] 02:41AM
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
5.7 3.38* 9.9* 30.2* 89 29.2 32.7 15.2 263
.
Pathology from surgery:
SPECIMEN SUBMITTED: RETROPERITONEAL MASS & AAA CONTENTS.
Procedure date Tissue received Report Date Diagnosed
by
[**2103-9-27**] [**2103-9-27**] [**2103-10-2**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/cma?????? \
DIAGNOSIS:
A. Retroperitoneal mass:
Portion of normal adrenal gland.
Fibrous tissue with necrosis, calcification, chronic
inflammation and giant cells.
Note: Stains for acid fast bacilli (AFB) and fungus (GMS) are
negative. The changes may represent retroperitoneal fibrosis
related to the aneurysm.
B. Abdominal aortic aneurysm contents: Thrombus.
.
CT scan
IMPRESSION:
1. Bilateral pleural effusions with areas of adjacent passive
atelectasis.
2. Postoperative changes involving the abdominal aorta including
periaortic fluid collections as noted.
3. Hyperattenuating renal lesions noted bilaterally for which
dedicated ultrasound is recommended for further
characterization.
4. Suggestion of splenic and hepatic infarcts as noted.
5. Findings most consistent with postoperative ileus.
Brief Hospital Course:
The patient presented to [**Hospital3 **] Hosptial with a 6 hour
history of abdominal pain. He was found on workup to have a
contained ruptured abdominal aortic aneurysm. The patient was
emergently transferred to [**Hospital1 18**] for operative repair. The
patient was taken to the operating room, where he underwent an
open AAA repair with 20mm dacron graft via a retroperitoneal
approach. A large incarcerated hiatal hernia was also found at
the time of surgery and repaired. The [**Female First Name (un) 899**] was taken down but not
re-implanted due to a profuse amount of backbleeding indicating
good collateralization of blood flow. The patient tolerated the
operative intervention and was transferred to the ICU intubated
and in guarded condition. Due to a massive amount of
intraoperative blood loss, the patient required transfusions of
blood, platelets and cryoprecipitate perioperatively. Pressor
support was slowly weaned off by post-operative day 1.
.
However, the patient developed acute renal failure (ischemic
ATN) post-operatively and was put on CRRT (Continuous Renal
Replacement Therapy) until [**10-14**], at which time he was put on
hemodialysis (requiring intermittent HD). His tunneled line was
removed when became septic. He tolerated hemodialysis on [**10-15**]
and [**10-17**]. His femoral HD catheter came out [**10-17**]. UOP improving
greatly. His creatinine decreased and then plateaued. The
nephrology service felt that the Cr will not return to baseline
(0.9) since AAA involved renal arteries. He will follow-up with
nephrology as an outpatient.
.
He was transferred to the floor on [**10-18**] in stable condition.
.
Skin:
Of note, he has an excoriating rash on coccyx and inguinal
region. He was cared for by wound care specialists - he been
receiving miconazole powder and anti-fungal cream. On the day
of discharge this was resolving.
.
Neuro:
No major issues. On the day of discharge his pain was well
controlled with acetaminophen
.
Cardiovascular:
Aneurysm as described above. In addition, His blood pressure
was well-controlled with lopressor by the day of discharge to
protect his AAA repair.
.
Pulmonary:
The patient also developed a post-operative pleural effusion and
pneumonia that required IR drainage. He had a prolonged
ventilator wean. He was also treated with chest physical
therapy, inhaled albuterol, and incentive spirometry.
.
GI:
The patient was transiently on total parenteral nutrition (TPN)
from [**Date range (1) 29441**] and also briefly on tubefeeds but on the day of
discharge had been advanced to a regular diet. He was followed
closely by our nutrition specialists. However, he is unable at
this time to feed himself secondary to weakness. The patient
has chronic diarrhea. He was ruled out multiple times for c.
difficil infection. He was treated with loperamide to slow down
his stool output.
.
Renal:
Pt had transient renal failure as described above. On the day
of discharge, he had good urine output with a creatinine of 2.4
(trending down from a high of 3.8).
.
ID: During his hospital course, the patient got septic from
pneumonia, growing out Stenotrophomonas from sputum, with
pleural effusion consistent with exudate status post tap. He
was briefly on pressors for blood pressure support. This
infection resolved with antibiotics. On the day of discharge,
he had no active infections, was afebrile, WBC =5.7, and was not
sent home with any antibiotics.
.
Prophylaxis:
The was on subcutaneous heparin. NO acute issues occurred.
Medications on Admission:
Celexa, Buspar
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q4H (every 4 hours) as needed.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
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. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed.
Disp:*1 bottle* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*0*
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
Disp:*1 bottle* Refills:*2*
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
10. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*60 Tablet, Chewable(s)* Refills:*0*
12. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
Disp:*1 bottle* Refills:*2*
13. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 3494**] TCU - [**Hospital1 8**]
Discharge Diagnosis:
1. abdominal aortic aneurysm ruptured (Ruptured type 4
thoracoabdominal aneurysm)
2. history of bladder cancer
3. history of prostate cancer
Discharge Condition:
stable to rehabilitation facility
Discharge Instructions:
You have had a surgical repair of your abdominal aortic
aneurysm.
Discharge Instructions: Please call your doctor or return to
the ER for any of the following:
* You experience new chest pain, pressure, squeezing or
tightness, or if you have any new back pain as these can be a
sign of a serious complication or bleeding.
*You have decreasing urination, or burning with urination, or
dark colored urine
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Call or return immediately if you have pain that is getting
worse or is changing location or moving to your chest or back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered. Continue on antibiotics for ... days.
* Continue to amubulate several times per day.
Followup Instructions:
1. Please follow-up with Dr. [**Last Name (STitle) 3407**] in Vascular surgery. Please
call to make an appointment: ([**Telephone/Fax (1) 2867**].
2. Please also follow-up with the kidney specialists in
nephrology clinic (Tuesdays) in two weeks. Please call to make
an appointment: [**Telephone/Fax (1) 60**] with Drs. [**Last Name (STitle) 5600**] and [**Name5 (PTitle) **].
3. Please also follow-up with your primary care doctor as soon
as possible. Please call to make an appointment.
ICD9 Codes: 5849, 0389, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1280
} | Medical Text: Admission Date: [**2122-2-26**] Discharge Date: [**2122-3-3**]
Date of Birth: [**2056-6-6**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
trauma/MVC
Major Surgical or Invasive Procedure:
none
History of Present Illness:
64M transferred from [**Hospital3 **] s/p MVC, unrestrained
driver of a high-speed vehicle +rolled over, fully ejected from
the vehicle, +LOC. GSC=3 at scene, intubated at scene and
brought to [**Hospital3 **].
Past Medical History:
PMHx,Allergies,Meds, social history, family history, ROS: unable
to determine
Social History:
nc
Family History:
nc
Physical Exam:
PHYSICAL EXAM:
O: SBP: 70's-120's/palp-70's unstable HR: 100-140
R-intubated AC RR 14 O2Sats:99%
Gen: intubated, best exam: GCS 4T
HEENT: Pupils: 1mm bilat, minimally responsive
Neck: in c-collar
Lungs: +BS bilat
Cardiac: reg rate
Abd: Soft
Extrem: cool to touch
Neuro:
GCS 4T, best exam: grimaces to pain, but does not open eyes, w/d
LLE to pain
Brief Hospital Course:
64 M s/p MVC, unrestrained driver, rollover, ejected, intubated
at scene for GCS 3, needle and L CT placed at OSH with no blood.
+Etoh
hypotensive, tachy in trauma bay--3uPRBC given, femoral a line
placed
.
Injuries:
1)Right diaphysis ulnar Frax
2)[**Doctor First Name **], R temp IPH
3)Aortic Dissection of descending aorta
4)B/L Hemothorax, L pneomothorax
5)B/L Rib frax
6)Mandibular fx, L maxialry sinus, L orbital wall fx, nasal bone
fx
7)Nasal Lac down to cartilage, L Eyelid Lac:down to orbicularis
muscle, chin lac
8)L common corotid throombosis, reconstitution of LIC, LEC
.
The patient was transfered to the TSICU and remained intubated.
The patient's family arranged for special religious ceremonies
and the patient was made CMO on [**3-3**]. The patient died at 1430
on [**3-3**]. Autopsy was refused
Medications on Admission:
n/a
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
na
Followup Instructions:
na
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1281
} | Medical Text: Admission Date: [**2120-6-12**] Discharge Date: [**2120-6-21**]
Date of Birth: [**2043-10-16**] Sex: F
Service: MEDICINE
Allergies:
Demerol / Vicodin / amiodarone / Ace Inhibitors
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
asymptomatic AFib/RVR
Major Surgical or Invasive Procedure:
Internal defibrillator placement
History of Present Illness:
76y/o lady with DM2, AFib on Warfarin s/p DCCV [**2116**] and also 2
weeks ago, h/o rheumatic fever s/p mechanical AVR and MVR in
[**2098**], systolic CHF (EF=20-25%), interstitial lung disease on
home O2 (question of amio toxicity), and h/o strep endocarditis
who was referred to the ED from her PCP's office due to
AFib/RVR, and is admitted to the CCU due to difficulty
controlling her HR in the ED.
.
Of note, she was recently admitted [**Date range (1) 69954**] from her PCP's
office due to AFib/RVR in the setting of UTI and volume
depletion from uptitrated diuretics. At that time, she was
given Diltiazem IV in the ED, dropped her BP, and was admitted
to the CCU. She was successfully cardioverted [**5-30**] and was in
NSR at the time of discharge. Her Lasix dose was decreased, her
Lisinopril was stopped due to hypotension, and she was started
on Cefpodoxime for UTI.
.
She has been doing well overall since discharge. Denies any
chest pain, worsened shortness of breath, lightheadedness, leg
swelling. 2 nights ago she felt the sudden onset of
palpitations; she took her pulse which was 160 so she figured
she might be back in AFib but she hoped it would only be
temporary. A few times since then, she repeated the pulse and
it was ~130. Today she was at her post-discharge PCP [**Name9 (PRE) 702**]
and was found to be in AFib/RVR so she was referred to the ED.
.
In the ED, initial VS were: T 98, HR 151, BP 108/67, RR 20, POx
100% 3L NC. EKG confirmed AFib/RVR, no changes concerning for
ischemia. Labs were notable for Cr 1.8 (this is the lowest it
has been in years), and therapeutic INR at 2.7. She was given
500cc normal saline over 45 minutes with no change in HR, but
she and developed mild crackles at the lung bases without
dyspnea or decrease in O2 sat. She was then given Diltiazem
10mg IV x1 with HR still 140's but BP dropped to 80/50. She was
Digoxin loaded with 0.5mg IV. She was started on a Diltiazem
gtt and was admitted to the CCU due to trouble controlling her
HR. VS prior to transfer were: HR 130-150, BP 108/70, RR 12,
POx 100% 2L NC.
.
On arrival to the CCU, she feels well. No chest pain, no
palpitations. She is at her baseline level of shortness of
breath (feels dyspneic even when walking a few feet).
.
REVIEW OF SYSTEMS
Pertinent for mild cough that is non-productive.
Also, mild left ankle edema, though better today.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope.
.
.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)DM, (+)HTN, (+)HLD
2. CARDIAC HISTORY: Afib s/p cardioversion in [**2116**], mechanical
MVR and AVR in [**2098**]
-h/o strep endocarditis in [**2115**] s/p 6 weeks of vanc/PCN
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
-psoriasis
-interstitial lung pathology per PFTs in [**3-21**]; felt to possibly
be [**3-14**] amiodarone toxicity.
-gallbladder removal
-hernia repair
-s/p TIA in [**2115**]
-DMII
-Gout
-Hypothyroidism
Social History:
Pt lives in [**Location 29789**] with her daughter and son. She has 5
children, 10 grandchildren, and 1 greatgrandchild.
-Tobacco history: Former, quit 23 yr prior, smoked 1 ppd for
'many years'
-ETOH: Denies
-Illicit drugs: Denies
Family History:
Father - died of MI at age 42
Mother - 2 MI, died of PE.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.7, HR 117, BP 113/64, RR 18, POx 97% 3L NC
GENERAL: Obese lady in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: Moon facies. Sclera anicteric. PERRL, EOMI. Conjunctiva
were pink, no pallor or cyanosis of the oral mucosa.
NECK: Obese, no JVD.
CARDIAC: Loud/mechanical clicks audible, irregularly irregular
and tachycardic. No murmur.
LUNGS: Mild bibasilar crackles.
ABDOMEN: Obese but nondistended, no masses.
EXTREMITIES: Mild left ankle/foot edema.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
DISCHARGE PHYSICAL EXAM:
VS: T 98.8/98.6 HR 69-70 SR BP 100-142/56-72 RR 18-20 O2 96-99%
3L NC
GENERAL: Obese lady in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: Moon facies.
NECK: Obese, JVD at 16cm
CARDIAC: Loud/mechanical clicks audible, RRR.
Incision: Left chest ICD incision, dressing c/d/i, no bleeding/
small atable hematoma/ mild ecchymosis. 2+ radial and ulnar
pulses, + CSM left hand
LUNGS: Decreased crackles BB.
ABDOMEN: Obese but nondistended, no masses.
EXTREMITIES: [**2-12**]+ bilat edema to knee
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
Labs on Admission:
[**2120-6-12**] 03:50PM BLOOD WBC-9.7# RBC-3.97* Hgb-12.9 Hct-42.3
MCV-107* MCH-32.6* MCHC-30.6* RDW-15.6* Plt Ct-152
[**2120-6-17**] 06:52AM BLOOD WBC-5.9 RBC-3.59* Hgb-11.6* Hct-37.3
MCV-104* MCH-32.2* MCHC-31.0 RDW-15.3 Plt Ct-136*
[**2120-6-12**] 03:50PM BLOOD PT-27.7* PTT-34.0 INR(PT)-2.7*
[**2120-6-12**] 03:50PM BLOOD Glucose-171* UreaN-33* Creat-1.8* Na-141
K-4.9 Cl-104 HCO3-25 AnGap-17
[**2120-6-13**] 03:03AM BLOOD ALT-41* AST-61*
[**2120-6-13**] 03:03AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.7
.
Imaging:
.
Chest x-ray [**6-12**]
FINDINGS: Single AP upright portable view of the chest was
obtained. The
patient is status post median sternotomy. The cardiac
silhouette remains
moderate-to-severely enlarged. The aorta is calcified. There
is mild
pulmonary vascular congestion. Hazy opacity projecting over the
left
costophrenic angle may relate to overlying soft tissue, although
a pleural
effusion cannot be excluded. Small right pleural effusion is
also difficult
to exclude.
IMPRESSION: Persistent moderate-to-severe enlargement of the
cardiac
silhouette. Difficult to exclude small bilateral pleural
effusions.
Pulmonary vascular congestion.
.
Renal US/Artery Doppler:
1. Bilateral renal cysts, as described above.
2. The left kidney is decreased in size. Left arterial
waveforms demonstrate blunted systolic upstroke, suggestive of
renal artery stenosis.
.
Chest x-ray [**6-19**]:
FINDINGS: There is a biventricular pacemaker in the left chest
wall with
leads in the right atrium, right ventricle, and a third lead
through the
coronary sinus. There is no pneumothorax. Left retrocardiac and
right basilar opacities are likely atelectasis. There is mild
improvement in pulmonary edema. Cardiomediastinal silhouette is
unchanged. There is no focal consolidation or pleural
effusions.
IMPRESSION:
1. Biventricular pacemaker/AICD with leads in appropriate
positioning.
2. Improved pulmonary edema.
.
Labs on D/c:
[**2120-6-21**] 07:00AM BLOOD WBC-8.4 RBC-3.60* Hgb-11.7* Hct-37.3
MCV-104* MCH-32.5* MCHC-31.4 RDW-15.6* Plt Ct-137*
[**2120-6-21**] 07:00AM BLOOD PT-20.7* INR(PT)-2.0*
[**2120-6-21**] 07:00AM BLOOD UreaN-38* Creat-1.5* Na-146* K-4.5 Cl-102
HCO3-38* AnGap-11
[**2120-6-21**] 07:00AM BLOOD Mg-2.4
Brief Hospital Course:
BRIEF CLINICAL SUMMARY:
Ms. [**Known lastname **] is a 76y/o lady with DM2, AFib on Warfarin s/p
DCCV [**2116**] and also 2 weeks ago, h/o rheumatic fever s/p
mechanical AVR and MVR in [**2098**] on warfarin, systolic CHF
(EF=20-25%), and interstitial lung disease on home O2 (question
of amio toxicity) who presents with recurrent AFib/RVR. She had
a BiV ICD placed and was started on dofetilide prior to
discharge, without complication.
ISSUES:
#. AFib with RVR: Patient had successful AC cardioversion on
[**2120-6-12**] from atrial fibrillation to sinus rhythm. The patient
then went back into atrial fibrillation, and dofetilide was
started, with conversion to sinus rhythm on [**2120-6-14**]. She then
had sinus bradycardia (likely from left atrial focus, not
actually sinus) with QT >500ms and offset pauses >3 seconds.
She had a BiV ICD placed on [**2120-6-18**], with future consideration
for AVJ ablation if Afib persists and is difficult to control.
The patient did have LUQ/flank discomfort post-procedurally
which may have been secondary to intermittent phrenic nerve
pacing, and the LV lead output was adjusted. The patient was
restarted on dofetilide 125mcg [**Hospital1 **], and QTc remained stable on
serial ECGs. The patient was also discharged on po Carvedilol
12.5mg [**Hospital1 **] and warfarin 5 mg M/Th and 2.5mg all other days. INR
on day of discharge 2.0. Goal INR for home is 2.5-3.5.
#. Chronic systolic CHF: Recent TTE showed EF 20-25% with TR and
mod PHTN. The patient's ACE-inhibitor was stopped, as was very
likely to be contributing to renal issues. The patient received
PRN diuresis with lasix in addition to home torsemide when
appeared volume up. The patient was discharged to home on
torsemide 20mg qd and carvedilol 12.5mg [**Hospital1 **].
#. CKD: Cr 1.5 on day of discharge, much better than ??????baseline??????.
Has left sided renal artery stenosis on renal ultrasound. While
in the hospital, avoided nephrotoxins, renally dose meds (e.g.
Allopurinol). We discontinued ACE-inhibitor and renal function
substantially improved, making us believe that the lisinopril
was likely contributing to renal dysfunction.
#. h/o rheumatic fever s/p mechanical AVR and MVR: stable.
Valves well seated on last TTE. INR therapeutic at admission.
Warfarin was held, and heparin drip started in anticipation of
ICD implantation and continued while INR<2.5. Warfarin
restarted after implantation, and INR increased to 2.0 by day of
discharge. She was discharged on warfarin 5 mg M/Th and 2.5mg
all other days at home, which is usual home dose, without
lovenox bridge. INR goal of 2.5-3.5 for mechanical mitral valve.
#. Interstitial lung disease: stable. At home she uses 3-5L NC
for interstitial lung disease thought to be from amiodarone
toxicity. We continued supplemental home O2 in the hospital,
and continued steroids. Discharged home on prednisone 15mg qd,
with continued slow taper to be directed by outpatient
practitioners.
#. Diabetes: stable. Steroids likely the cause of high blood
sugars, not DM-2. the patient was maintained on a diabetic diet.
hyperglycemia was treated with Humalog sliding scale while in
the hospital.
#. Gout: stable. continued Allopurinol (renally dosed)
#. Hypothyroidism: stable. continued Levothyroxine
TRANSITIONS OF CARE:
- Ace-inhibitor likely contributing contributing to renal
failure. Would strongly recommend against restarting an
ACE-inhibitor.
- monitor renal function intermittently as outpatient in setting
of dofetilide use
- INR monitoring for mechanical AVR/MVR
Medications on Admission:
carvedilol 12.5 mg [**Hospital1 **]
furosemide 40 mg daily
warfarin 5 mg MO,TH and 2.5 mg other days
prednisone 15 mg daily
levothyroxine 25 mcg daily
citalopram 20 mg daily
allopurinol 300mg daily
fluticasone 50 mcg/actuation Spray: 1 spray [**Hospital1 **]
folic acid 1 mg daily
ferrous sulfate 300 mg (60 mg iron) daily
multivitamin w/minerals daily
.
Discharge Medications:
1. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
2. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. warfarin 5 mg Tablet Sig: One (1) Tablet PO MONDAY AND
THURSDAYS ().
4. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO TUES, WED, FRI,
SAT, SUN ().
5. prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
12. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
13. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime).
14. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
15. dofetilide 125 mcg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
Disp:*60 Capsule(s)* Refills:*2*
16. Outpatient Lab Work
Please check INR, Chem 7 on Monday [**6-24**] with results to Dr.
[**Last Name (STitle) **] at Phone: [**Telephone/Fax (1) 68055**]
Fax: [**Telephone/Fax (1) 93673**]
ICD 9: 427.31
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Atrial fibrillation
Chronic Systolic congestive heart failure
Chronic Kidney disease
Hypertension
Intersticial Lung disease
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:
It was a pleasure caring for you at [**Hospital1 18**].
Your atrial fibrillation was beating very fast and we tried to
give you medicine to slow the rhythm but this led to a
dangerously slow heart rate. A pacemaker was placed and now you
are tolerating the medicine well. You will go home on dofetalide
to control your heart rate. No lifting more than 5 pounds with
your left arm or lifting your left arm over your head for the
next 6 weeks.
Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. START taking dofetalide to slow your heart rate
2. Decrease allopurinol to 100 mg daily
3. Stop taking furosemide, take torsemide instead to get rid of
extra fluid
4. START taking fluticasone inhaler to help improve your lung
function
Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2120-6-27**] at 9:00 AM
With: [**First Name11 (Name Pattern1) 539**] [**Last Name (NamePattern4) 13861**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) 68054**],[**First Name3 (LF) **]
Location: HEALTHWORKS
Address: [**Street Address(2) 93672**], [**Location (un) **],[**Numeric Identifier 9310**]
Phone: [**Telephone/Fax (1) 68055**]
Appointment: Wednesday [**2120-6-26**] 3:00pm
Name: [**Last Name (LF) **], [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD
Address: [**Hospital1 **], [**Location (un) **],[**Numeric Identifier 6425**]
Phone: [**Telephone/Fax (1) 6937**]
*Please call your cardiologist to book a follow up appointment
for your hospitalization. You need to be seen within 1 month of
discharge.
ICD9 Codes: 4168, 4280, 5859, 2749, 496, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1282
} | Medical Text: Admission Date: [**2124-6-25**] Discharge Date: [**2124-6-28**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
fever and cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Dr. [**Known lastname 2916**] is a [**Age over 90 **] year old gentleman with a PMH significant for
Alzheimer's dementia and BPH admitted for cough and fever. The
patient and his wife report a [**1-11**] week history of productive
cough, malaise, fatigue, rhinorrhea, and decreased PO intake.
Yesterday evening, the patient's wife felt that he was feverish,
and this morning noted an oral temperature of 101.3. He was then
transported to [**Hospital1 18**] for further evaluation.
.
In the [**Hospital1 18**] ED, VS 98.3 108/55 90 18 94%2L nc. The patient had
two CXRs (AP and PA/lateral) with suspicion for LLL
consolidation, for which he received vancomycin and
pipi/tazobactam. He also had a negative RUQ U/S for his
hyperbilirubinemia. The patient was febrile to 101.2 rectal in
the ED, and he received 2L IVF with a venous lactate that
trended from 4.9 to 3.7. He was then transferred to the [**Hospital Unit Name 153**] for
further management given concern for developing sepsis. Of note,
the patient's wife states that he has had increased coughing
with meals on further questioning.
.
Currently, the patient is resting comfortably without
complaints. Denies CP/SOB, f/c/s, n/v/d
.
ROS: Increased lower back pain over the past 6 months, no recent
falls. Per wife, lower back pain is associated with constipation
with improved symptoms after defecation. Last BM 2+ days ago. As
above, otherwise negative.
Past Medical History:
Alzheimer's Dx (per wife, baseline oriented to person and place)
BPH
Neuropathy - couple of years ago that resolved spontaneously
Social History:
Former navy flight physician and retired internist. Lives with
wife at [**Hospital3 **]. Denies tobacco, EtOH, IV,
illicit, or herbal drug use. Dependent on wife and home health
aide for IDLs.
Family History:
NC
Physical Exam:
VS 96 70 122/57 18 100%3Lnc 92%RA
Gen: Age appropriate male in NAD
HEENT: Perrl, eomi, sclerae anicteric. MM dry, OP clear without
lesions, exudate or erythema. Neck supple.
CV: Nl S1+S2, no m/r/g.
Pulm: Bibasilar rales L>R
Abd: Mild TTP in RLQ, no rebound or guarding. +bs
Back: No TTP midline, no CVA
Ext: Trace edema bilaterally.
Neuro: Oriented to person and place (at baseline). CN II-XII
grossly intact.
Pertinent Results:
[**2124-6-25**] 09:35AM BLOOD WBC-18.3*# RBC-3.34* Hgb-12.0* Hct-34.7*
MCV-104*# MCH-35.8*# MCHC-34.4 RDW-14.6 Plt Ct-166
[**2124-6-26**] 05:26AM BLOOD WBC-9.7 RBC-2.91* Hgb-10.2* Hct-31.2*
MCV-107* MCH-35.1* MCHC-32.7 RDW-14.7 Plt Ct-124*
[**2124-6-25**] 09:35AM BLOOD Glucose-210* UreaN-18 Creat-1.3* Na-137
K-4.5 Cl-101 HCO3-22 AnGap-19
[**2124-6-26**] 05:26AM BLOOD Glucose-136* UreaN-16 Creat-0.9 Na-140
K-3.4 Cl-111* HCO3-21* AnGap-11
[**2124-6-25**] 09:35AM BLOOD ALT-38 AST-54* AlkPhos-261* TotBili-2.4*
[**2124-6-25**] 07:45PM BLOOD DirBili-1.0*
[**2124-6-26**] 05:26AM BLOOD ALT-30 AST-51* LD(LDH)-190 AlkPhos-176*
TotBili-1.7*
[**2124-6-26**] 05:26AM BLOOD Albumin-2.3* Calcium-7.1* Phos-2.4*
Mg-1.7
[**2124-6-25**] 09:57AM BLOOD Lactate-4.9*
[**2124-6-26**] 05:49AM BLOOD Lactate-1.8
RUQ u/s [**2124-6-25**]
1. Small gallstones. No evidence for cholecystitis.
2. Two gallbladder polyps measuring up to 6 mm in diameter.
CXR:
Chest CT/abd pending
Brief Hospital Course:
He was treated with aggressive IVF given leukocytosis, fever,
and elevated lactate. The history was concerning for pneumonia
given productive cough and fever, although CXR was without
significant consolidation. He was empirically started on
Vancomycin Ciprofoxacin, and Zosyn for healthcare associated
pneumonia given his residence. He was hemodynamically stable on
arrival to ICU though BP trended down overnight and responded
appropriately to normal saline boluses. He had evidence of mild
acute renal failure but the following morning the creatinine
trended down to baseline and lactate normalized as well. The
source of infection remained unclear. [**Name2 (NI) **] did complain of
transient abdominal tenderness with mild LFTs abnormalities.
RUQ ultrasound showed old gallbladder stones but no sign of
acute cholecystitis or biliary duct dilatation. Speech and
swallow evaluation was conducted and there was no clear evidence
of aspiration. UA was clean and the urine culture was negative.
he had no other focal symptoms. Sputum samples were
contaminated. CT chest and abdomen was performed to evaluate for
intra-abdominal source and further document or rule out
aspiration pneumonia or pneumonitis. The CT showed ground-glass
opacities and tree-in-[**Male First Name (un) 239**] pulmonary nodules in both lower lobes
which most likely represented an infectious process. It did show
cholelithiasis but no evidence of acute cholecystitis. He had
prominent mediastinal, retroperitoneal and pelvic lymph nodes,
more prominent than on the prior study, most of which did not
meet CT criteria for pathologic enlargement. There was multiple
compression fractures, some of which were new from [**2120**]. In
regards to the hyperbilirubinemia, the patient had a benign
abdominal exam and negative RUQ U/S for CBD stones or CBD
dilatation. His LFT's remained the same and he was asked to see
his PCP in one week to follow the trend and conduct further
diagnostic tests, if needed. VNA and home PT were requested.
Total discharge time 45 minutes.
Medications on Admission:
Finasteride 5 mg po daily
ASA 81 mg daily
Lasix unknown daily dose
Calcium/Vitamin D
Claritin
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as
needed for Constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
8. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO TID (3 times a day) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Sepsis
Pneumonia
Abnormal Liver Function tests
Gallstones.
Discharge Condition:
Good.
Discharge Instructions:
You had sepsis (significant infection) related to pneumonia. You
should take the antibiotics for additional 7 days. You also had
abnormal liver function tests. Please follow up with your PCP [**Last Name (NamePattern4) **]
1 week to recheck your liver function tests. You had abdominal
ultrasound and CT and we found gallstones. If you develop any
new concerning symptoms, please call your PCP or return to the
ER.
Followup Instructions:
PCP
ICD9 Codes: 0389, 486, 5070, 5849, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1283
} | Medical Text: Admission Date: [**2143-3-19**] Discharge Date: [**2143-3-28**]
Date of Birth: [**2099-2-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Bactrim / Sulfa (Sulfonamide Antibiotics) / Atazanavir Sulfate
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
mitral valve repair with 32mm annuloplasty ring and
reimplantation of chordae [**2143-3-19**]
History of Present Illness:
The patient is a 43 year old white male who complained of
shortness of breath, chest pain, fatigue and decreased exercise
tolerance. He has a known history of mitral valve
prolapse/mitral regurgitation. Echo reveals 4+MR with a partial
flail anterior leaflet and ruptured chordae with preserved
ejection fraction. He presents for surgical intervention.
Past Medical History:
hypertension
HIV, AIDS
pneumonia
hepatitis A
hepatitis B
aphthuous ulcer
candidal esophagitis
Social History:
works as a property manager
lives alone
tobacco: quit 10-15 years ago
denies recreational drug use
EtOH: 2 glasses of wine per night
Family History:
no family history of premature coronary artery disease
Physical Exam:
VS: 148/92, 76, 18
general: comfortable
HEENT: unremarkable
neck: supple, full ROM
Chest: lungs CTAB
Heart: RRR, +systolic murmur left border
Abdomen: +BS, soft, non-tender, non-distended
Ext: warm, well-perfused, no edema
Varicosities: stage I-II varices L leg
Neuro: grossly intact
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 17606**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 17607**] (Complete)
Done [**2143-3-19**] at 8:45:21 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2099-2-23**]
Age (years): 44 M Hgt (in): 69
BP (mm Hg): 145/78 Wgt (lb): 170
HR (bpm): 67 BSA (m2): 1.93 m2
Indication: Left ventricular function. Mitral valve disease.
Right ventricular function. Shortness of breath. Valvular heart
disease. Intraoperative TEE for mitral valve repair
ICD-9 Codes: 424.0, 786.05
Test Information
Date/Time: [**2143-3-19**] at 08:45 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW5-: Machine: AW5
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *5.8 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.8 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *6.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Ascending: 2.5 cm <= 3.4 cm
Aorta - Descending Thoracic: 2.0 cm <= 2.5 cm
Findings
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness. Moderately
dilated LV cavity. Normal regional LV systolic function. Overall
normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. No atheroma in ascending aorta. Normal
descending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Partial mitral leaflet flail. Torn mitral chordae.
Severe (4+) MR. [**Name13 (STitle) 15110**] to the eccentric MR jet, its severity may be
underestimated (Coanda effect).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
Prebypass
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. Regional left ventricular wall motion is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Instirinsic function is depressed given the degree
of regurgitation. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. There is no
aortic valve stenosis. No aortic regurgitation is seen. There is
partial mitral anteriorleaflet flail. (A3) Torn mitral chordae
are present. Severe (4+) mitral regurgitation is seen. Due to
the eccentric nature of the regurgitant jet, its severity may be
significantly underestimated (Coanda effect). Dr. [**Last Name (STitle) **] was
notified in person of the results on [**2143-3-19**] at 830am.
Postbypass
Patient is in sinus rhythm amd receiving an infusion of
phenylephrine. LVEF is 45%. Globally reduced LVEF. RV function
is normal.
Annuloplasty ring seen in the mitral position. Appears well
seated. Trivial MR and there is NO [**Male First Name (un) **]. Peak gradient across the
mitral valve is 7mm Hg.
Aorta intact post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2143-3-20**] 14:43
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2143-3-19**] for surgical intervention of his mitral
regurgitation. He underwent mitral valve repair, including a
32mm annuloplasty ring and reimplantation of ruptured chordae.
See operative note for further details. Overall the patient
tolerated the procedure well and post-operatively was
transferred to the CVICU in critical but stable condition for
further monitoring and recovery. By POD 1 the patient was
extubated and vasoactive drips were weaned. He was
neurologically intact and hemodynamically stable and transferred
to the telemetry floor on POD 1. His chest tubes were
discontinued on POD 2 without complication. He was progressing
toward discharge but developed a fever 102 and his WBC rose from
4,000 to 11,000. Infectious disease was consulted and he was
placed on broad spectrum IV antibiotics. His fevers abated and
WBC decreased to 6,000 on this regimen. The atelectasis vs
pneumonia on his chest radiograph improved. Although his sputum
was not final by the time of discharge, it preliminarily
revealed normal flora. Blood and urine cultures were negative.
His hematocrit was 26.9 at the time of discharge and he was
placed on iron. He was discharged on post-operative day 9 to
home with a peripherally inserted central catheter and IV
antibiotics to be administered by a visiting nurses association.
These antibiotics will continue until [**2143-4-2**] and surveillance
labs will be followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**] of Infectious
Disease. He was encouraged to make follow-up appointments as
listed in the discharge summary.
Medications on Admission:
diflucan 200'
acyclovir 800'
alprazolam .25prn
dapsone 100'
truvada 200/300'
HCTZ 25'
kaletra 200/500 2tabs''
amoxicillin prn-dental
Discharge Medications:
1. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Acyclovir 800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
7. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
8. Lopinavir-Ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
10. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed.
11. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
12. Outpatient Lab Work
Needs CBC, LFT, BUN/Cre, Vanco trough drawn on Monday [**2143-4-1**]
with results faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**] ([**Telephone/Fax (1) 16411**].
13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days: until [**2143-4-2**] for presumed
pneumonia.
Disp:*10 Tablet(s)* Refills:*0*
14. Cefepime 1 gram Recon Soln Sig: One (1) Recon Soln Injection
Q8H (every 8 hours) for 5 days: until [**2143-4-2**] for presumed
pneumonia.
Disp:*15 Recon Soln(s)* Refills:*0*
15. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
bag Intravenous Q 12H (Every 12 Hours) for 5 days: until [**2143-4-2**]
for presumed pneumonia.
Disp:*10 bag* Refills:*0*
16. Ferrous Sulfate 325 mg (65 mg Iron) Capsule, Sustained
Release Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
17. Zidovudine 100 mg Capsule Sig: Three (3) Capsule PO twice a
day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
mitral regurgitation
s/p mitral valve repair [**2143-3-19**]
PMH: hypertension
HIV, AIDS
pneumonia
hepatitis A
hepatitis B
aphthuous ulcer
candidal esophagitis
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) **] (cardiac surgery) in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) 911**] (cardiology) in 1 week.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (PCP)in [**2-19**] weeks.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (ID) in 2 weeks.
Please call for appointments
Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Needs CBC, LFT, BUN/Cre, Vanco trough drawn on Monday [**2143-4-1**]
with results faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**] ([**Telephone/Fax (1) 16411**].
Completed by:[**2143-3-28**]
ICD9 Codes: 4240, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1284
} | Medical Text: Admission Date: [**2149-11-17**] Discharge Date: [**2149-11-21**]
Date of Birth: [**2080-8-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
Hemodialysis tunnelled line placement
History of Present Illness:
69 yo male with severe PVD, DMI, CVA, CHF (EF >55%), COPD, CKD
and h/o rectal CA (treated with palliative radiation) who
presents with cough and fever. Cough has been progressing over
the past week minimally productive of white sputum. He developed
fever to 100 at home, with chills, therefore came to the ED. He
denies subjective SOB but his wife reports that he has been
tachypneic especially when lying flat. He denies PND, orthopnea,
or LE edema. He denies any chest pain, chest tightness or
palpitations. He has chronically a poor appetite, +
fatigue/malaise at baseline (up to 20 hours sleep/night for
months-years). Chronic diarrhea (?due to pancreatic insuff),
controlled with immodium/lipram. +Occasional blood in stool, no
melena. +Frequency for "months"; no dysuria, urgency. He denies
sick contacts or recent travel. At baseline pt is wheelchair
bound.
Past Medical History:
1. Ischemic colitis [**2-8**], s/p ex lap and rigid sigmoidoscopy
without evidence of ischemic bowel.
2. PVD: s/p right popliteal to dorsalis pedis bypass and left
femoral-popliteal and popliteal-anterior tibial bypass, R CEA,
and right SFA stent.
3. Type I Diabetes mellitus - brittle diabetic; episodes of
severe hypoglycemia and DKA
4. Status post CVA >10 yrs ago.
5. History of CHF with preserved EF
6. COPD- no PFTs in system
7. Hypertension
8. Glaucoma
9. CKD-baseline cr 2.1-2.4 (Cr clearance of 25-30, stage 4)is
preparing for PD with Dr. [**First Name (STitle) 805**] at [**Last Name (un) **]
10. h/o Duodenal ulcer but on EGD above not seen
11. Anemia of chronic disease.
12. Esophageal dysmotility.
13. h/o VRE UTI
14. Rectal CA-dx [**2148**] no surgery due to comorbidities; s/p
palliative XRT
Social History:
Lives with his wife. [**Name (NI) **] smoked for >50yrs at most 2ppd. Remote
heavy EtOH use in past (3+ drinks per day), quit 2-3 years ago.
No recreational drug use. Used to work in greenhouse supply
business, then sold real estate now disabled.
Family History:
Mother colon cancer. Father throat cancer,
brother died of colon cancer at age 62.
Physical Exam:
Gen- Sleeping in bed, mildly tachypnic.
VS: 98.3, 118/80, 75, 24, 93% 2L
HEENT- EOMI. R facial droop (old per pt). MM Dry.
Hrt- RRR. [**1-13**] SM at RLSB.
Lungs- [**Month (only) **] at R base, crackles, rhonchi R lung. Scattered exp
wheezes.
Abd- +BS, NT, ND, no palpable masses
Extrem- No c/c/e.
Pertinent Results:
[**11-17**] Renal US: RENAL ULTRASOUND: Comparison is made with the
prior ultrasound dated [**2149-6-25**]. The right kidney measures
10.7 cm, the left kidney measures 11.2 cm, without evidence of
hydronephrosis, mass, or stone.
.
[**11-17**]: CXR: AP AND LATERAL CHEST: There is consolidation in the
right lower lobe consistent with pneumonia. The heart and
mediastinal contours are normal. The left lung is clear,
although there is underlying hyperinflation. No pleural
effusions or pneumothoraces are seen.
IMPRESSION: Consolidation in the right lower lobe is consistent
with
pneumonia. Follow up radiographs should be obtained to document
resolution.
.
[**11-17**]: CT Chest w/o contrast: IMPRESSION:
1. Limited study due to lack of intravenous contrast [**Doctor Last Name 360**].
2. Extensive soft tissue in the bronchus of the right lower
lobe, with post-
obstructive consolidation in the right lower lobe with effusion,
increased
since prior study dated [**2149-1-8**]. The endobronchial soft
tissue measures
30-40 [**Doctor Last Name **], and can represent protein-[**Doctor First Name **] mucus secretions.
However, in this
patient with history of heavy smoking and history of rectal
cancer, underlying
mass lesion such as primary lung cancer or less likely
endobronchial
metastasis cannot be totally excluded. Bronchoscopy is
recommended.
3. Increased bilateral extensive peribronchial opacities,
probably related to
infectious or inflammatory condition.
4. Unchanged dilated upper esophagus.
5. Extensive coronary artery calcification.
6. Unchanged low dense nodules in the thyroid gland.
.
[**2149-11-17**] 05:05PM URINE HOURS-RANDOM SODIUM-41 POTASSIUM-26
CHLORIDE-21 TOTAL CO2-LESS THAN
[**2149-11-17**] 05:05PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2149-11-17**] 05:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2149-11-17**] 05:05PM URINE RBC-[**2-9**]* WBC-21-50* BACTERIA-MOD
YEAST-NONE EPI-[**2-9**] TRANS EPI-0-2
[**2149-11-17**] 03:50PM GLUCOSE-254* UREA N-69* CREAT-5.3* SODIUM-137
POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-14* ANION GAP-19
[**2149-11-17**] 03:50PM CALCIUM-7.5* PHOSPHATE-9.8*# MAGNESIUM-2.3
[**2149-11-17**] 12:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2149-11-17**] 12:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2149-11-17**] 12:15PM URINE GRANULAR-0-2
[**2149-11-17**] 06:25AM GLUCOSE-139* UREA N-71* CREAT-5.4*#
SODIUM-136 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-12* ANION
GAP-24*
[**2149-11-17**] 06:25AM estGFR-Using this
[**2149-11-17**] 06:25AM proBNP-[**Numeric Identifier 16483**]*
[**2149-11-17**] 06:25AM WBC-8.7 RBC-3.49* HGB-10.6* HCT-31.8* MCV-91
MCH-30.4 MCHC-33.4 RDW-14.2
[**2149-11-17**] 06:25AM NEUTS-78.1* LYMPHS-10.5* MONOS-6.3 EOS-4.8*
BASOS-0.3
[**2149-11-17**] 06:25AM HYPOCHROM-1+
[**2149-11-17**] 06:25AM PLT COUNT-565*
[**2149-11-17**] 06:20AM LACTATE-0.9
Brief Hospital Course:
69 yo male with Type I DM, CKD-ARF, colorectal CA, new R lung
mass, COPD, CHF w/preserved EF who presents with SOB, cough and
fever.
.
#. Hyperglycemia: Pt w/Type I DM, w/known epsiodes of severe
hypoglycemia and DKA. Multifactorial process to account for
uncontrolled BS-inadequate insulin coverage per ED as well as
infectious process. No ketones in urine. Pt was treated with
Insulin gtt and then transitioned to sc insulin once anion gap
was closed. He was hydrated appropriately. [**Last Name (un) **] was consulted
and help with management. His insulin regimen was changed to NPH
12U QAM and 3U of HUmalog with meals in addition to a sliding
scale.
.
#. ARF: Pt w/CKD due to longstanding Type I DM, now w/Cr 5.6 up
from baseline 2.1-2.4. Significant acidemia in setting of
worsening renal failure. Renal team was consulted. Renal U/S
normal, no postobstructive etiology to account for worsening
renal failure. No recent dye load or change in meds. Pt was
given Bicarbonate. Tunnelled cath was placed per Renal to
prepare for possible CVVH vs HD if becomes fluid overloaded
w/current management of hyperglycemia and worsening acidemia.
The patients ARF improved and he never required HD, therefore
tunneled line was pulled on the day of discharge. ACE-I was held
in the context of ARF on CRF.
.
#. Respiratory: New O2 requirement in setting of new R lung
mass, post obstructive PNA. Received 2 doses of levoflox and
flagyl per ED and floor team. Also h/o CHF w/preserved EF-no
current evidence of volume overload. In fact, appears
hypovolemic.
Pt was continued on Levo and will have to complete a 10 day
course. D/c flagyl. Pt contiuned to improve over next days and
had no more O2 reuirement on the day of discharge. The patient
will need a bronchoscopy for tissue dx of new mass as an
outpatient. Cultures of sputum were unrevealing.
.
#. UTI: Initial UA contaminant followed by +UA, Urine culture
negative. Continue coverage w/levofloxacin.
.
#. HTN: Pt well controlled on home regimen. ACE-I were held in
the setting of ARF on CRF. Pt was continued on short acting BB,
Hydralazine. Amlodipine was held initially because of concern
for early sepsis but was restarted before discharge. ACE-I
should be considered again once renal function stable.
.
#. Anemia- baseline Hct is 28/pt currently at baseline. Takes
iron, folate, MVI at home, however, iron studies in the past
have been normal and folate has consistantly been >20. Anemia
likely [**1-9**] chronic disease, CRF (low epo); may have an element
of chronic blood loss due to rectal CA/trace blood in stool. Pt
was continued on supplements and Procrit TIW.
.
# Pancreatic insufficiency- continued Lipram w/meals.
.
# FEN- Diabetic diet. Swallow consult suggested PO diet of thin
liquids and soft consistency solids. Small single sips of thin
liquid and aspiration precuations.
.
# PPX- pneumoboots, PPI, hep sc
.
Code-full
Medications on Admission:
Hydralazine 50mg qd
Metoprolol 50mg [**Hospital1 **]
Insulin NPH 12 qam with Regular 14 qam with occasional night
dose
Amlodipine 5mg qd
Lisinopril 10mg qhs
Omeprazole 20mg qd
Iron
Imodium 1 tab qHS
Lasix 40mg qd
Lipram 4500 2 caps AC
?Phoslo
MVI
Folate
Hectorol 0.5 mg [**Hospital1 **]
Neurontin 100 mg qAM, 200mg qhs
Flaxseed Oil 1000 [**Hospital1 **]
Discharge Medications:
1. Lipram-PN16 Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO before meals ().
2. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
8. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO QHS (once a
day (at bedtime)).
9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every
48 hours) for 7 days: Please take two hours apart from iron
tablets.
Disp:*3 Tablet(s)* Refills:*0*
10. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
11. Calcium Acetate 667 mg Capsule Sig: Three (3) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*200 Capsule(s)* Refills:*2*
12. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*7 Patch 24HR(s)* Refills:*0*
13. Lanthanum 250 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day).
Disp:*180 Tablet, Chewable(s)* Refills:*2*
14. Insulin NPH Human Recomb 300 unit/3 mL Insulin Pen Sig:
Twelve (12) Units Subcutaneous QAM.
Disp:*qs Units* Refills:*2*
15. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: ASDIR
Subcutaneous ASDIR: per sliding scale.
Disp:*qs qs* Refills:*2*
16. Insulin Lispro (Human) 300 unit/3 mL Insulin Pen Sig: Three
(3) U Subcutaneous TID/with meals.
Disp:*qs qs* Refills:*2*
17. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
18. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetes Ketoacidosis
Diabetes mellitus type I
Postobstructive pneumonia
Urinary tract infection
Acute renal failure
Chronic renal failure
Congestive heart failure
Discharge Condition:
Good, no oxygen requirement, good po intake
Discharge Instructions:
You were diagnosed with a postobstructive pneumonia, acute on
chronic renal failure and diabetes ketoacidosis. A mass was
found in your lung on CT scan. You will need to be evaluated for
that as an outpatient. We have arranged follow up for you as
below.
.
Please notify your physicians or come to the emergency room if
you notice any shortness of breath, chest pain, blood in your
sputum, abdominal pain, blood glucose > 400 or any other
concerns.
Followup Instructions:
You have the following appointments scheduled for you:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2149-12-4**] 10:15
.
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2149-12-9**] 9:30
.
Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2149-12-9**] 10:00
Completed by:[**2149-12-4**]
ICD9 Codes: 5849, 4280, 496, 5990, 4439 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1285
} | Medical Text: Admission Date: [**2140-8-21**] Discharge Date: [**2140-8-29**]
Service: MEDICINE
Allergies:
Ampicillin / Penicillins / Bactrim
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
medical intensive care unit stay; femoral venous central line;
History of Present Illness:
82 yo F with history of recurrent UTI's with chronic indwelling
foley, CVA/seizures, htn, AF, who presented from NH with 2-3
days of abdominal pain. She was treated with bowel regimen for
presumed constipation. She also had nausea and 2 episodes of
nonbloody vomiting. In the ED she was febrile to 102.8,
normotensive, and leukopenic (~2.5) with lactate elevated to
6.6. UA showed UTI. MS appeared at baseline per family. No
CP/SOB/cough/meningeal signs. In the ED she was given
vanco/levaquin/flagyl. Likely urosepsis.
Past Medical History:
-TB exposure, s/p treatment with INH and rifampin
-sinusitis
-arthritis
-bilateral cataract surgery
-dementia
-atrial fibrillation
-HTN
-recurrent UTIs
-seizure disorder in association with UTI/infection
-R MCA stroke c residual L hemiplegia
-lichen planus
-NSTEMI in [**7-23**].
Social History:
The pt. is a nursing home resident. She denied use of tobacco,
alcohol, or IV drugs. From [**Country **].
Family History:
Noncontributory.
Physical Exam:
VS: T 98.5 HR 85 BP 98/48 RR 20 O2Sat 98% on 2L nc. FS 157
Gen: awake, alert. Talkative, but aphasic and difficult to
understand at times.
HEENT: PERRL, EOMI. MM moist.
Neck: no JVD
Heart: RRR, S1S2, no m/r/g
Lungs: CTA anteriorly
Abd: +BS, soft, NT/ND.
Ext: 1+ nonpitting edema of B/L LE [**1-24**] way to knees; Femoral
line in place.
Neuro: L sided hemiparesis: Cannot lift L arm, can wiggle toes,
L moves less than R. Otherwise nonfocal.
Pertinent Results:
WBC 2.6 on admission, incr to 31.1 with steroids, down to 13.5
at discharge
Bands 18->5
INR 3.9->5.8--> 1.4 by the time of discharge
TnT peaked at 0.09-> <0.01 by discharge
[**2140-8-21**] 08:13PM BLOOD Fibrino-455* D-Dimer-3211*
[**Last Name (un) **] Stim test:
[**2140-8-21**] 09:02AM BLOOD Cortsol-44.0*
[**2140-8-21**] 09:42AM BLOOD Cortsol-47.4*
[**2140-8-21**] 10:18AM BLOOD Cortsol-48.5*
[**2140-8-20**] 11:00PM BLOOD Phenyto-6.9*
CXR: IMPRESSION: Bibasilar atelectasis. No chf or free air.
CT abd/pelvis: IMPRESSION: Moderate hydronephrosis and
hydroureter within the collecting systems bilaterally. The
bladder is distended even though a Foley catheter lies within
it. Reassessment of the foley catheter and urine output is
recommended.
URINE CULTURE (Final [**2140-8-29**]):
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
YEAST. ~3000/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- =>16 R
MEROPENEM------------- =>16 R
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ =>16 R
Blood cultures:
AEROBIC BOTTLE (Final [**2140-8-23**]):
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM
ANAEROBIC BOTTLE.
ANAEROBIC BOTTLE (Final [**2140-8-23**]):
REPORTED BY PHONE TO [**Doctor Last Name **] HARDY [**2140-8-21**] 1350.
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Trimethoprim/Sulfa sensitivity available on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 16 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 32 I
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
Brief Hospital Course:
82 yo woman with hx of afib on coumadin, s/p CVA, with recurrent
UTI, GNR bacteremia, and urosepsis.
.
1. Septic shock/urosepsis: The patient was hypotensive on
admission to the ICU, with SIRS + lactic acidosis and
hypotension not responding to IVF. A femoral line was placed in
the ED given her coagulopathy (INR 3.8). Sepsis protocol ws
initiated, with fluid bolus prn (titrated to urine output),
Levophed started to keep MAP>65. SvO2 (from groin line) falsely
high at 91%. Insulin drip was started to optimize glucose
control in the setting of sepsis, but was stopped soon after
with good glucose control. She was empirically started on
Vancomycin, Levofloxacin and Gentamicin in the ICU. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**]
stimulation test returned with elevated baseline cortisol at 44,
with poor response (48 at 60 minutes), and she was started on HC
and FC. An infectious work-up was initiated pre-abx, remarkable
for +U/A with alkalotic pH (history of Proteus UTI). Foley was
changed, with good urine outputBlood cultures subsequently grew
GNR 4/4 bottles (cx from [**8-21**]), identified at E coli, sensitive
to cephalosporins and gent. Gentamicin was continued for
treatment and was dosed by level. CXR wihtout acute CP process.
Lactate improved with antibiotics. Levophed was titrated off on
day #3. Pt was transferred to the floor on [**2140-8-23**]. A PICC line
was placed for antibiotics and the femoral line was removed.
Culture of the femoral line tip was negative. Hydrocortisone
was changed to PO prednisone and tapered down. Short taper will
continue on discharge. Fludrocort was discontinued prior to
discharge. The patient was afebrile for several days prior to
discharge, and her WBC count was decreasing. Blood cultures
remained positive until [**2140-8-22**]. Cultures drawn on [**2140-8-24**] were
pending at the time of discharge but had no growth to date.
Urine culture on [**8-27**] grew pseudomonas which was pan-resistant,
but only 10-100,000/mL so we did not treat this. If the patient
is symptomatic, a UA and Urine culture should be repeated at the
nursing home. Treatment with gentamicin will continue for 1
more week. A gentamicin peak and trough level should be checked
tomorrow.
*
2. CAD: History of NSTEMI in '[**37**]. EKG on admission with lateral
ST depressions, ruled out for MI with negative cardiac enzymes
(CK rose from 50-->375, with trop <0.01 to peak 0.09, then
trending down. Flat CK-MB). On ASA and statin. Pt is not on a
BB because this has aggravated her lichen planus in the past
(see below).
*
3. Coagulopathy: On Coumadin as an out-patient for atrial
fibrillation, with supatherapeutic INR on admission. She
received Vitamin K 1 mg IV X 1 on [**8-21**] in order to reverse her
coagulopathy. Platelets and fibrinogen were stable, not
suggestive of DIC (although FDP elevated). When INR decreased
<2, a heparin drip was started for anticoagulation. Coumadin
was re-started prior to discharge. Given history of
supratherapeutic INR, pt will be discharged on 4mg coumadin
rather than her home dose of alternating 5mg/6mg.
*
4. Afib: On diltiazem at home, which was held initially due to
hypotension. BB was started given her hx of CAD, but this was
discontinued due to lichen planus (see above). Discharged on
home dose of diltiazem. On coumadin at home. Anticoagulation
as described above.
*
5. Dementia: Mental status was close to her baseline per family
on [**8-21**]. Patient also on Dilantin for ? seizure disroder, level
6.9 on [**8-21**] with albumin 3.1. No change made in dose.
*
6. Lichen planus: Pt was briefly started on metoprolol given her
hx of CAD. However, the patient developed worsening lichen
planus rash, and upon checking past dermatology notes she has a
history of lichen planus being exacerbated by BB. Metoprolol
was stopped and home diltiazem resumed for her afib.
*
7. Anemia: Transfused 1U PRBCs [**8-22**] for hct 27.9. Hct increased
to 32.9. Hct was stable after that point. No evidence of
hemolysis. Stools were guaiac negative. Hct drop likely was
dilutional in the setting of large volume IV fluid
resuscitation.
*
8. Glucose control: Started on insulin gtt in the ICU for
optimization of glycemic control in the context of sepsis. This
was stopped within 24-36h with good glycemic control after that
point. FS were checked QID and pt was covered with insulin
sliding scale. NPO at present, ? advance on [**8-22**].
*
9. FEN: Pt failed swallow eval on [**8-22**]. However, successful
bedside informal swallow evaluation was done prior to discharge.
The patient had an NGT when she came to the floor from the ICU,
but she coughed it out prior to discharge and it was not
replaced. She tolerated a regular diet with thickened liquids.
She should have aspiration precautions.
*
10. The patient was full code during this admission. This was
also discussed with her family.
Medications on Admission:
cardizem 120
lasix 40 daily
MVI
dilantin 200qam/300qpm
protonix 40
colace/senna
tylenol prn
coumadin 5mg Sun/M/W/F/Sat
coumadin 6mg Tue/Th
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Dilantin 100 mg Capsule Sig: Two (2) Capsule PO qAM.
4. Dilantin 100 mg Capsule Sig: Three (3) Capsule PO at bedtime.
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
hold for loose stools.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for Headache/fever.
7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)) for 2 days.
8. Warfarin Sodium 1 mg Tablet Sig: Four (4) Tablet PO once a
day: need to check INR blood test in [**4-26**] days and adjust dose
accordingly for goal INR [**2-25**].
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. Diltiazem HCl 120 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO DAILY (Daily).
11. Vitamin C 100 mg Tablet Sig: One (1) Tablet PO once a day.
12. Zinc 50 mg Tablet Sig: One (1) Tablet PO once a day.
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) for 2 weeks: apply to affected skin.
14. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day.
15. Triamcinolone Acetonide 0.1 % Ointment Sig: One (1) Appl
Topical DAILY (Daily).
16. Gentamicin 40 mg/mL Solution Sig: Two [**Age over 90 8821**]y (240) mg
Injection Q24H (every 24 hours) for 7 days.
Discharge Disposition:
Extended Care
Facility:
Hollywell - [**Location (un) 5110**]
Discharge Diagnosis:
urinary tract infection
bacteremia, E. coli, likely urosepsis
atrial fibrillation
coronary artery disease
anemia, stable
chronic foley for urinary retention
history of CVA
Discharge Condition:
stable, tolerating POs, baseline L-hemiparesis
Discharge Instructions:
contact MD if you develop fever/chills, shortness of breath,
abdominal pain, or other concerning symptoms
A urine culture on [**8-27**] grew pseudomonas which was pan-resistant,
but only 10-100,000/mL so we did not treat this. If the patient
is symptomatic, a UA and Urine culture should be repeated at the
nursing home.
Followup Instructions:
follow-up with primary care physician [**Name Initial (PRE) 176**] 2-4 weeks
Urine culture on [**8-27**] grew pseudomonas which was pan-resistant,
but only 10-100,000/mL so we did not treat this. If the patient
is symptomatic, a UA and Urine culture should be repeated at the
nursing home.
ICD9 Codes: 5990, 412, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1286
} | Medical Text: Admission Date: [**2150-1-13**] Discharge Date: [**2150-1-18**]
Date of Birth: [**2150-1-13**] Sex: M
Service: NEONATOLOGY
HISTORY OF PRESENT ILLNESS: [**Known lastname **] [**Known lastname 1263**] is the former 2.325
kilogram product of a 34 and 2/7 weeks gestation pregnancy
born to a 34-year-old gravida 1, para 0 woman.
Prenatal screens revealed blood type O negative, antibody
negative, Rubella immune, rapid plasma reagin nonreactive,
hepatitis B surface antigen negative, group B strep status
unknown.
The pregnancy was complicated by premature prolonged rupture
of membranes which occurred on [**2149-12-29**] at
approximately 32 weeks gestation. She was admitted and
treated with bed rest and antibiotics. She received a full
course of betamethasone and was complete on [**2149-12-31**].
She underwent elective induction on [**2150-1-12**] with
oxytocin and Cytotec. The infant was born by vaginal
delivery. There was no maternal fever or other sepsis risk
factors, and the mother received ampicillin prior to
delivery. The infant emerged with good tone and cry. Apgar
scores were 7 at 1 minute and 8 at 5 minutes. He required
blow by oxygen in the delivery room. He was admitted to the
Neonatal Intensive Care Unit for treatment of prematurity.
PHYSICAL EXAMINATION ON PRESENTATION: Examination on admission
to the Neonatal Intensive Care Unit revealed a weight of 2.325
kilograms (50th to 75th percentile), length was 45 cm (50th
percentile), and head circumference was 34 cm (greater than
the 90th percentile). In general, a well-developed preterm
male consistent with 34 weeks gestation. Moderate
respiratory distress at rest. Head, eyes, ears, nose, and
throat examination revealed moderate molding. Positive
caput. Anterior fontanel was soft and flat. The palate was
intact. Red reflex was present bilaterally. Chest revealed
moderate aeration. There were coarse breath sounds.
Grunting and retractions were present. Cardiovascular
examination revealed a regular rate and rhythm. No murmurs.
Femoral pulses were 2 plus. The abdomen was soft and
nondistended. There were quiet bowel sounds. There was no
hepatosplenomegaly. There were no masses. There was a 3-
vessel cord. Genitourinary revealed normal male. The testes
were descended bilaterally. The anus was patent. The
extremities were warm and well perfused. Brisk capillary
refill. The hips and back were normal. Neurologically,
mildly diminished tone and activity. Intact Moro and grasp.
HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY
DATA:
1. RESPIRATORY: [**Known lastname **] was admitted on room air and continued
on room air throughout his Neonatal Intensive Care Unit
admission. He has not had any episodes of apnea,
bradycardia, or oxygen desaturations. The mild
respiratory distress noted at the time of admission
resolved within a few hours after birth. At the time of
discharge, his was breathing comfortably on room air with
a respiratory rate of 30 to 60 times per minute and oxygen
saturations greater than 96 percent on room air.
2. CARDIOVASCULAR: The infant has maintained normal
heart rates and blood pressures. No murmurs have been
noted. At the time of discharge, his heart rate was 120
to 150 beats per minute with a recent blood pressure of
73/49 with a mean of 59 mmHg.
3. FLUIDS, ELECTROLYTES AND NUTRITION: [**Known lastname **] was initially
nothing by mouth and started on intravenous fluids.
Enteral feedings were started on day of life one and
gradually advanced. At the time of discharge, he was
taking 140 cc/kilogram per day of breast milk or Special
Care premature formula at 20 calories per ounce. He takes
small amounts of oral intake in addition to breastfeeding, but
the majority of his feedings are by gavage. His weight on the
day of discharge was 2.225 kilogram. Serum electrolytes
were sent on day of life two and were within normal
limits.
4. INFECTIOUS DISEASE: Due to the prolonged rupture of
membranes and unknown group B strep status, [**Known lastname **] was
evaluated for sepsis. His white blood cell count was
11,800 with a differential of 31 percent polymorphonuclear
cells and 0 percent band neutrophils. A blood culture was
obtained prior to starting intravenous antibiotics. The
blood culture was no growth at 48 hours, and the
antibiotics were discontinued.
5. GASTROINTESTINAL: [**Known lastname **] required treatment for unconjugated
hyperbilirubinemia with phototherapy. Peak serum
bilirubin occurred on day of life three with a total of
14.9/0.3 mg/dL direct. His most recent serum bilirubin was
obtained on the morning of [**2150-1-18**] and was 12.8
total/0.3 mg/dL direct. He remains on phototherapy at the time
of discharge.
6. HEMATOLOGICAL: [**Known lastname **] is blood type O negative and Coombs
negative. Hematocrit at birth was 48 percent. He did not
receive any transfusions of blood products
7. NEUROLOGICAL: [**Known lastname **] has maintained a normal neurologic
examination during admission, and there are no concerns at
the time of discharge.
8. SENSORY: Hearing screening has not yet been performed and
is recommended prior to discharge.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Transfer to [**Hospital6 2561**] in
[**Hospital1 8**], [**State 350**] for continuing Level 2 care.
PRIMARY PEDIATRICIAN: The primary care provider will be Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 59547**], [**Hospital1 8**] Family Practice, [**State 59548**], [**Location (un) 3307**], [**Numeric Identifier 59549**] (telephone number [**Telephone/Fax (1) 59550**]; fax number [**Telephone/Fax (1) 59551**]).
CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE:
1. Feedings: 140 cc/kilogram per day of breast milk or
Special Care premature formula by mouth or by gavage.
2. Medications: None.
3. Car seat position screening is recommended prior to
discharge.
4. State newborn screen was sent on [**2150-1-16**].
IMMUNIZATIONS RECEIVED: No immunizations administered.
IMMUNIZATIONS RECOMMENDED: Synagis respiratory syncytial
virus 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:
Daycare during respiratory syncytial virus 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 six 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.
DISCHARGE DIAGNOSES:
1. Prematurity at 34 and 2/7 weeks gestation.
2. Transitional respiratory distress.
3. Suspicion for sepsis ruled out.
4. Unconjugated hyperbilirubinemia.
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Last Name (Titles) **]
MEDQUIST36
D: [**2150-1-18**] 14:14:01
T: [**2150-1-18**] 14:53:59
Job#: [**Job Number 59552**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1287
} | Medical Text: Admission Date: [**2105-4-11**] Discharge Date: [**2105-4-17**]
Date of Birth: [**2036-8-31**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1899**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
68 yo M no known medical history presents with 2 day history of
shortness of breath and fatigue. He did state that he had
pneumonia in [**Month (only) **] and required hospitalization. He also was
diagnosed with diabetes after hospital discharge but has not
been taking any oral hypoglycemic agents. He does not like to go
to the doctor [**First Name (Titles) **] [**Last Name (Titles) 15797**] any prior medical history.
In the ER, initial vital signs were at 03:02 0 were 38 (? if
documented incorrectly as triggered for tachycardia) 141/75 16
100% RA.
Patient was triggered for HR 138 consistent with atrial
fibrillation with RVR (no known history of atrial fibrillation).
He was given 300 cc NS with improvement of HR to 100s. CXR
showed RLL infiltrate/effusion. It was thought that he might
have pneumonia, so he was given ceftriaxone and azithromycin.
Labs were performed. WBC was initially 10 with rise to 18.2,
normal Hgb 15.3, platelet 240. Initial INR was 1.7 with rise to
2.
Patient was going to be admitted for pneumonia, new atrial
fibrillation, and renal failure.
Patient then went into atrial fibrillation with RVR to 150s with
resultant hypotension. He was given 2 L NS. Patient was then
became tachyneic to 35, SBP 82. Repeat BP 108/93. He was then
started on an esmolol infusion. Patient was then intubated as
patient was becoming lethargic/less reponsive with push dose
phenylephrine, etomidate, rocuronium given that he looked like
he was deteroriating. He then had bradycardia to 40s and went
into PEA arrest. CPR was performed for about 2 minutes per
reports with epinephrine 1 mg IV x 1 given. A non-sterile
femoral line was placed.
He was then started on phenylephrine, levophed with resultant
hypertension to SBP 220s. He was in RVR again to 150s at which
time DCCV was performed with resultant NSR. Cursory ECHO showed
global hypokinesis with poor squeeze. He then coded again with
weaning of pressors with resultant hypotension and PEA arrest.
He was given epinephrine x1, and CPR was performed for about [**1-19**]
minutes with ROSC. GCS was 3 off sedation after the second code.
His baseline in department was AAOx3. Cooling was not performed
in ER but he was placed on ice and sent to the MICU.
On arrival in the CCU,VS were T 97.4 166/33 HR 97 RR 22 on PRVC
500x22, PEEP 18, FiO2 50. ECHO is being performed. Artic sun
protocol was initiated. Post-arrest was consulted. He was given
cefepime and vancomycin for ? pneumonia. He was weaned off
levophed. He was started on a heparin infusion. ECHO was
performed showing EF ~ 25 % with global hypokinesis.
Past Medical History:
DM
Social History:
Lives with fiance. [**Doctor First Name **] Scientist. He rarely went to the
doctor in the past and did not take any medications.
Family History:
Unknown
Physical Exam:
General Appearance: No acute distress
Eyes / Conjunctiva: PERRL, pupils 1 mm bilaterally
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG
tube
Lymphatic: Cervical WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Respiratory / Chest: difficult exam [**2-19**] artic sun vest
Abdominal: Soft, Non-tender
Extremities: Right lower extremity edema: 2+, Left lower
extremity edema: 2+
Skin: Cool
Pertinent Results:
[**2105-4-15**] 04:13AM BLOOD WBC-19.0* RBC-4.14* Hgb-12.2* Hct-38.9*
MCV-94 MCH-29.4 MCHC-31.3 RDW-15.9* Plt Ct-205
[**2105-4-15**] 04:13AM BLOOD PT-18.4* PTT-46.9* INR(PT)-1.7*
[**2105-4-15**] 04:13AM BLOOD Glucose-166* UreaN-72* Creat-2.9* Na-141
K-4.1 Cl-110* HCO3-21* AnGap-14
[**2105-4-15**] 04:13AM BLOOD ALT-56* AST-16 AlkPhos-51 TotBili-0.8
[**2105-4-11**] 11:37AM BLOOD %HbA1c-7.9* eAG-180*
[**2105-4-11**] ECHO
The left atrium and right atrium are normal in cavity size. Mild
symmetric left ventricular hypertrophy with normal cavity size.
There is severe global left ventricular hypokinesis (LVEF = 25
%). Systolic function of apical segments is relatively
preserved. The estimated cardiac index is depressed
(<2.0L/min/m2). A left ventricular mass/thrombus cannot be
excluded due to suboptimal apical images, but none is seen. The
right ventricular cavity is mildly dilated with moderate global
free wall hypokinesis. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The
descending thoracic aorta is mildly dilated. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. Trace 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.
Significant pulmonic regurgitation is seen. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with severe global systolic dysfunction
suggestive of a non-ischemic biventricular cardiomyopathy.
Dilated thoracic aorta. Mild mitral regurgitation. Pulmonary
artery hypertension.
Brief Hospital Course:
68 yo M with DM who presented to the ED with dyspnea and was
found to have atrial fibrillation in RVR. He had a PEA arrest
twice in the ED, and was then admitted to the CCU under
post-arrest cooling protocol.
# PEA cardiac arrest
Patient presented with shortness of breath with moderate right
pleural effusion seen on CXR. He likely has some baseline aspect
of heart failure although he is not seen on regular basis by a
doctor. He had new atrial fibrillation with RVR that likely led
to flash pulmonary edema. He eventually required intubation with
subsequent PEA arrest in setting of transient
hypotension/hypoxia. Circulation was returned but then PEA
arrest occurred again. He was packed with ice and admitted to
the CCU. On arrival in the CCU he was started on the Arctic sun
cooling protocol, then actively rewarmed over the course of the
next 24 hours. There was no evidence of STEMI on ECG or cardiac
enzymes. An echo showed global systolic dysfunction with LVEF of
25%, which is possibly acute stunning vs chronic heart failure.
Post-arrest consult service was notified. He required ongoing
pressor support with norepinephrine and phenylephrine. Pressors
were eventually weaned and he remained normotensive.
On further discussions with patient's family, it was noted that
he is a devout [**Doctor First Name **] Scientist. He has rarely seen doctors
in the past, and was not taking any medications for diabetes or
heart disease. His daughters stated that given his prior
reluctance to obtain medical care, he would not want to be
intubated or in the ICU. They felt that any aggressive measures
would be against his wishes. On [**4-15**], the decision was made to
withdraw care and pursue comfort measures only. His ventilator,
medications and vitals were all stopped. He was transferred to
the floor and expired on the morning of [**4-17**].
# Hypoxemic respiratory failure
His respiratory failure was felt to be related to flash
pulmonary edema from afib with RVR. He was intubated in the ED.
Serial ABGs were monitored with adjustment of vent settings.
Prior to withdrawal of care, he had been on pressure support.
After the goals of care discussion, the ventilator was stopped
and he was extubated.
# Atrial fibrillation s/p DCCV
Patient was noted to be in new atrial fibrillation with RVR on
arrival to ER. ECG without significant underlying conduction
disease. [**Month (only) 116**] have had atrial fibrillation in setting of chronic
heart failure exacerbation. No evidence of PE or other
precipitants. He was cardioverted on [**2105-4-11**].
# Neuroprotection s/p arrest: Patient had GCS of 3 after return
of circulation post-arrest. He was immediately cooled and Artic
Sun protocol was initiated on arrival to CCU. Protocol included
MAPs>65, head of bed 30 degrees, core temp 33 degrees for 24
hours, sedation with fent/midaz, paralyzing wiht cisatracurium.
Video EEG was obtained. A neuro consult was obtained as he awoke
post-arrest. He was agitated but unable to respond to most
commands. He could blink and squeeze hands. Neuro consult was
unsure if he would regain further functioning. The family
decided he would not want to undergo the significant rehab if it
was necessary.
# Bilateral opacifications/pleural effusion
Concern was initially for pneumonia and he was covered with
vancomycin, cefepime, flagyl in event of aspiration or
underlying pneumonia given right pleural effusion.
# Diabetes
Patient diagnosed with DM as outpatient but was not taking
medications. Kept on ISS during hospitalization. ISS stopped
when CMO.
Medications on Admission:
None
Discharge Medications:
N/a
Discharge Disposition:
Expired
Discharge Diagnosis:
N/a
Discharge Condition:
N/a
Discharge Instructions:
N/a
Followup Instructions:
N/a
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1905**]
ICD9 Codes: 5070, 5849, 2762, 4280, 4275, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1288
} | Medical Text: Admission Date: [**2111-7-5**] Discharge Date: [**2111-7-11**]
Date of Birth: [**2060-8-8**] Sex: F
Service: MEDICINE
Allergies:
Reglan / Compazine / Gentamicin / Sulfonamides / Tigan /
Meperidine / Iodine; Iodine Containing / Prednisone / Cefotaxime
/ Vancomycin / Cephalosporins / Infliximab / Mercaptopurine /
Mesalamine / Ciprofloxacin / Heparin Agents
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Abd pain, n/v
Major Surgical or Invasive Procedure:
Knee arthrocentesis
History of Present Illness:
Mrs. [**Known lastname 1007**] is a 50 y/o woman with a history of Crohns disease
s/p multiple surgeries, SBO, currently on TPN who presents with
3-4d SOB, DOE, leg tingling followed by [**Known lastname 5283**] pain w/ N/V, and
fevers. She specifically developed rigors with a fever shortly
after accessing her Port-a-cath for TPN, after which she
presented to the ED with a temperature of 105.1 at 8 PM [**2111-7-5**].
ED staff attempted access several times in both femoral veins
but were unsuccessful; surgery placed a femoral line prior to
transport. IV linezolid and meropenem were given via her
existing port.
.
Hospital course: She was admitted to the [**Hospital Unit Name 153**] and required
Levophed for hypotension until [**7-7**] AM. Blood cultures were
notable for Klebsiella, which was treated with meropenem and
aztreonam which was allowed to dwell in the port to clear the
infection. She was also initially treated with vancomycin and
Flagyl until blood cultures showed GNR. Abdominal CT
demonstrated no abscess or source of infection, but did show
asymmetric wall thickening of the ileocolonic anastomotic site
which could be compatible with recurrent Crohn's disease.
She had a recent dental procedure two weeks ago (root canal x
2), for which she did receive ampicillin.
*
ROS: Of note, pt has chronic [**Month/Day (1) 5283**] pain, though current pain is
worse/more severe and higher location. (+) N & V No GU sx's. No
cough. +HA/neck stiffness, nausea/vomiting, no GU sxs other than
passing air thru vagina, LE pain but no swelling.
Past Medical History:
1) Crohn's disease dx [**2079**], s/p ~13 surgeries, including
transverse/ascending colectomy
- rectovaginal fistula
2) h/o multiple SBOs
3) SVC syndrome s/p angioplasty
4) h/o line/portocath infections
5) Depression
6) Fatty liver with mildly elevated LFTs at baseline
7) s/p TAH BSO
8) s/p ccy
9) Gastric dysmotility
10) Short bowel syndrome
11) Parathyroid adenoma s/p removal
12) Fibromyalgia
13) hypothyroidism
14) HIT+ Ab: s/p 30 days treatment with Fondaparinux
15) Fe deficiency anemia
16) Mediastinal lymphadenopathy NOS: followed by Dr. [**Last Name (STitle) 575**]
Social History:
Lives with husband. [**Name (NI) **] 5 children. Currently disabled. Used to
work as teacher. Denies hx of tobacco, etoh, illicit drugs
Family History:
Significant for family history of Crohn's disease and
osteoarthritis. No reported family history of CAD or DM.
Physical Exam:
VS 99.5 109/80 98 20 96% RA
Somnolent but pleasant middle-aged female, occasionally
grimacing in pain which she describes in [**Name (NI) 5283**] of abdomen
No carotid bruits, JVP flat
CTA B anteriorly
RRR S1S2 I/VI SEM LLSB
Abd obese, slightly high-pitched bowel sounds but nondistended,
she c/o diffuse tenderness which limits exam. Non-tympanitic
No edema or rash
R chest portacath site with tegaderm over it c/d/i without rash.
Pertinent Results:
[**2111-7-5**] 08:47PM BLOOD Lactate-4.1* K-4.1
[**2111-7-6**] 04:06AM BLOOD Lactate-4.6*
[**2111-7-8**] 02:12AM BLOOD Lactate-1.9
[**2111-7-5**] 09:00PM BLOOD Lipase-16
[**2111-7-5**] 09:00PM BLOOD ALT-27 AST-33 AlkPhos-184* Amylase-22
TotBili-0.8
[**2111-7-8**] 04:01AM BLOOD ALT-21 AST-28 LD(LDH)-194 AlkPhos-91
TotBili-1.1
[**2111-7-5**] 09:00PM BLOOD Glucose-92 UreaN-13 Creat-0.9 Na-137
K-4.0 Cl-99 HCO3-23 AnGap-19
[**2111-7-11**] 10:50AM BLOOD UreaN-4* Creat-0.5 K-4.1
[**2111-7-8**] 04:01AM BLOOD Gran Ct-1360*
[**2111-7-8**] 04:01AM BLOOD FDP-40-80
[**2111-7-5**] 09:00PM BLOOD PT-13.3* PTT-22.2 INR(PT)-1.2*
[**2111-7-8**] 04:01AM BLOOD PT-17.3* PTT-40.8* INR(PT)-1.6*
[**2111-7-10**] 04:30PM BLOOD PT-13.4* PTT-31.5 INR(PT)-1.2*
[**2111-7-11**] 10:50AM BLOOD Plt Ct-114*
[**2111-7-5**] 09:00PM BLOOD WBC-3.4* RBC-4.39 Hgb-11.8*# Hct-33.8*
MCV-77* MCH-27.0# MCHC-35.0# RDW-18.6* Plt Ct-202
[**2111-7-7**] 03:09PM BLOOD WBC-1.2* RBC-2.64* Hgb-7.1* Hct-20.9*
MCV-79* MCH-27.0 MCHC-34.1 RDW-18.9* Plt Ct-73*
[**2111-7-11**] 10:50AM BLOOD WBC-2.7* RBC-3.42* Hgb-9.7* Hct-28.0*
MCV-82 MCH-28.5 MCHC-34.8 RDW-17.9* Plt Ct-114*
[**2111-7-6**] 03:44AM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.020
[**2111-7-6**] 03:44AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-15 Bilirub-SM Urobiln-NEG pH-5.0 Leuks-NEG
[**2111-7-10**] 12:14PM JOINT FLUID WBC-6200* RBC-250* Polys-95*
Lymphs-4 Monos-1
[**2111-7-10**] 12:14PM JOINT FLUID Crystal-NONE
.
[**2111-7-10**] 12:14 pm JOINT FLUID Source: Kneeright.
GRAM STAIN (Final [**2111-7-10**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
.
Blood cultures 6/3 (4/4 Bottles)
KLEBSIELLA PNEUMONIAE
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 8 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
.
CT ABDOMEN WITH IV CONTRAST: Multiple foci of ground-glass
opacity in the left lower and right middle lobes have decreased
in size and number. A nasogastric tube courses down the
esophagus with tip at the GE junction. There is mild
splenomegaly. The liver, adrenal glands, left kidney, and
pancreas are unremarkable. A small hypodensity in the mid pole
of the right kidney likely represents a cyst but is not fully
characterized. At the small- to-large bowel anastomotic site,
there is mild asymmetric wall thickening indicative of recurrent
Crohn's disease. Multiple scattered mesenteric and
retroperitoneal lymph nodes are stable in appearance. The colon
and rectum are mildly distended without evidence of obstruction.
There is no free fluid or free air within the abdomen.
.
CT PELVIS WITH IV CONTRAST: The patient is status post
hysterectomy and bilateral salpingo-oophorectomy. No enlarged
pelvic nodes are visualized. There is no free fluid within the
pelvis. A right femoral central venous line courses through a
collateral into the right external iliac vein.
Osseous structures demonstrate no suspicious lytic or sclerotic
foci.
.
IMPRESSION:
1. Asymmetric wall thickening at the ileocolonic anastomotic
site consistent with recurrent Crohn's disease.
2. Mildly dilated loops of large bowel and rectum without
obstruction.
3. Splenomegaly.
.
Echo EF >60%
The left atrium is normal in size. The estimated right atrial
pressure is 5-10 mmHg. Left ventricular wall thickness, cavity
size, and systolic function are normal (LVEF>55%). Regional left
ventricular wall motion is normal. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic regurgitation. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
.
Right Knee Xray
IMPRESSION: Large suprapatellar effusion as detailed above.
Otherwise as best can be determined stable bicompartment
osteoarthritis with no traumatic injury evident.
Brief Hospital Course:
Pt is a 50 yo woman with multiple medical problems including
chronic [**Name (NI) 5283**] abd pain. She presented with n/v, acute exacerbation
of her abd pain. She was found to have low blood pressure in the
ED. After a great deal of difficulty, they were able to place a
femoral line in the ED by Dr.[**Name (NI) 1482**] team for IV access.
She was started on IVFs and given broad spectrum abx. She was
admitted to the ICU where she got more fluids, IV abx and
Levophed to support her BP. She improved symptomatically and she
was in the ICU for 3-4 days. A CT scan of her abd revealed
inflammation in her ileum concerning for exacerbation of her
crohn's dz. Her blood cultures grew out Klebsiella resistant to
Unasyn and Cipro. She was transferred to the floor under the
care of the hospitalist service.
.
#Bacteremia: followed by Surgery and ID. Etiology felt to be
secondary to line. Per Surgery and ID, plan to treat through.
Will continue on meropenem (and meropenem dwells in port) until
[**7-20**]; needs follow up cx 5 days after abx done.
.
#knee effusion: ?secondary to OA. No crystals; cultures
negative.
.
#Crohn's: now off tpn due to line sepsis. Was able to tolerate
liquids by day of discharge. Pt to f/u with Dr. [**Last Name (STitle) **]
regarding timing of reinitiation of TPN.
.
#pancytopenia - improving once sepsis cleared. Will need repeat
CBC next week.
Medications on Admission:
Benadryl IV
Serax 15 mg QAM & afternoon; 30mg QHS
methadone to 5 mg morning, 5-10 mg in the afternoon depending on
her pain, and 10 mg q.h.s.
Levothyroxine 50 mcg
Hyoscyamine 0.125 mg--[**2-3**] tablet(s) sublingually four
times a day as needed for pain
Discharge Medications:
1. Routine Port a Cath care
2. Meropenem 1 g Recon Soln Sig: One (1) 1 gram Intravenous
every eight (8) hours for 10 days: please rotate ports for
infusion. And leave antibiotic in port between infusions.
Course to finish on [**7-20**].
Disp:*qs 1gm bags* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
4. Oxazepam 15 mg Capsule Sig: One (1) Capsule PO BID (2 times a
day).
5. Oxazepam 15 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
6. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Methadone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for pain.
8. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual QID PRN as needed for pain.
Disp:*30 Tablet, Sublingual(s)* Refills:*0*
10. Diphenhydramine HCl 50 mg/mL Solution Sig: One (1) 50 mg
Injection Q6H (every 6 hours) as needed for nausea.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] home therapies
Discharge Diagnosis:
Klebsiella Pneumonia Bacteremia
Line Sepsis, resolved
Knee effusion, likely secondary to OA
Crohn's Disease
Pancytopenia, resolving
Discharge Condition:
Stable
Discharge Instructions:
Please follow up with primary care doctor's office as noted
below.
Return to ED with any fever, abdominal pain, nausea, inability
to self hydrate, knee pain
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2111-7-20**] 11:45 (Infectious Disease)
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Date/Time:[**2111-8-4**] 1:40pm
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**]
Date/Time:[**2111-7-27**] 8:00
Please give Dr.[**Name (NI) 1482**] office a call regarding when it is
safe to resume your TPN.
ICD9 Codes: 2762, 5849, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1289
} | Medical Text: Admission Date: [**2120-8-30**] Discharge Date: [**2120-9-15**]
Date of Birth: [**2051-9-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
aspirin / Codeine / Penicillins / Iodine
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
[**2120-9-2**] Cardiac Cath
[**2120-9-5**] Urgent coronary artery bypass graft x5: Left internal
mammary artery to left anterior descending artery and saphenous
vein grafts to diagonal ramus obtuse marginal and posterior
descending arteries
History of Present Illness:
68 year old male with insulin dependent DM, HTN, obesity
admitted to CCU for aspirin desensitization in setting of chest
pain with exertion over past week. Symptoms started 1 week ago
with substernal chest pain while carying luggage to cruise ship
- substernal/dull, radiates to abdomen "like ruler", occurs
during exertion. Resolved with rest. Then tried to exert himself
again throughout week, but developed same chest pain. He has
been "taking it slowly", however, still gets symptoms with
decreasing amount of exertion. New symptom for him. Denies
peripheral edema, palpitations, syncope. Came to ED for eval. He
was found to have multivessel disease upon cardiac
catheterization and is now being referred to cardiac surgery for
revascularization.
Past Medical History:
Diabetes
Hypertension
Arthritis
Kidney Stones
Bullet wound to right leg
s/p Back surgery
s/p Right rotator cuff repair
Social History:
Race:Caucasian
Last Dental Exam:3-4 months ago
Lives with: family
Contact:[**Name (NI) **] (daughter)
Occupation:Retired prison crew manager
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**1-15**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Premature coronary artery disease- Brother deceased from sudden
cardiac death at 58. Father with MI in mid-70's
Physical Exam:
Pulse:65 Resp:15 O2 sat: 99/RA
B/P Right:176/103 Left:147/71
Height:6' Weight:260 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: palp Left: palp
DP Right: dop Left: dop
PT [**Name (NI) 167**]: palp Left: palp
Radial Right: Left:
Pertinent Results:
[**2120-9-9**] 05:10AM BLOOD WBC-10.4 RBC-3.45* Hgb-10.7* Hct-30.2*
MCV-88 MCH-31.0 MCHC-35.5* RDW-13.2 Plt Ct-230
[**2120-9-5**] 01:04PM BLOOD PT-13.8* PTT-33.7 INR(PT)-1.2*
[**2120-9-9**] 05:10AM BLOOD Glucose-156* UreaN-32* Creat-1.3* Na-136
K-4.0 Cl-95* HCO3-31 AnGap-14
[**2120-9-11**] 06:24AM BLOOD WBC-8.1 RBC-3.52* Hgb-10.6* Hct-31.9*
MCV-91 MCH-30.1 MCHC-33.3 RDW-12.8 Plt Ct-337
[**2120-9-10**] 12:50PM BLOOD WBC-9.9 RBC-3.62* Hgb-10.8* Hct-33.3*
MCV-92 MCH-29.8 MCHC-32.5 RDW-13.1 Plt Ct-341
[**2120-9-11**] 06:24AM BLOOD Glucose-92 UreaN-34* Creat-1.3* Na-135
K-4.0 Cl-95* HCO3-29 AnGap-15
[**2120-9-10**] 12:50PM BLOOD Glucose-140* UreaN-33* Creat-1.4* Na-135
K-4.2 Cl-94* HCO3-28 AnGap-17
[**2120-9-9**] 05:10AM BLOOD Glucose-156* UreaN-32* Creat-1.3* Na-136
K-4.0 Cl-95* HCO3-31 AnGap-14
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: PFO is present. Left-to-right
shunt across the interatrial septum at rest.
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV systolic function.
AORTA: Normal aortic diameter at the sinus level. Simple
atheroma in aortic arch. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not visualized.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
PRE-BYPASS:
-No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage.
-A small patent foramen ovale is present. A slight left-to-right
shunt across the interatrial septum is seen.
- Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is normal (LVEF>55%)
with normal free wall contractility.
-There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta.
-There are three aortic valve leaflets. 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.
POSTBYPASS:
The patient is AV paced on low dose phenylephrine infusion.
Biventricular funtion is maintained. The valves remain
unchanged. The aorta remains intact.
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2120-9-13**] 10:28 AM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 91676**]
Reason: eval for effusion
Final Report
PA LATERAL VIEWS OF THE CHEST
REASON FOR EXAM: Status post CABG.
Comparison is made with prior study performed the day earlier.
Mediastinal widening has improved. Cardiac size is top normal.
Right basilar
atelectasis has resolved. Small atelectasis in the left lower
lobe remain.
Bilateral pleural effusions are small. There is no evidence of
pneumothorax.
[**Hospital 93**] MEDICAL CONDITION:
68 year old man with ileus/obstruction
REASON FOR THIS EXAMINATION:
eval ileus
Final Report
INDICATION: Question ileus or obstruction.
COMPARISON: Abdominal radiographs on [**2120-9-12**].
FINDINGS: Six frontal views of the abdomen were obtained. Again
seen is
small bowel dilation, similar to yesterday's study, with air
again seen in the transverse colon. There is no evidence of free
air. There are scattered air-fluid levels seen. Again seen is
hyperostosis of the lumbar spine, consistent with DISH. Again
seen is a cluster of calcifications within the region of the
prostate likely representing prostate calcifications. There are
sternotomy wires in place.
IMPRESSION: Some small bowel dilation with air in the colon,
consistent with
ileus.
[**2120-8-30**] 12:40PM BLOOD WBC-7.7 RBC-4.50* Hgb-13.9* Hct-40.2
MCV-90 MCH-30.8 MCHC-34.5 RDW-12.6 Plt Ct-239
[**2120-8-31**] 05:18AM BLOOD WBC-6.4 RBC-4.39* Hgb-13.2* Hct-38.1*
MCV-87 MCH-30.1 MCHC-34.6 RDW-13.2 Plt Ct-189
[**2120-9-1**] 05:55AM BLOOD WBC-7.2 RBC-4.43* Hgb-13.4* Hct-39.9*
MCV-90 MCH-30.4 MCHC-33.7 RDW-13.0 Plt Ct-185
[**2120-9-2**] 06:45AM BLOOD WBC-7.4 RBC-4.41* Hgb-13.9* Hct-39.3*
MCV-89 MCH-31.5 MCHC-35.4* RDW-13.3 Plt Ct-201
[**2120-9-3**] 02:40AM BLOOD WBC-9.1 RBC-4.16* Hgb-12.6* Hct-36.6*
MCV-88 MCH-30.3 MCHC-34.4 RDW-13.2 Plt Ct-200
[**2120-9-4**] 07:15AM BLOOD WBC-11.0 RBC-4.25* Hgb-13.3* Hct-37.6*
MCV-89 MCH-31.4 MCHC-35.5* RDW-13.3 Plt Ct-192
[**2120-9-6**] 02:05AM BLOOD WBC-12.2* RBC-3.70* Hgb-11.0* Hct-32.9*
MCV-89 MCH-29.9 MCHC-33.6 RDW-13.2 Plt Ct-171
[**2120-9-8**] 05:29AM BLOOD WBC-13.4* RBC-3.46* Hgb-10.6* Hct-29.8*
MCV-86 MCH-30.6 MCHC-35.6* RDW-13.3 Plt Ct-213
[**2120-9-10**] 12:50PM BLOOD WBC-9.9 RBC-3.62* Hgb-10.8* Hct-33.3*
MCV-92 MCH-29.8 MCHC-32.5 RDW-13.1 Plt Ct-341
[**2120-9-11**] 06:24AM BLOOD WBC-8.1 RBC-3.52* Hgb-10.6* Hct-31.9*
MCV-91 MCH-30.1 MCHC-33.3 RDW-12.8 Plt Ct-337
[**2120-9-12**] 05:50AM BLOOD WBC-7.2 RBC-3.44* Hgb-10.6* Hct-30.1*
MCV-88 MCH-30.7 MCHC-35.0 RDW-12.7 Plt Ct-308
[**2120-9-13**] 09:34AM BLOOD WBC-7.2 RBC-3.76* Hgb-11.1* Hct-34.7*
MCV-92 MCH-29.6 MCHC-32.1 RDW-12.8 Plt Ct-396
[**2120-9-14**] 07:15AM BLOOD WBC-7.8 RBC-3.41* Hgb-10.1* Hct-30.5*
MCV-90 MCH-29.8 MCHC-33.3 RDW-12.2 Plt Ct-323
[**2120-8-30**] 12:40PM BLOOD Neuts-55.1 Lymphs-36.0 Monos-5.6 Eos-2.6
Baso-0.7
[**2120-8-30**] 12:40PM BLOOD PT-11.1 PTT-22.3 INR(PT)-0.9
[**2120-8-30**] 12:40PM BLOOD Plt Ct-239
[**2120-9-14**] 07:15AM BLOOD Plt Ct-323
[**2120-8-30**] 12:40PM BLOOD Glucose-96 UreaN-30* Creat-1.1 Na-141
K-4.6 Cl-106 HCO3-27 AnGap-13
[**2120-9-9**] 05:10AM BLOOD Glucose-156* UreaN-32* Creat-1.3* Na-136
K-4.0 Cl-95* HCO3-31 AnGap-14
[**2120-9-10**] 12:50PM BLOOD Glucose-140* UreaN-33* Creat-1.4* Na-135
K-4.2 Cl-94* HCO3-28 AnGap-17
[**2120-9-11**] 06:24AM BLOOD Glucose-92 UreaN-34* Creat-1.3* Na-135
K-4.0 Cl-95* HCO3-29 AnGap-15
[**2120-9-12**] 05:50AM BLOOD Glucose-98 UreaN-29* Creat-1.2 Na-139
K-4.1 Cl-99 HCO3-29 AnGap-15
[**2120-9-13**] 09:34AM BLOOD Glucose-70 UreaN-21* Creat-1.2 Na-138
K-4.1 Cl-99 HCO3-27 AnGap-16
[**2120-9-14**] 07:15AM BLOOD Glucose-73 UreaN-18 Creat-1.1 Na-140
K-4.1 Cl-104 HCO3-25 AnGap-15
[**2120-9-15**] 07:10AM BLOOD UreaN-17 Creat-1.0 Na-138 K-4.1 Cl-102
[**2120-9-10**] 12:50PM BLOOD ALT-19 AST-30 LD(LDH)-266* AlkPhos-51
Amylase-23 TotBili-0.8
[**2120-8-30**] 12:40PM BLOOD cTropnT-<0.01
[**2120-8-30**] 10:38PM BLOOD cTropnT-<0.01
[**2120-8-31**] 05:18AM BLOOD cTropnT-<0.01
[**2120-9-5**] 05:50PM BLOOD cTropnT-0.46*
[**2120-9-6**] 02:05AM BLOOD CK-MB-18* MB Indx-4.6
[**2120-9-6**] 02:06AM BLOOD cTropnT-0.34*
[**2120-9-7**] 04:08AM BLOOD cTropnT-0.31*
[**2120-9-9**] 05:10AM BLOOD cTropnT-0.27*
[**2120-9-3**] 02:40AM BLOOD %HbA1c-6.7* eAG-146*
[**2120-8-31**] 05:18AM BLOOD Triglyc-168* HDL-44 CHOL/HD-3.6
LDLcalc-80 LDLmeas-96
Brief Hospital Course:
Mr. [**Known lastname 4281**] presented to the ED with chest pain. He was
appropriately medically managed and admitted for further
work-up. He underwent a cardiac cath on [**9-2**] which revealed
severe three vessel coronary artery disease. He underwent
pre-operative work-up and on [**9-5**] was brought to the operating
room where he underwent a coronary artery bypass graft x 5 (Left
internal mammary artery to left anterior descending artery and
saphenous vein grafts to diagonal ramus obtuse marginal and
posterior descending arteries). Please see operative report for
surgical details. Following surgery he was transferred to the
CVICU for invasive monitoring intubated and sedated in stable
condition. Later this day he was weaned from sedation, awoke
neurologically intact and extubated. On post-op day one he was
started on beta-blockers/ statin/aspirin/diuretics and gently
diuresed towards his pre-op weight. Chest tubes and epicardial
pacing wires were removed per protocol. Later on this day he was
transferred to the step-down floor for further care. Physical
Therapy was consulted for evaluation of strength and mobility
and cleared him safe to return to home with VNA services when
ready. He did have some abdominal pain, nausea and abdominal
distention on post operative day 4. A KUB showed marked small
bowel dilation with air-fluid levels concerning for small bowel
obstruction. All liver function tests and amylase/ lipase were
essentially normal. His Lasix was stopped, IVF was given and
his abdominal pain slowly resolved. Repeat KUB showed ileus. At
the time of discharge he was ambulating without difficulty,
passing flatus and stool, tolerating a regular oral diet and his
incisions were healing well. The remainder of his hospital
course was essentially uneventful. He continued to progress and
was cleared for discharge to home with VNA on POD 17. All follow
up appointments were advised.
Medications on Admission:
- Metformin 1000 mg qam
- Humalin-N 30 units daily
- Humalin-R 30 units daily
- Lisinopril 20 daily
- paroxetine 20 daily
Discharge Medications:
1. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. senna 8.6 mg Capsule Sig: One (1) Capsule PO twice a day:
hold for loose stools.
10. glucometer Sig: One (1) four times a day: Glucometer for
home monitoring.
Disp:*1 meter* Refills:*0*
11. test strips Sig: One (1) four times a day.
Disp:*1 box* Refills:*2*
12. insulin regular human 100 unit/mL Solution Sig: Fifteen (15)
units Injection every morning: [**Month (only) 116**] need to increase to 30 units
when oral intake better.
13. Humulin N 100 unit/mL Suspension Sig: Fifteen (15) units
Subcutaneous every morning: [**Month (only) 116**] need to increase to 30 units
when oral intake back to normal.
14. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
15. potassium chloride 10 mEq Tablet Extended Release Sig: One
(1) Tablet Extended Release PO once a day for 5 days.
Disp:*5 Tablet Extended Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Community Nurse [**First Name (Titles) **] [**Last Name (Titles) **] Care,Inc
Discharge Diagnosis:
Coronary artery disease s/p coronary artery bypass graft x 5
Past medical history:
Diabetes
Hypertension
Arthritis
Kidney Stones
Bullet wound to right leg
s/p Back surgery
s/p Right rotator cuff repair
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Trace Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2120-10-7**] at
1:30pm in the [**Hospital **] Medical office building [**Hospital Unit Name **]
Cardiologist: Dr. [**Last Name (STitle) 8098**] on [**10-7**] at 1:15pm
WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2120-9-17**] at 10:15
at [**Last Name (un) 2577**] building [**Hospital Unit Name **]
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 39008**] in [**12-10**] weeks [**Telephone/Fax (1) 57082**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2120-9-15**]
ICD9 Codes: 5849, 4111, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1290
} | Medical Text: Admission Date: [**2153-10-14**] Discharge Date: [**2153-10-14**]
Date of Birth: [**2088-7-24**] Sex: M
Service: Cardiothoracic Surgery.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 36437**] is a 65 year old male
who awoke from sleep at 4:00 a.m. on the morning of admission
with crushing chest and back pain. He was triaged at his
local Emergency Room and transferred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **]
[**First Name (Titles) **] [**Last Name (Titles) **], where a CT scan was obtained, revealing
dissection of his aorta starting at his aortic valve annulus
and extending to his iliac bifurcation. He was emergently
taken to the Operating Room for surgical repair.
PHYSICAL EXAMINATION: On physical examination, the patient
was alert and oriented. Cardiovascular: Regular rate and
rhythm, no murmurs appreciated. Lungs: Clear. Abdomen:
Scaphoid, soft, nontender. Extremities: Warm with palpable
pulses throughout. Neurologic: Within normal limits.
LABORATORY DATA: Data were not available prior to patient's
going to the Operating Room.
HOSPITAL COURSE: The patient was emergently taken to the
Operating Room, where he had emergent repair of his
dissection. His aortic valve was replaced and the ascending
aorta was also replaced with a tube graft.
Post bypass, the patient suffered from primary cardiac
failure. He was unable to be weaned from the cardiopulmonary
bypass circuit and expired in the Operating Room.
CONDITION ON DISCHARGE: Dead.
DISCHARGE STATUS: Death.
DISCHARGE DIAGNOSES:
Post cardiotomy syndrome, causing death.
Aortic dissection.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern4) 36438**]
MEDQUIST36
D: [**2153-10-13**] 02:24
T: [**2153-10-14**] 15:48
JOB#: [**Job Number **]
ICD9 Codes: 4241, 9971 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1291
} | Medical Text: Admission Date: [**2106-3-12**] Discharge Date: [**2106-4-13**]
Date of Birth: [**2032-12-19**] Sex: M
Service: SURGERY
Allergies:
Bactrim / Ace Inhibitors
Attending:[**First Name3 (LF) 4111**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
[**2106-3-17**] tracheostomy recannulated at bedside
[**2106-3-25**] temporary right IJ dialysis line placed
[**2106-4-6**] bedside left thoracentesis
[**2106-4-10**] right IJ tunnelled hemodialysis catheter placed
History of Present Illness:
73 year old male recently admitted to [**Hospital1 18**] for dysphagia
work-up, admitted to acute care hospital in [**State 108**] for
evaluation and treatment of possible pneumonia. Work-up
included sputum cx/bronchial washings which showed pseudomonas
and MRSA and [**Last Name (LF) 23087**], [**First Name3 (LF) **] report; pt. was treated with Linezolid,
Ceftaz, and empiric Fluc. CT chest [**3-5**] showed patchy areas of
consolidation bilaterally. Bronchial washing/biopsy [**3-9**] showed
edema and mild chronic inflammation. Pt. was transferred to
[**Hospital1 18**] by medical air transport for further evaluation and
treatment.
Review of systems: + SOB, no CP, no headaches, no abdominal pain
Past Medical History:
CABG x 3 vessel [**2090**], RUL lobectomy [**2094**], Right
hemicolectomy w/ primary anastomosis ([**4-21**]), LGIB requiring
end
ileostomy and colonic mucus fistula ([**6-21**]), trach/PEG for
prolonged hospital stay ([**6-21**]), ileostomy takedown ([**10-22**])
c/b anastomotic leak requiring anastomotic resection and
revision
3 days later. Percutaneous drain placed in abdominal fluid
collection [**2105-12-16**].
Social History:
Pt is married for 54 years. Has 2 grown children. Spends 3months
a year in [**State 108**]. He lives with his wife in [**Name (NI) 5936**], MA.
Denies ETOH since [**2105-5-15**], Quit Tobacco in [**2091**].
Family History:
Non-contributory
Physical Exam:
T 97.6 HR 77afib BP125/79 RR19 100%on CPAP+PS 0.40
NAD
trach in place
irregularly irregular rhythm, 2/6 systolic murmur
coarse breath sounds b/l
abd: soft, NT/ND
extr: no edema
Pertinent Results:
on admission:
[**2106-3-12**] 10:05PM BLOOD Glucose-95 UreaN-75* Creat-3.6* Na-144
K-4.3 Cl-110* HCO3-22 AnGap-16
[**2106-3-12**] 10:05PM BLOOD WBC-5.8 RBC-3.98* Hgb-11.6* Hct-35.5*
MCV-89 MCH-29.1 MCHC-32.7 RDW-17.1* Plt Ct-150
[**2106-3-12**] 10:05PM BLOOD PT-15.0* PTT-32.3 INR(PT)-1.3*
[**2106-3-12**] 10:05PM BLOOD ALT-20 AST-15 AlkPhos-61 Amylase-55
TotBili-0.4
at discharge:
[**2106-4-9**] 01:46AM BLOOD WBC-7.2 RBC-3.33* Hgb-9.7* Hct-30.3*
MCV-91 MCH-29.0 MCHC-31.9 RDW-19.2* Plt Ct-205
[**2106-4-9**] 01:46AM BLOOD PT-16.9* PTT-44.7* INR(PT)-1.5*
[**2106-4-9**] 01:46AM BLOOD Glucose-123* UreaN-59* Creat-4.1* Na-130*
K-5.0 Cl-96 HCO3-22 AnGap-17
[**2106-4-9**] 01:46AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.2
[**2106-3-25**] 06:00PM BLOOD HCV Ab-NEGATIVE
[**2106-3-25**] 06:00PM BLOOD HBcAb-NEGATIVE
[**2106-3-25**] 06:00PM BLOOD HEPATITIS Be ANTIBODY-Test
[**2106-3-25**] 06:00PM BLOOD HEPATITIS Be ANTIGEN-Test
Nutrition labs:
[**2106-3-12**] 10:05PM BLOOD Albumin-3.2* Calcium-8.6 Phos-5.2* Mg-1.9
Iron-21*
[**2106-3-12**] 10:05PM BLOOD calTIBC-179* Ferritn-261 TRF-138*
[**2106-3-12**] 10:05PM BLOOD Triglyc-29
[**2106-3-22**] 02:06AM BLOOD calTIBC-170* Ferritn-487* TRF-131*
[**2106-3-22**] 02:06AM BLOOD Albumin-3.1* Calcium-9.1 Phos-4.5 Mg-2.7*
Iron-42*
[**2106-3-29**] 02:59AM BLOOD calTIBC-185* Ferritn-304 TRF-142*
[**2106-3-29**] 02:59AM BLOOD Albumin-3.1* Calcium-8.7 Phos-3.3 Mg-2.3
Iron-35*
[**2106-4-4**] 02:57AM BLOOD calTIBC-179* Ferritn-177 TRF-138*
[**2106-4-4**] 02:57AM BLOOD Albumin-2.9* Calcium-8.6 Phos-2.7 Mg-2.0
Iron-42*
Imaging:
[**2106-4-1**] echo: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and global systolic function (LVEF>55%). Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is a small pericardial effusion.
The effusion appears circumferential.
IMPRESSION: Dilated left atrium. Mild symmetric left ventricular
hypertrophy with preserved global biventricular systolic
function.
[**2106-4-5**] Renal US: The right kidney measures 11.4 cm and the left
kidney measures 12.2 cm. There is no evidence of hydronephrosis
or renal calculi bilaterally. Both kidneys display diffusely
increased echogenic renal parenchyma. The right kidney contains
a 1.7 x 1.7 x 1.6 cm simple cyst within the lower pole and a
slightly more complex-appearing exophytic cyst measuring 1.6 x
1.7 x 1.1 cm off the upper pole, both of which appear grossly
stable from prior CT examination. Limited evaluation of the
urinary bladder is unremarkable. Incidentally noted is a large
left pleural effusion.
IMPRESSION: No evidence of hydronephrosis or renal calculi
bilaterally. Diffusely increased echogenicity of the renal
parenchyma is consistent with underlying medical renal disease.
[**4-9**] CXR IMPRESSION: 1. Worsening left pleural effusion;
moderate-to-severe with associated worsening left lower lobe
atelectasis.
2. Prior lung intervention with an associated stable peripheral
opacity in the right upper lung. 3. Small stable right pleural
effusion.
4. Tracheostomy tube tip is 7 cm above the carina and the
patient's neck is flexed. Tracheostomy tube can be adjusted if
clinically indicated.
Cytology:
[**4-6**] Pleural fluid: NEGATIVE FOR MALIGNANT CELLS. Mesothelial
cells, histiocytes and abundant blood.
Brief Hospital Course:
Mr. [**Known lastname 76336**] was admitted to the general surgery service on
[**2106-3-12**].
On admission, he had a chest xray with small left pleural
effusion left lower lobe opacity concerning for pneumonia. He
was continued on antibiotics including ceftazidime, Linezolid
and fluconazole. The Linezolid was changed to Vancomycin on
[**3-13**]. On admission he had a BUN/Cr of 75/3.6. He was started
on Nutren Renal tube feeds and continued on his home
medications. He was continued with aggressive pulmonary toilet
and sputum cultures were sent which were unremarkable and the
antibiotics were discontinued on [**3-16**]. On [**3-14**] he had increasing
shortness of breath, +accessory muscle use and tachypnea. An
ABG showed respiratory acidosis with a PCO2 of 65 and he was
transferred to the ICU for further management of respiratory
distress. He was intubated after transfer to the ICU for
progressive respiratory distress with improvement of his ABG.
He was also started on zoloft for depression. He was started on
a bicarbonate infusion [**3-15**] secondary to persistently low HC03
levels and given PO bicarb tabs. Nephrology was consulted on
[**3-16**] for increasing creatinine (BUN 83/Cr 4.0) and metabolic
acidosis and he was felt to have acute on chronic renal failure.
His bicarb level improved, however he continued to have
difficulty pressure support, with hypercarbia and acidosis after
attempting to decrease vent settings. His old trach site was
recannulated at the bedside on [**3-17**]. He was also started on
nephramine TPN for renal failure in addition to his tube feeds
which were decreased for a total protein intake of 40-50g daily.
He continued to have agitation/delirium at night, haldol and
xanax were tried for treamtent. He received a 3 day course of
Cipro [**Date range (1) 76337**] for a +UA but had negative urine culture. He was
given intermittent lasix IV on [**3-17**] and started on a lasix IV
drip on [**3-18**] with little improvement in respiratory status and it
was stopped on [**3-22**]. He was found to have an increased TSH level
and his levothyroxine dose was increased. He had continued
increase in his BUN/Cr, although his urine output remained
stable.
He continued to be seen by physical therapy through out his
hospitalization and was out of bed to the chair almost daily and
ambulated well even though he was ventilated. He intermittently
had to be switched to assist control for acidosis. Tube feeds
were held on [**3-23**] and he was continued on nephramine. On [**3-24**],
he was found to be c. diff positive and was started on flagyl
for a 14 day course. On [**3-25**] his BUN/Cr continued to increase
(118/6.8) and it was agreed to start dialysis. A temporary R IJ
dialysis catheter was inserted and he was started on
hemodialysis with slow improvement in his BUN/Cr. He was
restarted on Impact Tube feeds 3/4 strength to goal of 80cc/hr
and his nephramine was stopped. He was continued on dialysis on
Mon/Wed/Fri per nephrology. His urine output trended down and
he was making minimal urine at the time of discharge. He was
continued on pressure support with slow wean of pressure support
attempted with continued failure due to hypercarbia. On [**3-29**] he
was noted to be in atrial fibrillation with rapid ventricular
rate. He had EKG changes which were felt to be nonspecific by
cardiology. Rate control was achieved with IV/PO lopressor,
cardiac enzymes were cycled which were negative, he was given 1
unit packed RBCs and cardiology was consulted. Per Dr. [**Last Name (STitle) 957**],
anticoagulation was not started. An echo was done [**4-1**] which
showed a dilated left atrium, LVEF>55% and LVH. Psychiatry was
consulted on [**3-30**] for concerns of depression, suicidal gestures
and night time agitation. He denied any suicidal ideations but
did admit to feeling depressed. Recommendations included xanax
taper, haldol as primary med for delerium and to continue
zoloft. He was eventually maintained on 3mg haldol qHS with
improved nighttime agitation. He was restarted on nephramine on
[**3-31**]. On [**3-31**] he also had a Tmin of 93.1 rectally and he was
pan-cultured. Blood cultures were no growth, however sputum
cultures from [**3-30**] grew pseudomonas on [**4-1**]. He was started on
Vancomycin/zosyn on [**4-1**], which was later found to be resistant
to zosyn and sensitive to meropenem and he was started on a 14
day course of meropenem on [**4-2**]. Pulmonology was consulted on
[**4-2**] at the request of the family, and it was felt that he had
multi-focal respiratory failure secondary to pseudomonas VAP,
muscle weakness and the left pleural effusion causing a
restrictive ventilatory defect. They recommended to do a
thoracentesis of the left lung effusion, which was performed on
[**4-6**] with 1.5L of bloodly pleural fluid drained. Cultures were
negative and cytology showed no malignant cells. He tolerated
the procedure well and post procedure chest xray was improved.
C diff toxin recheck on [**4-6**] was negative. He was continued on
hemodialysis and the vent was slowly weaned. He continued to
have periods of atrial fibrillation and normal sinus. His
nephramine was stopped on [**4-9**] secondary to increasing left
effusion and concern for high fluid intake involvement in its
reaccumulation. He was taken to the operating room on [**4-10**] for
a R IJ tunnelled dialysis catheter. He tolerated the procedure
well. At the time of discharge, his vent settings were PS 5
peep 5, he will continue on meropenem (last day [**4-15**]), continue
on tube feed impact with fiber [**2-16**] strenght at 80ml/hr and
hemodialysis per nephrology. His portable chest x-ray at time
of discharge showed start of re-accumulation of his left sided
effusion. This should be followed with films while in rehab.
Medications on Admission:
Meds on Transfer: LINEZOLID, CEFTAZ, FLUC, xanax, norvasc,
aranesep, welchol, ferrous gluconate, lactobacillus,
levothyroxine 175', megace, metoprolol 50", seroquel
Allergies: sulfa, trimethoprim, ACE inhibitors
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
respiratory failure
acute renal failure
pneumonia
Clostridium difficile infection
atrial fibrillation
malnutrition
Discharge Condition:
stable
Completed by:[**2106-4-12**]
ICD9 Codes: 5070, 5849, 5119, 5990, 2761, 496, 2449, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1292
} | Medical Text: Admission Date: [**2101-7-30**] Discharge Date: [**2101-8-6**]
Date of Birth: [**2039-8-28**] Sex: F
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 61-year-old female
with end-stage renal disease on hemodialysis, diabetes type 2
controlled by diet with no medications. She has got a
history of pituitary adenoma status post resection and
subsequent panhypopituitary syndrome. She was brought in by
EMS to the Emergency Room with changes in mental status and
hypoglycemia, [**Year (4 digits) **] glucose 30. The patient reportedly had
been difficult to arouse at home.
She has had diarrhea for the last two weeks and has no p.o.
intake in the last few days. Her sister called EMS because
the patient was confused and slurring her speech. On
arrival, EMS found that she had a [**Year (4 digits) **] glucose at 30 at 10
a.m. After being given 1 amp of D50 and 100 mg of thiamine
IV, the patient's glucose rose to 80. Her mental status
improved and she was taken to the hospital. She denied
taking any medications for her diabetes.
In the ED, the patient complained of mild chest pressure with
nausea and vomiting. Her [**Year (4 digits) **] glucose was measured at 47,
and the patient was hypothermic at 95 degrees and hypotensive
at 60 systolic. She again responded to 100 mg of
hydrocortisone IV and ceftriaxone and Vancomycin empirically
for possible sepsis.
SOCIAL HISTORY: She is currently living in an apartment with
her sister, 58 years old. She is separated from her husband,
[**Name (NI) 26864**], and denies any EtOH, tobacco, or drugs.
FAMILY HISTORY: Mother is [**Age over 90 **] years old with diabetes. She
has diabetes all along that side of the family.
ALLERGIES: She has no known allergies.
MEDICATIONS:
1. Lisinopril 10 mg p.o. q.d.
2. Atenolol 25 mg p.o. q.d.
3. Prednisone 5 mg p.o. b.i.d.
4. Tums 500 mg p.o. q.i.d.
5. Protonix 40 mg p.o. q.d.
6. Thiamine.
7. Folate.
8. Levoxyl 50 mg p.o. q.d.
9. Epo q dialysis.
PAST MEDICAL HISTORY:
1. The patient has had several prior hospitalizations for
hypoglycemia; from [**6-8**] to [**6-10**], she was brought in
with a [**Month (only) **] glucose of 38 with diarrhea and nausea and
vomiting. On [**4-23**]-30th, she had a [**Month (only) **] glucose of 28,
and was hospitalized, and even required bag ventilation.
2. Also another recent hospital admit is she was hospitalized
with coffee-ground emesis from an upper GI bleed on [**6-27**]
through [**6-29**]. She was scheduled for ERCP as an
outpatient, but later refused.
3. Panhypopituitary syndrome status post pituitary adenoma
resection. The patient has had prior unstimulated a.m.
cortisol at 34.7, but was placed empirically on 5 mg q.d. of
prednisone. She is currently also taking 50 mg q.d. of
Levoxyl for hypothyroid.
4. Diabetes diagnosed 20-30 years. Since going on dialysis,
she has been diet controlled only.
5. Hemosiderosis diagnosed during abdominal MRI 05/[**2100**].
6. End-stage renal disease on hemodialysis Monday, Wednesday,
Friday.
7. Hypertension.
8. Severe coronary artery disease, ejection fraction of 30.
9. Gastroesophageal reflux disease.
10. H. pylori which is treated.
11. Pancreatic cyst that was discovered on [**7-16**] on
MRI. The head of the pancreas contains a 1.8 cm nonenhancing
lesion of fluid signal intensity. This may represent IPMT or
residua of prior pancreatitis.
PHYSICAL EXAMINATION: On exam in the field, she was
sleeping, unarousable to sternal rub. PERRLA. She had a
positive doll's eye with flaccid tone. She had vitals of
temperature 93-94. [**Month (only) **] pressure 95-125/52-67, pulse of
75-83, respirations [**10-18**], and was 100% on room air. In the
ED, she was a thin, lethargy, elderly female in no apparent
distress. Her mucous membranes are mildly dry. Her throat
was clear. She had no lymphadenopathy and no jugular venous
distention. She had a regular, rate, and rhythm, 3/6
systolic ejection murmur at the left lower sternal border
with a soft diastolic decrescendo murmur at the aortic valve
area. Her chest showed bilateral crackles at the bases. Her
abdomen was soft, nontender, nondistended with good bowel
sounds. Her right upper extremity showed a thrill with an
A-V fistula with a bruit, and she also had 2+ pulses. Her
neurologic exam was nonfocal. Cranial nerves II through XII
intact. Face symmetric. Extraocular movements are intact.
Tongue midline.
LABORATORIES ON ADMISSION: Her Chem-7 showed she had a
glucose of 47. Patient had a CBC: White [**Month/Year (2) **] cell count
5.1 to a 75.6 neutrophils. She had a hematocrit of 35.4 and
platelets of 94. She had a CK of 95 and a troponin which is
negative.
Her EKG showed a Mobitz I at 65 beats per minute with flat T
waves in V1 to V6.
Chest x-ray showed cardiomegaly with no infiltrate or
congestion.
Head CT showed no masses or bleeds.
HOSPITAL COURSE: Hypoglycemia: The etiology differential
was insulinoma versus adrenal insufficiency versus renal
hypoglycemia, versus poor liver glycogen reserves, versus
accidental ingestion of diabetes medication. The patient
denied taking any diabetes medications and her [**Month/Year (2) **] was
negative for sulfonylurea.
In order to address the possibility of insulinoma, the
patient was put on a prolonged glucose fast in which the
patient was made NPO, and her fingersticks were monitored
every four hours until she reached 60 after that one hour.
The test was discontinued either when the patient's [**Month/Year (2) **]
glucose reached less than 45 or when she is symptomatic.
Between 60 and 45 in the fingersticks, the patient's [**Month/Year (2) **]
drawn were levels of insulin, proinsulin, peptide C and beta
hydroxybutyrate. The results were sent out and will be
reviewed by Endocrine.
Based upon the results of the fingersticks, which was a slow
progression of fingersticks 117 to 89 to 67 to 68 to 72 to
53, to 61 to 60 and then finally to 47, this is suggestive of
low glycogen reserves causing a hypoglycemia when the patient
does not eat enough.
On discharge, the patient was stable, and she was told to
increase her p.o. intake with frequent snacks such as peanut
butter with crackers before bed. Patient's PCP was also
notified to contact Endocrine regarding the results of the
prolonged fast.
Regarding the patient's hemosiderosis, a Hematology consult
was ordered and they believe that based upon the results of
the iron study, which showed the patient was overloaded with
iron and the MRI at the patient's liver, kidneys, and spleen,
and bone marrow were full of iron, there was a strong
possibility of a iron storage disease as the etiology to the
patient's multiple medical problems.
They discussed the possibility of phlebotomy at hemodialysis
and the patient's nephrologist was notified of this
suggestion by Hematology.
As far as Endocrine, the patient's Levoxyl was increased to
75.
Neurology: The patient has had several episodes of
nonresponsiveness in which not even sternal rub could wake
her up from sleep. At the same time, while the patient was
on a monitor, everything was normal. An EEG was done and it
was found that the patient had a marked metabolic
encephalopathy. They recommended a sleep-deprived EEG with
sphenoidal electric nodes. The patient was given the number
of Dr. [**Last Name (STitle) **], who is a neuro-endocrinologist for followup as
an outpatient of her EEG.
Regarding her hypotension upon admission, it normalized after
receiving IV fluids and glucose.
Regarding the patient's coronary artery disease, the patient
had an echocardiogram that was done. It showed a profound
global hypokinesia with an ejection fraction of less than 20.
It had gotten worse over the last two years. Based upon the
results of that, it is unlikely that simple atherosclerosis
is responsible for this. The differential of amyloidosis and
hemachromatosis.
Regarding physical therapy, a consult was made. The patient
was cleared by Physical Therapy for a safety evaluation at
home and also home physical therapy every morning after
breakfast several times a week.
DISCHARGE MEDICATIONS:
1. Prednisone 5 mg one tablet p.o. q.d.
2. Docusate sodium 100 mg one tablet p.o. b.i.d.
3. Folic acid 1 mg one tablet p.o. q.d.
4. Levothyroxine sodium 75 mcg one tablet p.o. q.d.
5. Thiamine 100 mg one tablet p.o. q.d.
6. Lisinopril 5 mg one tablet p.o. q.d.
DISCHARGE DIAGNOSIS: Hypoglycemia of unknown etiology.
SECONDARY DIAGNOSES:
1. Chronic renal failure.
2. Hypopituitary/hypoadrenal syndrome.
3. Coronary artery disease.
4. Heart failure.
5. Diabetes.
CODE STATUS: Full.
DISCHARGE FOLLOWUP: With her PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1022**] in [**1-3**] days.
Follow up also with Dr. [**Last Name (STitle) **] of Neuro-Endocrinology,
telephone number is [**Telephone/Fax (1) 26865**].
DISCHARGE INSTRUCTIONS: Along with regular meals, please
have a late night snack of whole grain toast or crackers with
peanut butter, or pudding, or cheese to prevent low sugar in
the morning. Also she was told that if she feels nauseated,
lightheaded, shortness of breath, please call her PCP and
come to the Emergency Room. Finally, to make sure she keeps
all appointments with her primary care physician.
DISPOSITION: She is discharged to home with Visiting Nurses
Association and also Physical Therapy, safety evaluation and
home physical therapy.
DISCHARGE STATUS: Fair with being able to ambulate with
assistance.
CODE STATUS: Full.
Discharge followup is as mentioned above.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], M.D. [**MD Number(1) 20316**]
Dictated By:[**Last Name (NamePattern1) 18596**]
MEDQUIST36
D: [**2101-8-6**] 14:40
T: [**2101-8-8**] 07:36
JOB#: [**Job Number 26866**]
ICD9 Codes: 2765, 4280, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1293
} | Medical Text: Admission Date: [**2105-1-14**] Discharge Date: [**2105-1-20**]
Date of Birth: [**2042-8-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Worsening fatigue (sleeps 12 hrs /day) and exertional angina
Major Surgical or Invasive Procedure:
[**2104-1-15**]
1. Aortic valve replacement with a 23 mm [**Doctor Last Name **] pericardial
valve, model number 3300TFX, serial number [**Serial Number 92165**].
2. Coronary artery bypass grafting x2, left internal mammary
artery to left anterior descending coronary artery and reverse
saphenous vein graft from the aorta to the posterior descending
coronary artery.
3. Endoscopic greater saphenous vein harvesting.
History of Present Illness:
This is a 62 year old male with known aortic stenosis and
coronary artery disease. He has been followed with serial
echocardiograms which have shown progression of his aortic valve
disease. Most recent echocardiogram in [**2104-11-11**] revealed
severe aortic stenosis, with [**Location (un) 109**] ~ 0.8 cm2 with peak/mean
gradients of 80/46 mmHg. Given the above findings, he has been
referred for surgical consultation.
Past Medical History:
- Aortic Stenosis
- Coronary Artery Disease, s/p LAD angioplasty in [**2086**]
- History of TIA [**2099**]
- Severe intracranial left internal carotid disease
- Obesity
- Dyslipidemia
- Obstructive Sleep Apnea
- Impaired Glucose Tolerance
- Asthma
- Depression
- Erectile Dysfunction
- Colonic Polyps
Past Surgical History
- R thoracotomy/rib resection ( benign mass at age 1)
Past Cardiac Procedures: PTCA of LAD in [**2086**]
Social History:
Race: Caucasian
Last Dental Exam:5 months ago
Lives with: Wife
Contact: same Phone #
Occupation: Electronic Tech
Cigarettes: Denies
Other Tobacco use:never
ETOH: < 1 drink/week [x] [**2-17**] drinks/week [] >8 drinks/week []
Illicit drug use-none
Family History:
Non-contributory
Physical Exam:
Pulse:59 Resp:16 O2 sat: 98%
B/P Right: 112/63 Left: 128/68
Height: 67" Weight:205
General:NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]anicteric sclera; OP unremarkable
Neck: Supple [x] Full ROM [x]no JVD appreciated
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade 4/6 SEM radiates
throughout precordium and into B carotids
Abdomen: Soft [x] non-distended [x] non-tender [] bowel sounds +
[x]
no HSM, pinpont epigastric tenderness on deep palpation; no CVA
tenderness
Extremities: Warm [x], well-perfused [x] Edema [] none_____
Varicosities: None [x]; 2.5 cm scar at each medial malleolus
(venous cutdowns during pediatric surgery)
Neuro: Grossly intact ,nonfocal exam, MAE [**5-16**] strengths
Pulses:
Femoral Right: 1+ Left:1+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2_ Left:2+
Carotid Bruit: murmur radiates to B-carotids
Pertinent Results:
ECHO [**2104-1-15**] PRE-BYPASS: The left atrium is dilated. No
spontaneous echo contrast or thrombus is seen in the body of the
left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. The right atrium is dilated. No
atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global systolic function (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened. There is severe aortic
valve stenosis (valve area 0.8-1.0cm2). Mild to moderate ([**1-12**]+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild to moderate ([**1-12**]+) mitral regurgitation
is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was
notified in person of the results before surgical incision.
POST-BYPASS: Preserved biventricular systolic function. LVEF
55%. Intact thoracic aorta. The aortic bioprosthesis is stable,
functioning well with peak 18 and meann 9 mm of Hg. Mild MR.
[**2105-1-18**] CXR: Post-sternotomy wires and replaced aortic valve are
unremarkable. There is overall improvement in the aeration of
both lungs with still present opacities seen in right upper,
right lower, and left lower lung. There is small amount of
bilateral pleural effusion still present. There is no evidence
of pneumothorax.
[**2105-1-19**] 04:45AM BLOOD Glucose-119* UreaN-23* Creat-0.8 Na-134
K-3.6 Cl-94* HCO3-28 AnGap-16
[**2105-1-19**] 04:45AM BLOOD WBC-12.2* RBC-3.38* Hgb-10.4* Hct-30.3*
MCV-90 MCH-30.6 MCHC-34.3 RDW-12.9 Plt Ct-236
Brief Hospital Course:
This is a 62 year old male with known aortic stenosis and
coronary artery disease who was a same day admission into the
operating room for aortic valve replacement and coronary bypass
grafting with Dr [**Last Name (STitle) 914**]. Please see the operative report for
details, in summary he had Aortic valve replacement and Coronary
artery bypass grafting x 2. His bypass time was 121 minutes,
with a cross clamp time of 101 minutes. He tolerated the
operation well and post-operatively was transferred to the
cardiac surgery ICU in stable condition on Neo-Synephrine to
support his blood pressure. In the immediate post-op period he
remained hemodynamically stable, anesthesia was reversed-he woke
neurologically intact and was extubated. On post-op day one he
was started on diuretics and beta-blockers and transferred to
the stepdown floor for continued recovery. All tubes, lines, and
drips were removed per cardiac surgery protocol. Once on the
floor he worked with nursing and physical therapy to advance his
activity and endurance. The remainder of his hospital course was
uneventful. He was discharged to Lifecare of [**Location (un) 2199**] with
visiting nurses on post-op day six. He is to follow up with Dr.
[**Last Name (STitle) 914**] in 1 month.
Medications on Admission:
Medications at home:
- Aspirin 325mg daily
- Atenolol 25mg daily
- Crestor 40mg daily
- Sertraline 200mg daily
- Flovent HFA 110mcg 1 inhale twice daily prn
- Ventolin HFA 90mcg 2 puffs every 4-6 hours prn
- Fluticasone Nasal spray
- Omega 3 Fatty Acids 1000 mg daily
- Multivitamin Centrum daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
7. metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
9. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal DAILY (Daily).
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
11. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
14. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO twice a day for 7 days.
Discharge Disposition:
Extended Care
Facility:
Lifecare Center of [**Location (un) 2199**]
Discharge Diagnosis:
Aortic Stenosis s/p Aortic valve replacement
Coronary Artery Disease s/p Coronary artery bypass graft x 2
Past medical history:
- s/p LAD angioplasty in [**2086**]
- History of TIA [**2099**]
- Severe intracranial left internal carotid disease
- Obesity
- Dyslipidemia
- Obstructive Sleep Apnea
- Impaired Glucose Tolerance
- Asthma
- Depression
- Erectile Dysfunction
- Colonic Polyps
Past Surgical History
- R thoracotomy/rib resection ( benign mass at age 1)
Past Cardiac Procedures: PTCA of LAD in [**2086**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage
Edema: 1+
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 one month or while taking narcotics. Drivng will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon: Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**] in the [**Hospital **] Medical Office on
[**2-23**] at 1:15pm
Cardiologist: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2-11**] at 11:10am
Vascular: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Please call to schedule appointments with your
Primary Care: Dr. [**First Name (STitle) **], [**First Name3 (LF) 1785**] K. [**Telephone/Fax (1) 31019**] in [**4-16**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2105-1-20**]
ICD9 Codes: 2724, 2859, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1294
} | Medical Text: Admission Date: [**2153-1-4**] Discharge Date: [**2153-1-18**]
Date of Birth: [**2079-1-15**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Lower extremity ischemia
Major Surgical or Invasive Procedure:
Right below knee amputation [**2153-1-11**]
History of Present Illness:
This is a 74 year old female with multiple medical problems
including peripheral vascular disease status-post a bilateral
femoral to dorsalis pedis bypasses with vein graft in '[**50**] who
now presents with right [**Doctor Last Name **] extremity pain 48 hours after
having a hemodialysis catheter inadvertanly placed in her right
femoral artery on [**2152-12-20**]. She says that the pain started 48
hours ago and was accompanied by discoloration of her right
foot. History at time of admission was limited because patient
was a poor historian.
Past Medical History:
1.CHF: last exacerbation two months ago
2.Aortic stenosis: s/p AVR c St. Jude's valve->coumadin, goal
INR=2.5-3.5
3.Type 2 DM x 10 years; with neuropathy
4.CRI: Cr~1.2 [**1-/2151**]; Cr~2.0 since [**2152-5-25**]
5.COPD
6.Morbid obesity
7.Severe post-op delerium [**12/2150**]
8.Post-op respiratory failure requiring re-intubation [**12/2150**]
9.Unclear psychiatric history-on risperdal, stelazine
10. Bilateral femoral to DP bypass with vein graft '[**50**]
11 Vein patch angioplasty of left femoral-DP vein graft [**2152-7-13**].
12. Osteomyelitis
13. Schizophrenia
Social History:
Pt is a widow who currently lives with a daughter. She quit
smoking cigarettesafter a 10 pack year history. She does not
drink alcohol. She uses a walker to ambulate. She has home
physical therapy.
Family History:
Noncontributory.
Physical Exam:
ON admission
Neuro: alert, awake, no acute distress
CV: irreg irreg rhythm, 2/6 SEM
Pulm: clear to auscultation bilaterally, pt c some increased
work of breathing
Abd: soft, non-tender, non-distended, normoactive bowel sounds
Extr: right lower extremity mottled and mildly tender to touch,
slightly cooler than left
Pulses: RIGHT: 1+ femoral, 1+ popliteal, palpable graft,
negative DP and PT; LEFT: 1+ femoral, 1+ popliteal, palpable
graft, 1+ DP, monophasic PT
Pertinent Results:
SEROLOGIES:
[**2153-1-4**] 07:40PM BLOOD WBC-6.1 RBC-3.69* Hgb-10.5* Hct-32.9*
MCV-89 MCH-28.4 MCHC-31.8 RDW-16.4* Plt Ct-125*
[**2153-1-5**] 05:00AM BLOOD WBC-6.4 RBC-3.69* Hgb-10.8* Hct-34.0*
MCV-92 MCH-29.4 MCHC-31.9 RDW-16.5* Plt Ct-134*
[**2153-1-6**] 07:13AM BLOOD WBC-5.8 RBC-3.77* Hgb-11.1* Hct-35.4*
MCV-94 MCH-29.4 MCHC-31.3 RDW-16.3* Plt Ct-144*
[**2153-1-7**] 02:10AM BLOOD WBC-5.3 RBC-3.45* Hgb-10.0* Hct-31.4*
MCV-91 MCH-28.9 MCHC-31.8 RDW-16.3* Plt Ct-137*
[**2153-1-8**] 04:24AM BLOOD WBC-5.6 RBC-3.46* Hgb-9.9* Hct-31.1*
MCV-90 MCH-28.5 MCHC-31.7 RDW-16.6* Plt Ct-157
[**2153-1-8**] 06:59PM BLOOD WBC-6.4 RBC-3.49* Hgb-10.1* Hct-31.8*
MCV-91 MCH-28.8 MCHC-31.6 RDW-16.5* Plt Ct-159
[**2153-1-9**] 02:05AM BLOOD WBC-5.8 RBC-3.46* Hgb-9.8* Hct-31.9*
MCV-92 MCH-28.4 MCHC-30.9* RDW-16.7* Plt Ct-161
[**2153-1-10**] 03:01AM BLOOD WBC-5.8 RBC-3.37* Hgb-10.1* Hct-31.8*
MCV-94 MCH-29.8 MCHC-31.6 RDW-16.4* Plt Ct-157
[**2153-1-10**] 02:28PM BLOOD WBC-5.2 RBC-3.55* Hgb-10.1* Hct-32.8*
MCV-92 MCH-28.5 MCHC-30.8* RDW-16.2* Plt Ct-175
[**2153-1-11**] 03:56AM BLOOD WBC-5.8 RBC-3.41* Hgb-9.8* Hct-31.6*
MCV-93 MCH-28.7 MCHC-31.0 RDW-16.2* Plt Ct-178
[**2153-1-12**] 01:11AM BLOOD WBC-5.4 RBC-3.21* Hgb-9.2* Hct-29.1*
MCV-91 MCH-28.6 MCHC-31.6 RDW-16.3* Plt Ct-167
[**2153-1-13**] 04:52AM BLOOD WBC-5.7 RBC-3.11* Hgb-8.8* Hct-28.6*
MCV-92 MCH-28.4 MCHC-30.8* RDW-16.2* Plt Ct-188
[**2153-1-14**] 05:45AM BLOOD WBC-6.8 RBC-3.16* Hgb-8.9* Hct-28.7*
MCV-91 MCH-28.3 MCHC-31.1 RDW-16.2* Plt Ct-200
[**2153-1-4**] 07:40PM BLOOD PT-15.6* PTT-29.8 INR(PT)-1.5
[**2153-1-5**] 05:00AM BLOOD PT-14.2* PTT-82.2* INR(PT)-1.3
[**2153-1-6**] 07:13AM BLOOD PT-14.9* PTT-29.5 INR(PT)-1.4
[**2153-1-7**] 02:10AM BLOOD PT-17.7* PTT-78.8* INR(PT)-2.0
[**2153-1-7**] 10:18AM BLOOD PT-18.3* PTT-86.6* INR(PT)-2.1
[**2153-1-7**] 08:09PM BLOOD PT-21.3* PTT->150* INR(PT)-2.9
[**2153-1-8**] 04:24AM BLOOD PT-18.4* PTT-69.1* INR(PT)-2.1
[**2153-1-8**] 10:50AM BLOOD PT-18.3* PTT-64.4* INR(PT)-2.1
[**2153-1-8**] 06:24PM BLOOD PT-22.3* PTT-150 IS HIG INR(PT)-3.1
[**2153-1-9**] 02:05AM BLOOD PT-18.3* PTT-42.4* INR(PT)-2.1
[**2153-1-9**] 04:20AM BLOOD PT-18.4* PTT-47.2* INR(PT)-2.1
[**2153-1-9**] 08:19PM BLOOD PT-19.0* PTT-62.1* INR(PT)-2.3
[**2153-1-10**] 03:01AM BLOOD PT-20.3* PTT-69.8* INR(PT)-2.6
[**2153-1-10**] 12:25PM BLOOD PT-21.4* PTT-76.3* INR(PT)-2.9
[**2153-1-10**] 02:28PM BLOOD PT-22.3* PTT-57.3* INR(PT)-3.1
[**2153-1-11**] 03:56AM BLOOD PT-21.6* PTT-90.9* INR(PT)-2.9
[**2153-1-12**] 01:11AM BLOOD PT-17.5* PTT-67.4* INR(PT)-1.9
[**2153-1-13**] 04:52AM BLOOD PT-17.9* PTT-71.3* INR(PT)-2.0
[**2153-1-14**] 05:45AM BLOOD PT-19.8* PTT-34.4 INR(PT)-2.5
[**2153-1-4**] 07:40PM BLOOD Glucose-177* UreaN-87* Creat-2.2* Na-144
K-5.1 Cl-103 HCO3-34* AnGap-12
[**2153-1-5**] 05:00AM BLOOD Glucose-53* UreaN-87* Creat-2.3* Na-144
K-4.7 Cl-103 HCO3-35* AnGap-11
[**2153-1-6**] 07:13AM BLOOD Glucose-185* UreaN-98* Creat-2.6* Na-143
K-5.2* Cl-102 HCO3-35* AnGap-11
[**2153-1-7**] 02:10AM BLOOD Glucose-123* UreaN-109* Creat-3.2* Na-143
K-5.9* Cl-102 HCO3-32* AnGap-15
[**2153-1-8**] 04:24AM BLOOD Glucose-167* UreaN-110* Creat-3.3*
Na-148* K-5.0 Cl-110* HCO3-33* AnGap-10
[**2153-1-8**] 06:59PM BLOOD Glucose-185* UreaN-52* Creat-2.0*#
Na-148* K-4.4 Cl-113* HCO3-26 AnGap-13
[**2153-1-9**] 02:05AM BLOOD Glucose-108* UreaN-58* Creat-2.1* Na-148*
K-4.4 Cl-113* HCO3-32* AnGap-7*
[**2153-1-10**] 03:01AM BLOOD UreaN-70* Creat-2.3* Na-142 K-4.8 Cl-108
HCO3-30* AnGap-9
[**2153-1-11**] 03:56AM BLOOD Glucose-195* UreaN-79* Creat-2.6* Na-143
K-5.5* Cl-106 HCO3-33* AnGap-10
[**2153-1-12**] 01:11AM BLOOD Glucose-91 UreaN-56* Creat-2.0* Na-140
K-5.0 Cl-106 HCO3-31* AnGap-8
[**2153-1-13**] 04:52AM BLOOD Glucose-144* UreaN-65* Creat-2.2* Na-142
K-4.9 Cl-105 HCO3-35* AnGap-7*
[**2153-1-14**] 05:45AM BLOOD Glucose-107* UreaN-71* Creat-2.2* Na-142
K-5.2* Cl-105 HCO3-33* AnGap-9
[**2153-1-6**] 04:57PM BLOOD CK(CPK)-52
[**2153-1-7**] 02:10AM BLOOD CK(CPK)-47
[**2153-1-6**] 04:57PM BLOOD CK-MB-NotDone cTropnT-0.36*
[**2153-1-7**] 02:10AM BLOOD CK-MB-6 cTropnT-0.31*
[**2153-1-9**] 02:05AM BLOOD cTropnT-0.53*
[**2153-1-4**] 07:40PM BLOOD Calcium-7.7* Phos-4.5 Mg-2.6
[**2153-1-8**] 06:59PM BLOOD Calcium-8.3* Phos-4.6* Mg-2.2
[**2153-1-10**] 02:28PM BLOOD Calcium-7.8* Phos-4.2 Mg-2.4
[**2153-1-13**] 04:52AM BLOOD Calcium-8.0* Phos-3.6 Mg-2.4
[**2153-1-14**] 05:45AM BLOOD Calcium-7.7* Phos-3.9 Mg-2.5
RADIOLOGY
[**2153-1-5**] Angiogram: 1) Nonvisualization suggesting complete
occlusion of the right femoral to dorsalis pedis artery bypass
graft. 2) Markedly diseased right superficial femoral artery
with a long mid and distal segment occlusion, which
reconstitutes distally through the profunda collaterals to the
popliteal artery.
3) Complete occlusion of the right posterior tibial and
anterior tibial arteries. Single-vessel runoff through a small
and diseased peroneal artery.
4) Occlusion of most of the dorsalis pedis artery, starting just
distal to its proximal portion. No visualization of plantar
arteries or the posterior tibial artery is seen within the
right foot.
[**2153-1-6**] CXR: Left effusion. Left lower lobe infiltrate not
excluded.
[**2153-1-6**] CT Head: No acute intracranial hemorrhage or mass effect.
If there is clinical concern for acute stroke, MRI with
diffusion weighted imaging is recommended.
[**2153-1-10**] pMIBI: 1) Normal myocardial perfusion. : No angina with
no significant ECG changes over baseline. 2) Normal left
ventricular cavity size. Calculated ejection fraction of 49%,
however upon visual inspection, the left ventricular function is
likely within normal limits.
[**2153-1-11**] CXR: Proximally positioned right internal jugular
catheter. Left basilar opacity consistent with atelectasis,
consolidation and/or effusion.
MICROBIOLOGY:
[**2153-1-7**] Sputum Cx: SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA}
Sensitive to Levoquin
Brief Hospital Course:
This is a 73 year old female with peripheral vascular disease
status-post bilateral femoral to DP bypasses in '[**50**] who was
admitted on [**2153-1-4**] with ischemia of her right lower extremity.
She was started on anticoagulation on admission and underwent an
angiogram on [**2153-1-5**] which demonstrated near complete occlusion
of the right femoral to DP bypass graft. She was planned for
operative below-knee amputation, but had a pre-operative course
complicated by hypercapnic respiratory failure requiring
extubation on [**2153-1-7**] and a 2-day stay in the intensive care
unit. She was extubated on [**2153-1-8**] without complication and chest
x-ray and sputum culture revealed that she had had pneumonia
which was exacerbating her baseline COPD; she was started on
levoquin for this pneumonia and had no further respiratory
exacerbations in the remainder of her hospital course. She was
taken to the operating room on [**2153-1-11**] where a below knee
amputation was done. Post-operatively she did well, with good
pain control. She was transferred out of the vascular intensive
care unit on post-operative day 2 in stable condition and her
diet was advanced to a regular diet. Anticoagulation was resumed
for her heart valve and she was found to be therapeutic by
post-operative day 3 with INR of 2.5. [**Last Name (un) **] Diabetes was
consulted for management of blood sugars. Physical therapy
worked with her and deemed her to be not safe for home, so
rehabilitation services were sought. The patient was discharged
to rehab with planned follow-up with vascular surgery within [**12-3**]
weeks. All questions were answered to her satisfaction upon
discharge.
Medications on Admission:
Fortaz 1 mg po qd
Protonix 40 mg PO qd
Lasix 120 mg PO BID
Lantus insulin 60 units qd
risperdal 0.5 mg PO QD
Stelazine 1 mg Po QD
Amiodarone 200 mg PO QD
Lipitor 10 mg PO QD
Predniosone 30 mg PO QD
Colace 100 mg PO BID
Cardizem 300 mg PO QID
Flagyl 500 mg PO QID
Coumadin 7.5 mg po QD
KCl 20 mg PO BID
Aluminum Hydroxide 15 mg PO QID
Aranesp 60 qwk
Discharge Medications:
1. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
3. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Albuterol Sulfate 0.083 % Solution Sig: One (1) inhalation
Inhalation Q6H (every 6 hours) 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. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Warfarin Sodium 7.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): Goal INR 2.5 to 3.5 for artificial heart valve.
10. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN. Inspect site every shift
11. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 6 days: 2-week course started on [**1-6**].
12. Trifluoperazine HCl 1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
14. Aluminum Hydroxide Gel 600 mg/5 mL Suspension Sig: 5-10 MLs
PO Q8H (every 8 hours) as needed.
15. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: Two (2)
units Subcutaneous four times a day: per sliding scale, with
goal sugars 80-120.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
(1) left lower extremity ischemia
(2) Pneumonia, St. [**Male First Name (un) 1525**] heart valve, s/p CABG, COPD, chronic
renal insufficiency
Discharge Condition:
Fair
Discharge Instructions:
Please contact the office or come to the emergency room with any
worsening pain at your incision not improved with narcotics,
worsening drainage or redness at the incision, or any questions.
Take all medications as prescribed.
Followup Instructions:
Please contact the office of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] to set-up a
follow-up appointment within 1-2 weeks. [**Telephone/Fax (1) 1393**]
Completed by:[**2153-1-15**]
ICD9 Codes: 4280, 486, 5849, 2767 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1295
} | Medical Text: Admission Date: [**2193-10-14**] Discharge Date: [**2193-10-20**]
Date of Birth: [**2143-2-1**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
CABG x3 (LIMA>LAD, SVG>OM, SVG>PDA) AVR (23 ONX) [**10-14**]
History of Present Illness:
50 yo M who presented to [**Hospital 1474**] Hospital with chest pain,
ruled in for NSTEMI, was transferred to [**Hospital1 18**] for cath which
showed 3VD. Echo showed severe AS. Referred for CABG/AVR.
Past Medical History:
- CAD: s/p cath in [**6-25**] with occluded RCA, 50% prox LAD
- Moderate AS with peak gradient 20-25mmHg per cath
- HTN
- DM2 - last A1c 7.1%
- Hyperlipidemia: Chol 157, HDL 53, LDL 82, in [**6-25**] - has had it
checked since then, results unknown
- Chronic back pain
- Neuropathic leg pain
Social History:
He lives with his wife who is a nurse, and his 16yo son.
[**Name (NI) 1139**]: never smoked
EtOH: 1-2 beers/weekend
Illicits: denies, including no cocaine
Family History:
Father passed away at 54 of CVA, brother with stents placed at
43, another brother with AS
Physical Exam:
NAD 67 16 127/86
CV RRR SEM heard t/o -> carotids
Lungs CTAB ant/lat
Abdomen benign
Extrem warm, no edema
No varicose veins
5'[**95**]" 205#
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 73736**], [**Known firstname 251**] [**Hospital1 18**] [**Numeric Identifier 73737**] (Complete)
Done [**2193-10-14**] at 11:51:21 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Last Name (Prefixes) 413**], [**First Name3 (LF) 412**]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2143-2-1**]
Age (years): 50 M Hgt (in): 70
BP (mm Hg): / Wgt (lb): 205
HR (bpm): BSA (m2): 2.11 m2
Indication: Intraoperative TEE CABG/AVR
ICD-9 Codes: 746.9, 410.91, 440.0, 424.1
Test Information
Date/Time: [**2193-10-14**] at 11:51 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5740**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2007AW2-: Machine: 2
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.5 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.3 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 60% to 65% >= 55%
Left Ventricle - Stroke Volume: 59 ml/beat
Aorta - Ascending: 2.8 cm <= 3.4 cm
Aorta - Descending Thoracic: *2.7 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 0.5 m/sec <= 2.0 m/sec
Aortic Valve - LVOT pk vel: 0.61 m/sec
Aortic Valve - LVOT VTI: 17
Aortic Valve - LVOT diam: 2.1 cm
Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. Normal interatrial
septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Simple
atheroma in aortic arch. Mildly dilated descending aorta. Simple
atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Severe AS (AoVA
<0.8cm2). Trace AR.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
PRE-BYPASS:
1. No atrial septal defect is seen by 2D or color Doppler.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
3. The right ventricular cavity is mildly dilated. Right
ventricular systolic function is normal.
4. There are simple atheroma in the aortic arch. The descending
thoracic aorta is mildly dilated. There are simple atheroma in
the descending thoracic aorta.
5. There are three aortic valve leaflets that are fused along
the right and non-coronary cusps and is a functionally bicuspid
valve.. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (area
<0.8cm2). Trace aortic regurgitation is seen.
6. The mitral valve appears structurally normal with trivial
mitral regurgitation.
POST-BYPASS:
The patient was removed from cardiopulmonary bypass on
phenylephrine infusion and AV pacing.
1. There is a mechanical prosthetic valve in the aortic
position. The valve is well seated and there is no evidence of
paravalvular leaks or aortic regurgitation. There is noted
washing jets from the valve. The peak gradient across the valve
is 25mmHg and the mean gradient is 14mmHg.
2. Biventricular function is preserved; LVEF> 55%.
3. Aortic contours are intact post-decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2193-10-15**] 06:44
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2193-10-16**] 5:07 PM
CHEST (PORTABLE AP)
Reason: eval for hemothorax in pt with dropping Hct
[**Hospital 93**] MEDICAL CONDITION:
50 year old man s/p CABGx3
REASON FOR THIS EXAMINATION:
eval for hemothorax in pt with dropping Hct
REASON FOR EXAMINATION: Dropping hematocrit in a patient after
CABG.
Portable AP chest radiograph compared to [**2193-10-15**].
No change in the global or mediastinal contour is demonstrated
since the previous study although there is overall increased
fullness at the level of the ascending aorta and azygos vein.
There is gradual worsening of left retrocardiac atelectasis with
slight increase in left pleural effusion although still small to
moderate. There is no pneumothorax. There is no evidence of
pulmonary edema.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
DR. [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1508**]Approved: [**Doctor First Name **] [**2193-10-17**] 12:29 PM
Brief Hospital Course:
He was taken to the operating room on [**10-14**] where he underwent a
CABG x 3 and AVR (On-X mechanical valve). He was transferred to
the ICU in critical but stable condition. He was extubated
later that same day. He was weaned from his neosynephrine and
transferred to the floor on POD #1 to begin increasing his
activity level. Chest tubes and pacing wires removed without
incident. Coumadin started for mechanical valve. INR therapeutic
on POD #6 and cleared for discharge to home. Target INR is
2.0-3.0.
Medications on Admission:
ASA 325 mg daily
glyburide 10 mg [**Hospital1 **]
pioglitazone 15 mg daily
vytorin daily
lisinopril 10 mg daily
oxycodone 15 mg [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
3. 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*
4. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Ezetimibe 10 mg 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).
Disp:*30 Tablet(s)* Refills:*2*
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Oxycodone 5 mg Tablet Sig: Three (3) Tablet PO Q6H (every 6
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day as
needed for AVR (onx).
Disp:*40 Tablet(s)* Refills:*0*
11. Keflex 500 mg Capsule Sig: Two (2) Capsule PO three times a
day for 7 days.
Disp:*42 Capsule(s)* Refills:*0*
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
13. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
CAD, AS now s/p CABG & AVR
NSTEMI, HTN, DM, ^ chol, Chronic back pain, Neuropathic leg pain
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
COUMADIN dosing/INR follow up with.........
First blood draw............
Target INR 2.0-3.0
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (STitle) 17887**] 2 weeks
Dr. [**Last Name (STitle) **] 2 weeks
Dr. [**Last Name (Prefixes) **] 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2193-10-21**]
ICD9 Codes: 4241, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1296
} | Medical Text: Admission Date: [**2140-10-31**] Discharge Date: [**2140-11-29**]
Date of Birth: [**2072-2-24**] Sex: M
Service: NEUROSURGERY
Allergies:
Flomax / Biaxin
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Urinary Incontience, Increased urinary frequency and
decreased ability to walk
Major Surgical or Invasive Procedure:
1. Arthrodesis from the occiput to C2, C3, C4, C5, C6 and C7
with lateral mass plates.
2. Instrumentation from occiput to C6.
History of Present Illness:
Mr [**Known lastname 105075**] has hx of C2-6 ependymoma with syringomyelia.
The tumor was removed in [**2123**] by Dr. [**Last Name (STitle) 105076**] at the Univ. of
Western [**Location (un) 50842**]. He subsequently was stable for many years, In
[**2138**] he developed a T10 hematoma from a cavernous hemangioma. He
has baseline right upper extremity weakness, he reports over the
last 6 months he feels his balance and gait has worsened over
the
last two months resulting in 2 recent falls. On [**10-26**] he
developed urinary incontience (pt's wife state it was inablility
to get to restroom quick enough) he called his primary care who
sent him to the ER where he was ruled out for UTI an MRI of his
spine showed progression of myelomalcia of the cervical cord
particularly involving C3-C4 levels. During his hospital stay
at
[**Hospital **] Hospital he felt he had worsening upper extremity
weakness. He was seen by a neurosurgeon at [**Hospital **] Hospital who
recommended surgery for stabilization. He was transferred here
for a second opinion.
Past Medical History:
C2-6 Ependymoma resected [**2123**], T10 Cavernous Hemangioma,
Asthma, Hypothyroidism, anxiety, transient hyponatremia, UTIs,
enlarged prostate, inguinal hernia repair complicated by
hemorrhage
Social History:
married with 3 children retired art teacher, non smoker,
non drinker
Physical Exam:
T 99.2 124/60 P 81 R 20 95%
Gen: Appear cachetic poor muscle mass
Lungs: Clear bilaterally
Card: RRR S1 S2
Abd: soft nondistended
Ext: No edema
Neuro: Awake, alert and orientated X3 anxious appropriate,
follows commands, PERRLA Right eye lateral nystagumus, EOMs
full,
Speech and comprehension intact
Skin has duoderm over area right shoulder and sternal area from
collar
D B T WE WF IO IP AT [**Last Name (un) 938**] G
Right 0 3+ 3+ 3 3+ 4- 4- 4 3 4
Left 4 2 2 4 4 4 4+ 4+ 4+ 4
Toes:
Reflexes 3+ at patella bilaterally
2+ at left bicep
Unable to illict in right upper
Toes downgoing on right mute on left
Decrease rectal tone, normal sensation
Sensation decreased to absent via pinprick on bilateral hands,
fingers up to elbow otherwise pt perceives as normal to light
touch through out
Brief Hospital Course:
Upon transfer from [**Hospital **] Hospital, the patient was admitted to
the Neurosurgery service. He was diagnosed with cervical
myelomalacia and had anterolisthesis of the cervical spine at
multiple levels. On admission after a formal plan was discussed
wtih the patient - he was refusion surgery and the Halo
placement as well. He wished to have his case reviewed with [**Hospital1 2025**]
surgeons as well as have as obatin the opinion of as many
doctors as possible. Ultimately he agreed to hav a Halo placed
and this was done to stabilize his neck. His exam fluctuated at
times. It was not always clear if his exam was worse or if the
patient was succumbing to anxiety attacks. He was adjusted
manually by Dr. [**Last Name (STitle) 739**] with follow up lateral c-spine
xrays after each adjustment to assess alignment of the cervical
spine over the course of 2 days. Ultimately it was decided that
though radiographically the patient did not have good alignment
he felt worse and had more complaints of numbness and immobility
when trying to adjust the alignment,so it was elected to leave
the anterolisthesis as is to prvent neurologic compromise, which
was happening with every attempt to correct the alignment . He
was adjusted again so that he felt symptomatic relief.
Radiographically he was improved from the original studies, but
he was not in optimal alignment - the patient was made aware of
this.
Prior to any surgical intervention he had an episode of
hypotension that lasted a while without any change in MS but the
next morning he had significanmt deterioration of his neuro
exam. MRI done showed worse edema at the C6 level.
He was seen and evaluated by PT, OT and speech and swallow
teams. He was also evaluated by the skin care RN for multiple
pressure ulcers r/t to use of a hard collar prior to admission.
As of [**11-3**] he was maintained on a regular diet, crush pills for
administration. He was also placed on a bowel regime. It was
agreed by the patient, after risks and benefits were discussed
that he would benifit from surgical cervical stabilization. He
was pre-op'd for surgery.
Subsequently he was taken to the operating room in order to
provide cervical stability - His first cervical procedure was
on [**2140-11-7**] when he underwent a posterior cervical fusion from
the occiput to C6. He was kept in the Halo postoperatively. He
tolerated this procedure well. Post-operatively, he was
carefully monitored in the PACU for one day and transfered to
step-down an then to a regular floor. He was extubated POD#2.
He exam was unchanged with minimal movement to Left toes and
distal Left upper extremity with some shoulder shrugging. He
was again re-evaluated by speech and swallow on [**2140-11-9**] and kept
on full po's as tol, with whole meds with water. He was
re-evaluated by PT and OT as well and was having some difficulty
with orthostatic BP maint. His post op cspine image was stable
and he had LE dopplers that were neg or DVT on [**2140-11-10**]. His Na
was 129 which we planned to follow closely. On [**2140-11-11**] pt was
seen for an event of difficulty breathing while on the floor.
Assessment revealed bilateral crackles [**1-10**] way up. he was
treated with a CXR, lasix 10, strict I/O's , am labs, PRN neb
tx. and repositioning. His sat was 96% on 3L- after the
intervention he improved clinically. He was transferred up to
the ICU for closer observation combined with the fact that he
would be a difficult intubation in the halo if he were to do
poorly. Baseline abg and PFT were obtained. His Na continued
to drop to 118 and an Renal consult was called for. He was fluid
restricted and placed on Nacl Tabs. Their recs were follwed.
[**2140-11-14**] he was having difficulty mainting stable BP's - they
were ranging 73-138/ 35-75. He was given fluid bolus' for
treatment. His Na today was 130 and the fluid restriction was
d/c'd. He was seen by Psychiatry as well for eval of coping
mechanisms. Their recs were followed. He had an MRI of the
spine on [**2140-11-15**] and noted was collapse of the cervical collumn
with cord compression secondary to posterior subluxation. The
radiologica findings were discussed with Dr. [**Last Name (STitle) 10442**] (neurology)
the patient and his wife. [**Name (NI) **] agreed that patient may benefit
from corpectomies of C345 with graft/fusion C2-C6. The patient
was brought to the OR urgently on [**2140-11-15**] for the procedure.
Postoperatively his imaging revealed an epidural hematoma - he
was taken back to the OR for evacuation of the hematoma. He
remained intubated postoperatively for airway control and was
electively trached on [**2140-11-17**]. His Na once again dropped to
117 and then came up to 129 with 3% NS. A neo drip was started
to maintain his sys BP - His decadron was placed on a taper to
end on [**11-24**]. His ventilator was weaned and he is breathing
well on his own on a trach mask. After failing a second swallow
evaluation, he underwent placement of a PEG tube on [**11-21**] and
tube feeds were initiated on [**11-22**] without complication. His
sodium levels stabilized. An AP/lateral xray of the c-spine was
obtained on [**11-28**] to rule out any changes after a shift in his
halo apparatus was noted. The xray was negative. He will need
another c-spine xray 2 weeks after discharge when he is seen by
Dr. [**Last Name (STitle) 23813**] (see discharge instructions). The patient was
deemed ready for discharge to rehab on [**11-29**].
Medications on Admission:
Levoxyl, Pepcid, Provigil, Vitamin D, Oscal,
Cardura and Colace
Discharge Medications:
1. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Levothyroxine Sodium 125 mcg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
3. Modafinil 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for FEVER/HEADACHE/PAIN.
5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
6. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] ().
7. Risedronate 35 mg Tablet Sig: One (1) Tablet PO qweek on
tuesdays ().
8. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
11. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
13. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
14. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
16. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-10**]
Drops Ophthalmic PRN (as needed).
17. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl
Topical QID (4 times a day) as needed for halo screw site
infectioin prophylaxis.
18. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal PRN (as needed) as needed for Hemorrhoids.
19. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
20. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
21. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Sliding scale.
22. Polyethylene Glycol 3350 17 g (100%) Packet Sig: One (1)
Packet PO q Daily () as needed for constipation.
23. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
24. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO 8 PM ().
25. Lansoprazole 15 mg Susp,Delayed Release for Recon Sig: One
(1) PO DAILY (Daily).
26. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
27. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q8H (every 8 hours) for 3 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. Significant cervical instability.
2. Cervical ependymoma.
Discharge Condition:
Stable
Discharge Instructions:
PLEASE TAKE MEDICATIONS AS PRESCRIBED AND READ WARNING LABELS
CAREFULLY. IF SIGNS AND SYMPTOMS OF INFECTION, SUCH AS FEVER
>101.5, PURULENT DISCHARGE FROM WOUND/INCISION SITE, INCREASED
REDNESS, INCREASED PAIN, PLEASE CALL OR GO TO THE EMERGENCY
ROOM. REMEMBER TO CALL TO SCHEDULE YOUR FOLLOW UP APPOINTMENT
(BELOW). [**Month (only) **] SPONGE BATH OR SHOWER, BUT KEEP WOUND/INCISION AS
DRY AS POSSIBLE. PAT DRY, DO NOT SCRUB.
Followup Instructions:
Please call Dr.[**Name (NI) 4674**] office for a follow up
appointment ([**Telephone/Fax (1) 88**] to be seen in 2 weeks. When you call
for the appointment, please tell them you need an xray of your
cervical spine (AP and lateral views) which they will schedule
for you to have before your appointment.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2140-11-29**]
ICD9 Codes: 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1297
} | Medical Text: Admission Date: [**2114-10-29**] Discharge Date: [**2114-11-5**]
Date of Birth: [**2058-5-23**] Sex: M
Service: [**Hospital1 212**]
HISTORY OF PRESENT ILLNESS: This is a 56-year-old male with
a history of diabetes type 2, hepatocellular carcinoma, colon
cancer with lung metastases and esophageal varices who
presents with an upper gastrointestinal bleed. The patient
was in his usual state of health until one day prior to
admission when he began experiencing coffee ground emesis
followed by melena. The patient went to an outside hospital
where his hematocrit was 32 with a baseline hematocrit of
35-40. He was transfused with one unit of packed red blood
cells, Vitamin K and transferred to [**Hospital6 649**].
Upon arrival his hematocrit was found to be 28 and
nasogastric lavage was done which showed mostly coffee
grounds. The patient did not complain of any abdominal pain.
Denied fevers, chills, nausea, vomiting prior to the day
before admission. He also denied chest pain and shortness of
breath.
PAST MEDICAL HISTORY:
1. Diabetes type 2.
2. Hepatocellular carcinoma diagnosed in [**2113-12-13**].
3. Colon cancer diagnosed in [**2105**] with metastatic disease of
the lung and to the liver.
4. Esophageal varices, status post wide resection of right
lung nodule in [**2106**].
5. Cirrhosis, status post sigmoid colectomy.
MEDICATIONS ON ADMISSION:
1. Regular insulin sliding scale.
2. Citalopram 20 mg daily.
3. Percocet prn.
4. Duragesic 50 mcg patch q. 72 hours.
5. Ativan prn.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives at home with his family
and his wife. [**Name (NI) **] does not smoke. Patient is a former
alcoholic and quit drinking four years ago.
FAMILY HISTORY: The patient's father died of prostate
cancer.
PHYSICAL EXAMINATION: Temperature 99.9. Heart rate 106.
Blood pressure 172/66. Respiratory rate 20. Oxygen
saturation 97% on room air. In general, pleasant in no acute
distress. Head, eyes, ears, nose and throat: Anicteric
sclera, clear oropharynx, moist mucous membranes. Supple
neck. Cardiovascular: Tachycardic, regular with no murmurs,
rubs or gallops. Lungs: Clear to auscultation bilaterally.
Abdomen: Soft, nontender, nondistended, slightly obese.
Extremities: No cyanosis, clubbing or edema, 2+ dorsalis
pedis pulses bilaterally. Neurological exam: Alert and
oriented times three. Cranial nerves II through XII are
intact.
LABORATORY DATA: White blood cell count 7.3, hematocrit
28.4, platelet count 132,000, INR 1.4, PTT 26.5, potassium
4.3, BUN 28, creatinine 0.7, ALT 85, AST 119, alkaline
phosphatase 197, T bilirubin 1.1. Recent alpha-fetoprotein
27,054.
Chest x-ray initially showed small right pleural effusion.
No consolidation.
HOSPITAL COURSE:
1. Upper gastrointestinal bleed: Because of his active
upper gastrointestinal bleed, the patient was admitted to the
Medical Intensive Care Unit where adequate intravenous access
was obtained. Patient was hemodynamically stable and
underwent an upper endoscopy. The upper endoscopy showed
Grade 2 varices in the lower third of the esophagus and
portal hypertensive gastropathy with blood in the duodenum.
However, initially, the patient was not cooperative with the
procedure and gastroenterologists' were unable to pass the
banding scope. The patient was started on an octreotide drip
and was intubated for protection of his airway and for an
attempt at variceal banding. The second upper endoscopy was
performed, however, again, the gastroenterologists' were
unable to pass the banding scope, therefore, the patient was
continued on his octreotide drip. His PPI and serial
hematocrits were followed. Patient's hematocrit remained
stable. He was extubated less than 24 hours and was
transferred out to the General Medicine Wards, and a third
repeat endoscopy was performed after five days of an
octreotide drip.
Repeat endoscopy showed, again, Grade 2 varices at the lower
third of the esophagus, erythema, congestion and abnormal
vascularity in the fundus and body of the stomach compatible
with portal gastropathy. At this time the banding scope
again was unable to be passed. As the patient's hematocrit
was stable and he was no longer having any gastrointestinal
bleeding, the patient was started on nadolol and he was
discharged on Protonix and nadolol with a follow-up endoscopy
scheduled for [**2114-11-14**]. At this time, the
gastroenterologists' will attempt scleral therapy for his
varices.
2. Aspiration pneumonia: 24-48 hours after extubation, the
patient developed fever, productive cough, crackles and
decreased bowel sounds at the left base of his lung despite
no radiographic findings. The patient was felt to have an
aspiration pneumonia versus pneumonitis. He was started on a
seven day course of Levaquin and clindamycin. After starting
antibiotics, the patient quickly defervesced and clinically
improved.
3. Ascites: The patient was found to have moderate ascites
on physical exam. He underwent a right upper quadrant
ultrasound with Doppler flow which showed liver nodules
consistent with metastatic disease and partial flow in the
main portal vein consistent with nonocclusive thrombus.
>........<left portal vein with normal right portal vein
flow. A small amount of ascites was also visualized in the
left lower quadrant. The patient was stable without any
spironolactone or additional diuretics, however, he will need
close follow-up and may need to be started on diuretics as an
outpatient.
4. Gastrointestinal malignancies: The patient has a history
of hepatocellular carcinoma, colon cancer with metastatic
disease of the lung and liver. He will follow-up as an
outpatient with his primary care physician, [**Name10 (NameIs) 3**] well as the
liver specialists at the Liver Clinic. This appointment will
be arranged at the time of his repeat endoscopy on [**2114-11-14**].
5. Depression: The patient was continued on his Citalopram.
6. Diabetes: The patient was continued on a regular insulin
sliding scale during this hospitalization. In addition he
was started on glargine for his inpatient stay. He was
discharged on his home regimen of regular insulin sliding
scale. He will follow-up with his primary care physician for
adjustment for his home insulin regimen.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: To home with follow-up for repeat
endoscopy on [**2114-11-14**].
PATIENT DISCHARGE INSTRUCTIONS: Please follow-up with your
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**Telephone/Fax (1) 36098**], in one to
two weeks. Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] for your
repeat endoscopy on [**2114-11-14**]. Your appointment is at
8:30 at [**Hospital Ward Name 121**] 8. Please arrive at 7:30 a.m. and do not eat or
drink anything after midnight the night before. If you have
any questions, please call the Endoscopy Suite at
[**Telephone/Fax (1) 100287**]. At this time, an outpatient follow-up
appointment will be arranged for a liver specialists.
DISCHARGE DIAGNOSES:
1. Esophageal varices.
2. Upper gastrointestinal bleed.
3. Portal hypertensive gastropathy.
4. Hepatocellular carcinoma.
5. Colon cancer with metastatic disease to the liver and
lung.
6. Diabetes mellitus type 2.
7. Hyponatremia.
8. Ascites.
9. Aspiration pneumonia.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2114-11-6**] 05:11
T: [**2114-11-7**] 21:50
JOB#: [**Job Number 100288**]
ICD9 Codes: 5715, 5070 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1298
} | Medical Text: Admission Date: [**2174-9-26**] Discharge Date: [**2174-10-17**]
Date of Birth: [**2103-2-25**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Attending Info 65513**]
Chief Complaint:
Nausea, vomiting, diarrhea, bloating, extreme fatigue x 5 weeks
Major Surgical or Invasive Procedure:
exploratory laparotomy, debulking of advanced ovarian cancer
including drainage of ascites, TAH-BSO, omentectomy,
rectosigmoid resection and colostomy, appendectomy, resection of
small bowel tumor, and ablation of diaphragmatic tumor.
History of Present Illness:
Ms. [**Known lastname **] is a 71 year-old postmenopausal Gravida 0 who presented
w/ complaints of persistent nausea, occasional vomiting,
anorexia, early satiety,bloating, and overall extreme fatigue
making it difficult to carry on any normal activities for the
last 5 weeks. She has lost ~10 pounds. Her primary care
physician ordered [**Name Initial (PRE) **] CT of the abdomen that showed massive
ascites and omental caking, concerning for possible metastatic
ovarian cancer, however the pelvis was not imaged. Her CA-125
level was elevated at 483 U/mL.
Past Medical History:
OB History: Gravida 0
Gynecologic History:
- Postmenopausal since age 55, no postmenopausal bleeding
- Reports ? abnormal Pap ~20 years ago followed by negative
biopsies, no Paps since
- Denies any history of ovarian cysts, fibroids, endometriosis
Past Medical History:
- TIA after her knee surgery in [**2172**]
- Hypertension
- Hypercholesterolemia
- Osteoarthritis
- Osteoporosis
- Asthma
- Last colonoscopy [**2169**], for next in [**2179**]
- Last mammogram [**2174-5-19**]
- Denies history of heart/valve disease or thrombosis
Past Surgical History:
- Right knee replacement [**2172**]
Social History:
Independent, lives at home alone and her husband recently passed
away. Has brothers, nieces and nephews that live in the area.
Denies tobacco, etoh or drug use.
Family History:
Aunt- unknown type of cancer
cousin- b/l breast cancer
Mother/ father- heart disease
Physical Exam:
On admission:
Vital Signs: T 97.8 HR 70 BP 182/97 -> 170/76 RR 18 O2 sat
97% on RA
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD,
No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**] however heart sounds very distant. JVP=6cm
LUNGS: CTAB except for decreased BS at bases b/l
ABDOMEN: Firm and distended, NT, +BS
EXTREMITIES: No edema. 2+ dorsalis pedis/ posterior tibial
pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout.
On discharge:
Pertinent Results:
[**2174-9-26**] 12:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2174-9-26**] 12:34PM LACTATE-1.4
[**2174-9-26**] 12:30PM CEA-2.2, CA-125 743
[**2174-9-26**] 12:30PM WBC-6.0 RBC-4.15* HGB-11.0* HCT-34.0* MCV-82
MCH-26.6* MCHC-32.5 RDW-14.3
TEE: Normal biventricular cavity sizes with preserved global and
regional biventricular systolic function
CT Pelvis: Extensive omental disease and ascites noted within
the pelvis. A single omental deposit is identified anterior to
the right external iliac artery and vein measuring 1.2 x 1.4 cm.
Further peritoneal deposits are identified along the posterior
aspect of the wall of the bladder measuring maximum thickness of
7 mm. There is a bulky uterus with a large fibroid identified
off the fundus measuring 4.5 x 4.0 cm. There are bilateral
adnexal lesions. The right side measures 3.0 x 3.3 cm and on the
left side measuring 3.1 x 3.9 cm.
Pathology: ovaries/ tubes/ uterus/ appendex/ omentum/ bowel/
pleural fluid/ ascites with evid of high grade serous carcinoma
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the GYN Onc service [**2174-9-26**] secondary
to suspicious for advanced ovarian malignancy with preoperative
CT scan demonstrating marked omental caking, ascites, and
bilateral adnexal masses. Her CA 125 was 743. Preoperatively
she was evaluated by medicine. A TEE was done which was within
normal limits. A therapeutic thoracentesis was performed and
cytology revealed malignant disease. VATs procedure did not
demonstrate any visible pulmonary disease.
She had an exploratory laparotomy with optimal tumor debulking.
Please see operative report for full details. She was
transferred to the [**Hospital Unit Name 153**] immediately postop given extensive
procedure, pleural effusions, intraop hypotension and
anticipated fluid shifts. She was monitored closely, given
fluids/ pRBC's for hypotension/ oliguria, and sucessfully
extubated on POD 1. Given extensive bowel surgery, she remained
NPO after surgery and was started on TPN on POD 2. She remained
stable and was transferred from the ICU to the floor on POD 2.
She continued on TPN until her diet was advanced and she was
able to tolerate PO's. Her ostomy appeared healthy throughout
her hospitalization and put out both gas and stool prior to
discharge.
She was weaned from oxygen on POD [**12-23**]. PleurX was in place on
left for intermittent thoracentesis as needed for pulmonary
effusions. She remained on flovent and albuterol as needed.
She was discharged on POD 17 in stable condition. She was
ambulating, voiding spontaneously, pain well controlled. Plan
in place for chemotherapy.
Medications on Admission:
Nifed 60', Atenolol 25 qD, Omeprazole 20mg ER',Flovent 220mcg,
Lorazepam 0.5mg, Albuterol PRN, Aspirin 325mg
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
2. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
3. nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
4. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for insomnia, nausea.
6. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
7. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
Life Care Center at [**Location (un) 2199**]
Discharge Diagnosis:
ovarian cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call your doctor for:
* fever > 100.4
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* No strenuous activity, nothing in the vagina (no tampons, no
douching, no sex), no heavy lifting of objects >10lbs for 6
weeks.
* You may eat a regular diet.
Incision care:
* You may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs for 6 weeks.
* If you have staples, they will be removed at your follow-up
visit.
Followup Instructions:
Followup with Dr. [**Last Name (STitle) 5797**] on [**10-24**] @ 1pm. Phone:
[**Telephone/Fax (1) 5777**]
Provider: [**First Name8 (NamePattern2) 828**] [**Name11 (NameIs) 829**], MD (Interventional pulmonology)
Phone:[**0-0-**] Date/Time:[**2174-10-20**] 9:30
Followup with Dr. [**Last Name (STitle) **] (oncology). Dr.[**Name (NI) 50760**] office should be
in touch with an appointment time. The office phone number is
[**Telephone/Fax (1) 65559**].
[**Name6 (MD) 35354**] [**Name8 (MD) **] MD [**MD Number(2) 65515**]
Completed by:[**2174-10-17**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1299
} | Medical Text: Admission Date: [**2165-8-2**] Discharge Date: [**2165-8-7**]
Date of Birth: [**2097-5-30**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
recurrent tumor
Major Surgical or Invasive Procedure:
[**2165-8-2**]: Left Temporal Craniotomy and resection of mass.
History of Present Illness:
[**Known firstname 73718**] [**Known lastname 11952**] is a 68-year-old right-handed man from [**Location (un) 4708**],
who had 2-3 weeks of forgetfulness in late [**2165-3-11**] and was
diagnosed with a glioblastoma multiforme in the left temporal
brain. He had:(1) a gross total surgical resection by Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) **] on [**2165-4-22**], and (2) status post involved-field cranial
irradiation with temozolomide from [**2165-5-15**] to [**2165-6-26**].
He is here today for a neurological follow up and he had a
post-radiation head MRI on [**2165-7-22**] with ASL. His dexamethasone
was weaned off on [**2165-5-28**]. But his family phoned radiation
oncology reporting that he was behaving aggressively and
becoming irritable. They put back on 2 mg of dexamethasone
twice daily on [**2165-7-16**]. His behavior did not improve. He is
also feeling
fatigued but he does not have dyspnea on exertion. An MRI
revealed some regrowth in the left temporal [**Doctor Last Name 534**]. He now
[**Doctor Last Name 82473**] presents for resection.
Past Medical History:
DM
Hyperlipemia
Carcinoid tumor
Social History:
Retired painter
Lives with his sister
Family History:
NC
Physical Exam:
His Karnofsky Performance Score is
90. He is awake, alert, and oriented times 3. His language is
fluent with good comprehension. Recent recall is fair. Cranial
Nerve Examination: His pupils are equal and reactive to light,
4
mm to 2 mm bilaterally. Extraocular movements are full; there
is
no nystagmus. Visual fields are full to confrontation. His
face
is symmetric. Facial sensation is intact bilaterally. His
hearing is intact bilaterally. His tongue is midline. Palate
goes up in the midline. Sternocleidomastoids and upper
trapezius
are strong. Motor Examination: There is no drift. His muscle
strengths are [**5-15**] at all muscle groups. His muscle tone is
normal. His reflexes are 2+ at biceps, brachioradialis, and
triceps bilaterally. His knee jerks are 2+ bilaterally. His
ankle jerks are absent. His toes are down. Sensory examination
is intact to touch and proprioception. Coordination examination
does not reveal dysmetria. His gait is steady. He can do
tandem
gait. He does not have a Romberg
PHYSICAL EXAM UPON DISCHARGE:
awake, alert to self only but is appropriate with answering
questions. PERRL 3mm, EOMI, face symmetric, no pronator drift.
MAE's symmetrically with good strengths. Incision is well
healing & staples are intact.
Pertinent Results:
[**2165-8-2**] Head CT:IMPRESSION:
1. Expected postoperative changes status post left temporal
craniotomy and
tumor resection. Air and fluid within the left frontotemporal
extra-axial
space and within the resection cavity in addition to mild sulcal
effacement involving the left frontal lobe secondary to
pneumocephaly. No shift of midline structures.
2. Small amount of hyperdense material layering within the
occipital [**Doctor Last Name 534**] of the left lateral ventricle could represent a
tiny amount of intraventricular blood. No hydrocephalus.
[**2165-8-3**] MRI: IMPRESSION: Status post tumor resection at the tip
of the left temporal lobe, the previous area of enhancement in
this region has been resected. Residual blood products,
vasogenic edema and minimal midline shifting towards the right
is demonstrated as described above. No new lesions are
identified. Small amount of fluid is noted in the surgical area
with associated soft tissue edema. No restricted diffusion is
noted to suggest acute/subacute ischemic changes. Small amount
of blood is demonstrated in the occipital ventricular horns and
small amount of pneumocephalus on the tip of the left temporal
region.
[**8-7**] valproic acid level =112 (not a true trough)
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2165-8-7**] 05:30 144*1 18 1.2 138 4.4 101 29
Brief Hospital Course:
Mr [**Known lastname 11952**] [**Last Name (Titles) 82473**] presented for craniotomy and resection of
his recurrent left temporal mass. Surgery was without
complication and the patient tolerated it well. Post operatively
he was admitted to the ICU for close neurological monitoring.
Routine post op head CT revealed post op changes, no hemorrhage.
He remained stable overnight. on POD#1 he had a routine post op
MRI for staging. This was performed and revealed excellent
resection without evidence of residual tumor. He was cleared for
transfer to the floor.
Pt continued to be neurologically stable. PT/OT were consulted
for assistance with discharge planning. Valproic Acid level was
checked and found to be low therefore his daily dosing was
increased. The patient was also noted to have poor PO intake,
but when nursing/family assisted him he improved significantly.
PT/OT Recommend discharge to acute rehab facility.
Valproic Acid level was rechecked on [**8-7**] and found to be 112.
This was discussed and since it was not a trough the current
dosing was continued and it is recommended that a trough be
checked [**8-8**].
On [**8-7**] the patient was free of pain, tolerating PO [**Month/Year (2) **],
voiding without difficulty and OOB with assist. He was cleared
at this time for discharge to rehab.
Medications on Admission:
valproic acid
decadron 2mg [**Hospital1 **]
colace
BRIMONIDINE
METFORMIN
ACTOS
Simvastatin
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, T>101.4.
6. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
7. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 units
Injection TID (3 times a day).
13. Valproic Acid 250 mg Capsule Sig: Three (3) Capsule PO Q8H
(every 8 hours).
14. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
left temporal brain tumor
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours after your
sutures are removed.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
[**Name10 (NameIs) **]
Usually no special [**Name10 (NameIs) **] is prescribed after a craniotomy. A
normal well balanced [**Name10 (NameIs) **] is recommended for recovery, and you
should resume any specially prescribed [**Name10 (NameIs) **] you were eating
before your surgery.
MEDICATIONS
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
o Narcotic pain medication such as Dilaudid (hydromorphone).
o An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? You have been discharged on Valproic Acid, you will not
require blood work monitoring. Your level was checked on [**8-7**]
and was 112 but this was not a trough and should be rechecked
[**8-8**].
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
ACTIVITY
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour, that you
are awake.
Followup Instructions:
Follow-Up Appointment Instructions
?????? Please have your staples removed on [**2165-8-12**] at rehab.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast before
this appointment.
Completed by:[**2165-8-7**]
ICD9 Codes: 2720 |
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