meta
dict | text
stringlengths 0
55.8k
|
|---|---|
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1300
} | Medical Text: Admission Date: [**2165-12-10**] Discharge Date: [**2165-12-16**]
Date of Birth: [**2111-8-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Unstable angina
Major Surgical or Invasive Procedure:
Coronary artery bypass graft--quadruple vessel
History of Present Illness:
Mr. [**Known lastname **] is a 54-year-old male who has worsening unstable
anginal symptoms with cardiac catheterization that showed severe
3 vessel disease with a tight ulcerated unstable looking right
coronary plaque with an ostial left anterior descending stenosis
and stenosis involving a good sized marginal branch and ramus
intermedius branch. His ejection fraction was mildly reduced. He
is presenting for revascularization.
Past Medical History:
NIDDM
Coronary artery disease
Social History:
Tobacco 2PPD, +EtOH 6 drinks on weekend, no IDU
Family History:
CAD-mother in 70s
Stroke-father
[**Name (NI) **] [**Name (NI) 64764**]
Brief Hospital Course:
Mr. [**Known lastname **] was transferred to Dr. [**Last Name (STitle) **] service at [**Hospital1 18**] on
[**2165-12-10**] after a cardiac catheterization that day showed cardiac
catheterization that showed severe 3 vessel disease with a tight
ulcerated unstable looking right coronary plaque with
an ostial left anterior descending stenosis and stenosis
involving a good sized marginal branch and ramus intermedius
branch. He had originally presented to [**Hospital 1474**] Hospital for
complaints of chest pain with radiation to his jaw having
awakened him from his sleep. He was ruled-out times three with
cardiac enzymes while at [**Hospital1 1474**]. He denies ever feeling short
of breath or any other symptoms besides the SOB. He underwent
an exercise stress test the morning of his presentation and
found to have EKG changes with reversible depressions in the
inferior and precordial leads relieved by rest and NTG. He was
then transferred to [**Hospital1 18**] for a catheterization which, after
showing the above, the patient was then evaluated for CABG and
moved quickly to the OR. He then underwent a quadruple vessel
bypass. For details of the procedure, see operative dictation.
Mr. [**Known lastname 64765**] post-operative course was stable and without
major issue. He was transferred out of the CSRU and to the
floor the day following his operation. the remainder of his
hospital course was straightforward and without major issue. He
was transfused, however, with 1 unit of PRBCs on POD 3 a low BP
and high HR in the face of a Hct = ~27; his Hct improved as
expected. On POD 6 he was doing well and ambulating with PT up
stairs. He had also been tolerating s regular, heart healthy,
diabetic diet without issue. Pain control had been good
post-operatively. He was deemed fir to return home on POD and
was so discharged with VNA care in good condition, ambulating
without issue, eating well and with good pain control. he is
asked to follow-up with Dr. [**Last Name (STitle) **] in 1 month and to return in
[**12-23**] weeks for a wound check to the Cardiac Surgery floor.
Medications on Admission:
Lopid 600mg PO QDaily
Metformin 500mg PO BID
ASA 325mg PO QDaily
Lisinopril 5mg PO QDaily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
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. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2
hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
Disp:*qs ML(s)* Refills:*2*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 5 days.
Disp:*10 Capsule, Sustained Release(s)* Refills:*0*
10. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary artery disease with blockage x4
Blood loss anemia
Discharge Condition:
Good
Discharge Instructions:
Go to an Emergency Room if you experience new and continuing
nausea,
vomiting, fevers (>101.5 F), chills, or shortness of breath.
Also go to the ER if your wound becomes red, swollen, warm, or
produces pus.
If you experience clear drainage from your wounds, cover them
with a
clean dressing and stop showering until the drainage subsides
for at
least 2 days.
No heavy lifting or exertion for at least 6 weeks.
No driving while taking pain medications.
Narcotics can cause constipation. Please take an over the
counter stool softener such as Colace or a gentle laxative such
as Milk of Magnesia if you experience constipation.
You may resume your regular diet as tolerated.
You may resume all of your previously prescribed medications.
You may take showers.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 170**] Follow-up appointment
should be in 1 month
Please return for a wound check in 2 weeks.
ICD9 Codes: 2851, 4111, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1301
} | Medical Text: Admission Date: [**2179-7-14**] Discharge Date: [**2179-8-20**]
Date of Birth: [**2114-8-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Abdominal pain, concern for mesenteric ischemia
Major Surgical or Invasive Procedure:
[**7-17**]:
1. Exploratory laparotomy.
2. Segmental ileal resection.
3. Mesenteric vessel exploration.
1. Resection 8 cm distal ileum
2. Resection of terminal ileum and right colon.
3. Ileotransverse colostomy.
4. [**State 19827**] patch temporary abdominal wall closure.
[**7-18**]:
1. Superior mesenteric artery stenting
[**7-27**]
1. Closure of abdominal wound
2. Tracheostomy with insertion of 8Fr tracheostomy tube
[**8-4**] cardiac catheterization
[**8-16**] EGD
[**8-19**]
1. inferior vena cava filter (Bard G2) via left femoral route.
with Fluoroscopic control for IVC filter placement.
History of Present Illness:
Transfer from OSH with concern for mesenteric ischemia
HNP 64 yo male with 14 days of colicky abdominal pain now
constant. Associated with brown maroon vomiting, and melena.
No [**Month/Year (2) **]. Patient was admitted to [**Hospital3 26615**] hospital with a
WBC of 5 increasing to 28. Ct scan was concerning for mesenteric
ischemia showing fluid around the spleen, [**Female First Name (un) 899**] not identified,
SMA severely diseased.
Patient was reported to have a Troponin leak at outside
hospital, concerning for myocardial ischemia.
Past Medical History:
PVD
DM
Bladder CA
COPD
Surgical History:
Open Chole
Aorto [**Hospital1 **] Fem Bypass
Social History:
90 pack/year smoker
6-12 beers/week
Retired highway heavy equipment operator
Family History:
non-contributory
Physical Exam:
GEN: Pt alert, in NAD
HEENT: PERRLA, trach in place, no erythema or drainage, on
ventilator
RESP: Slight wheezing bilaterally
CV: RRR
AB: + BS, soft, non tender, non distended. Abdominal incision
healing by secondary intention, no erythema or drainage.
Dressed with gauze and ab binder
EXT: 2+ edema, chronic changes on lower legs bilat
Neuro: follows commands
Pertinent Results:
CARDIAC CATH [**8-4**]
FINAL DIAGNOSIS:
1. Severe left main and three vessel coronary artery disease.
2. Moderate systolic left ventricular dysfunction.
COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated left
main and 3 vessel disease. The LMCA had a distal 70% lesion. The
LAD
had an 80% ostial lesion with mid/distal 80% lesion. The LCx
system had an occluded OM2 with collateral filling. The RCA was
proximally occluded with left coronary collaterals.
2. Resting hemodynamics revealed normal left ventricular
systolic
pressure of 104 mm Hg and normal LVEDP of 12 mm Hg. Sytemic
arterial
systolic and diastolic pressures were normal.
3. Left ventriculography revealed no mitral regurgitation, mild
global
hypokinesis, and LVEF of 45%.
ECHO [**2179-7-29**]
Overall preserved left ventricular systolic function. Mild
mitral regurgitation. Mildly dilated ascending aorta.
ECHO [**7-14**]:
There is mild regional left ventricular systolic dysfunction
with inferior and apical hypokinesis. 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. Mild (1+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
EGD: [**8-19**]
Normal mucosa in the whole esophagus; Erythema and congestion
in the stomach body and antrum compatible with mild gastritis;
Superficial ulcer -second part part of the duodenum at previous
BICAP site; Small hiatal hernia; Otherwise normal EGD to second
part of the duodenum
EGD [**8-16**]:
Erythema and congestion in the gastroesophageal junction
compatible with mild esophagitis; Erythema and congestion in
the antrum compatible with mild gastritis; Angioectasia in the
second part of the duodenum; Small hiatal hernia; Otherwise
normal EGD to second part of the duodenum
Brief Hospital Course:
Mr. [**Known lastname **] is a pleasant 64-year-old male with a significant past
medical history of diabetes, hypertension, prior bladder cancer
and a hiatal hernia who had signs and symptoms of progressive
chronic mesenteric ischemia. Of note, the patient had previously
undergone an aortobifemoral bypass approximately 15 years prior
to presentation for bilateral aorto-iliac occlusive disease. He
now had a several week to month history of progressive
postprandial angina and food fear and weight loss. However, the
patient presented to the vascular service on [**2179-7-14**] with
a several day history of nausea, vomiting, abdominal distention
and obstipation. Initial workup revealed leukocytosis and a CT
scan revealing evidence of a transition point in the right lower
quadrant. Suspicion for a high grade
small bowel obstruction was noted. However, given the
constellation of findings of his prior chronic mesenteric
ischemia, it was unclear as to whether or not this was also a
potential etiology of his pain presentation.
1 Mesenteric ischemia: On the morning of [**2179-7-17**], the
patient was noted to be focally tender with a 23,000 white count
and bandemia. In lieu of his CT scan done the prior day showing
a transition point in the right lower quadrant with the physical
constellation as described, an urgent general surgery
consultation was made by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] covering for Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 1391**]. Dr. [**Last Name (STitle) **] approached Dr. [**Last Name (STitle) **] and discussed the plan
of care. After review, it was determined that the patient
required urgent exploration. The patient was consented and risks
including bleeding, infection, bowel in discontinuity, open
abdomen, myocardial infarction, stroke and death, intracutaneous
fistula, recurrent abscesses, possible short bowel were
described.
He was taken to the OR on [**7-17**] and underwent an exploratory
laparotomy, segmental ileal resection, and mesenteric vessel
exploration. Abdomen was left open for a planned second look
operation. The patientleft the operating room hemodynamically
stable. However, he was quite volume outed. He was not on
vasopressors at the
completion of this operation. He was left intubated in critical
condition and returned to the trauma SICU for further monitoring
and care. The vascular surgery service had performed the
catheter-based revascularization of the superior mesenteric
artery. On [**7-18**] the patient then underwent resection 8 cm distal
ileum, resection terminal ileum and right colon. Ileotransverse
colostomy and [**State 19827**] patch temporary abdominal wall closure.
On [**7-27**] patient returned to the OR for definitive abdominal
wound closure and tracheostomy.
2. Myocardial infarction: Incidentally noted to have ST
depressions on telemetry, confirmed with 12-lead in V3-V6 on
[**7-25**]. Troponin leak: TnT baseline 0.05 on [**7-14**] noted to be
0.62=>0.51. Also with severe pulmonary edema on CXR. Once he
became hemodynamically stable, he was agressively diuresed with
lasix/spironolactone. Patient had a repeat ECHO that showed the
left atrium to to be normal in size. Left ventricular wall
thicknesses and cavity size are normal. Overall left ventricular
systolic function appeared normal (LVEF 55%). Mild (1+) mitral
regurgitation was seen. ST-T changes were though to be a result
of cardiac demand. It was thought that patient would benefit
from a cardiac catherization to better ellucidate his disease
process and defect. On [**8-4**] he underwent a cardiac catherization
that showed a right dominant system demonstrating left main and
3 vessel disease. The LMCA had a distal 70% lesion. The LAD
had an 80% ostial lesion with mid and distal 80% lesions. The
LCx system had an occluded OM2 with collateral filling. The RCA
was
proximally occluded with left coronary collaterals. Because of
this pathology, cardiac surgery team was consulted for
evaluation for CABG. Because of Mr. [**Known lastname **]' co-morbidities and
his recent illness, he was deamed to be at high risk for
procedure. He will be managed medically and will be re-evaluated
in several months after he heals from his recent insults.
Respiratory failure: Patient remained intubated after
procedure. He failed to wean from the ventilator and underwent a
tracheostomy on [**7-27**]. He remained on ventilatory support
throughout the remainder of the hospitalization and failing
weaning to trach mask secondary to respiratory muscle fatigue
and hypercarbia.
ID: Yeast in urine and sputum [**7-30**]. Patient was started on a
course of IV fluconazole and will finish on [**2179-8-7**]. On [**8-8**]
sputum cultures showed MRSA, and he began treatment with vanc
and zosyn
GI: Had several episodes of diarrhea, which were C. diff
negative x 3. On [**8-15**] pt began to have large melanotic stools
and his hct dropped from 27-21. GI was consulted and pt was
transfused several units of blood. EGD performed on [**8-16**] showed
a bleeding angioectasia in the second part of the duodenum which
was sucessfully cauterized. Otherwise, EGD revealed mild
esophagitis, mild gastritis, and a small hiatal hernia. Repeat
EGD on [**8-19**] showed Normal mucosa in the whole esophagus
Erythema and congestion in the stomach body and antrum
compatible with mild gastritis
Superficial ulcer -second part part of the duodenum at previous
BICAP site
Small hiatal hernia; Otherwise normal EGD to second part of the
duodenum. He was switched from famotidine to protonix. When
not NPO for procedures, the pt recieved tube feeds - most
recently - replete with fiber at 80 cc/hr
Heme: An IVC filter was placed [**8-19**] secondary to prolonged bed
rest, and unable to continue SQ heparin secondary to GI bleed.
Before the filter was placed, bilateral LENI's were performed,
showing no DVT and patent femoral veins.
He is being discharged to a rehabilitation facility with
instructions for follow-up.
Medications on Admission:
Albuterol, aspirin
Discharge Medications:
1. Insulin
Fingerstick Q6HInsulin SC Fixed Dose Orders
Breakfast Dinner
NPH 15 Units NPH 15 Units
Insulin SC Sliding Scale
Q6H
Regular
Glucose Insulin Dose
0-65 mg/dL [**1-5**] amp D50
66-120 mg/dL 0 Units
121-140 mg/dL 2 Units
141-160 mg/dL 4 Units
161-180 mg/dL 6 Units
181-200 mg/dL 8 Units
201-220 mg/dL 10 Units
221-240 mg/dL 12 Units
241-260 mg/dL 14 Units
261-280 mg/dL 16 Units
> 280 mg/dL Notify M.D.
Instructons for NPO Patients: [**1-5**] when NPO
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
4. Albuterol 90 mcg/Actuation Aerosol Sig: Ten (10) Puff
Inhalation Q2H (every 2 hours) as needed.
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**6-11**]
Puffs Inhalation Q4H (every 4 hours).
6. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for [**Month/Day (3) **].
8. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
12. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
15. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
Mesenteric ischemia requiring bowel resection, arterial stenting
Myocardial infarction
Discharge Condition:
Stable to rehabilitation facility
Discharge Instructions:
Please call doctor [**First Name (Titles) **] [**Last Name (Titles) **] greater than 101, nausea/vomiting,
inability to eat, wound redness/warmth/swelling/foul smelling
drainage, abdominal pain not controlled by pain medications or
any other concerns.
Please follow-up as directed.
No heavy lifting ([**10-18**] lbs)for 4 weeks or until directed
otherwise. [**Month (only) 116**] leave wound open to air.
Diet: Tube feeding
Wound Care: [**Month (only) 116**] shower/sponge bathe (no bath or swimming) if no
drainage from wound, if clear drainage cover with dry dressing
IF severe pain, persistent nausea and vomiting, [**Month (only) **]>101.5,
redness of wound??????call surgeon.
[**Month (only) 116**] restart asprin in [**1-5**] weeks depending on recommendations of
cardiology/PCP
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **]/Surgery clinic. Call to schedule
your appointment. [**Telephone/Fax (1) 600**] in 2 weeks.
Please follow up with Cardiac surgery in [**2-6**] months with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**]: [**Telephone/Fax (1) 170**].
Per GI, needs capsule or colonoscopy as outpatient to evaluate
for additional AVMS call [**Telephone/Fax (1) 41066**] for appt
ICD9 Codes: 5185, 496, 4280, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1302
} | Medical Text: Admission Date: [**2193-12-25**] Discharge Date: [**2194-1-4**]
Date of Birth: [**2119-1-4**] Sex: M
Service: GENERAL SURGERY/PURPLE SERVICE
HISTORY OF THE PRESENT ILLNESS: The patient is a 74-year-old
gentleman with a history of gastric CA who presented to [**Hospital1 18**]
for evaluation and management.
PAST MEDICAL HISTORY:
1. Prostate CA, status post XRT.
2. Hypertension.
3. GERD.
4. Emphysema.
5. URI.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Lisinopril.
2. Senna.
3. Zantac.
4. Tylenol.
PAST SURGICAL HISTORY:
1. Status post appendectomy.
2. Status post left knee surgery.
3. Status post colostomy.
PHYSICAL EXAMINATION ON ADMISSION: The patient was pleasant
and cooperative, in no acute distress. The heart revealed a
regular rate and rhythm. The lungs were clear to
auscultation bilaterally. The abdomen was soft, nontender,
nondistended. The extremities were warm and perfuse. No
edema.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2193-12-25**] where exploratory laparotomy was
performed. The patient had multiple metastases so
gastrectomy was not performed. The patient had two omental
biopsies, liver biopsy, and was transferred to the PACU in
stable condition and later to the floor.
However, on the floor, the patient's respiratory status had
decreased. He required increasing amounts of oxygen until
finally he became unresponsive and hypotensive. He was
intubated. IV fluids were started and he was transferred to
the SICU. He required levo for hypotension.
Chest x-ray showed a right infiltrate. He was also started
on Lasix for pulmonary edema. The patient did not require
levo by postoperative day number two. Attempts to extubate
the patient on postoperative day number two and three failed.
We were not able to wean him off the ventilator.
He was extubated on postoperative day number four. Over the
next few days he continued to have shortness of breath. He
developed tachycardia up to 120-130. His blood pressure
remained stable. He was producing large amounts of mucus.
His chest x-ray was unremarkable except for a suspicious
opacification in the left lobe which was considered to be a
possible pneumonia. The patient was started on levo. He was
also started on Lopressor and then Diltiazem drip for
tachycardia control.
On postoperative day number six, the patient was started on a
combination of oral and IV Lopresor which seemed to control
his tachycardia much better. There was a suspicion of
aspiration so a video swallow study was performed which
showed the patient aspirates some air when using a straw,
however, can drink normally from a cup without any
aspiration.
The patient's respiratory status has improved. He was
started on chest PT which produced a large amount of mucus.
His shortness of breath has improved. His heart rate and
blood pressure were under control.
He was transferred to the floor on postoperative day number
seven. On postoperative day number eight and nine, the
patient continued PT and chest PT with improving strength.
His respiratory status is improving. He has a little bit
less shortness of breath; however, he still requires 02. He
was progressed to a general diet which he was tolerating
well. He was passing gas and stool.
On postoperative day number nine, the patient was afebrile.
The vital signs were stable to 96-97% 02 saturation on 2
liters, producing large amounts of clear sputum (cultures
were negative to date on the oropharyngeal flora). The
patient was ambulating with help. No concerns. No active
issues at this time.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: The patient was discharged to rehabilitation.
The patient should continue his PT to a goal of independent
ambulation, chest PT with a goal of weaning off 02. Regular
diet as tolerated. The patient should not drink through a
straw.
FOLLOW-UP: The patient should contact Dr. [**Last Name (STitle) **] for a
follow-up appointment. The staples will be removed at
follow-up.
MEDICATIONS ON DISCHARGE:
1. Sarna lotion applied to affected area p.o. q.i.d. p.r.n.
2. Albuterol inhaler q. 4-6 hours p.r.n.
3. Ipratropium inhaler q. six hours p.r.n.
4. Beclomethasone inhaler two puffs q.i.d.
5. Lisinopril 20 mg q.d.
6. Percocet one to two tablets p.o. q. 4-6 hours p.r.n.
7. Lopressor 25 mg t.i.d.
8. Tamsulosin 0.4 mg q.d.
9. Protonix 40 mg q.d.
DIAGNOSIS ON DISCHARGE:
1. Gastric CA.
2. Prostatic CA, status post exploratory laparotomy, omental
biopsy, liver biopsy.
3. Hypertension.
4. Respiratory distress.
5. Pulmonary edema.
6. Hypertension.
7. Hypovolemia.
8. Gastroesophageal reflux disease.
9. Emphysema.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
[**MD Number(1) 6066**]
Dictated By:[**Last Name (STitle) 46350**]
MEDQUIST36
D: [**2194-1-3**] 08:16
T: [**2194-1-3**] 20:29
JOB#: [**Job Number 46351**]
ICD9 Codes: 9971, 5070, 2765 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1303
} | Medical Text: Admission Date: [**2163-2-18**] Discharge Date: [**2163-2-22**]
Date of Birth: [**2118-6-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
Body aches
Major Surgical or Invasive Procedure:
None
History of Present Illness:
44 year-old woman with history of sickle cell disease and breast
cancer admitted with body aches, fever, and sinus congestion for
one day. Per patient she was in her usual state of health until
the day of admission when she developed subjective fever after
her shower. She then felt like she was coming down with a cold
with sinus congestion, slight headache, and body aches. Then she
developed pain all over her body more severe than anything she
has ever experienced before.
ED VS: T:101.8 HR:106 RR:16 O2Sat:100. she was given IVF and
tamiflu. She spiked a fever to 102.1 at 8pm. Tachypneic in ED
so coming to unit. CTA negative for PE but did see infarcts in
lung and cannot tell if acute or chronic. No infiltrate. Tiny
right pleural effusion. PAH. Ibuprofen, tamiflu, morphine.
Labs with elevated WBC (13.4) and thrombocytosis, hct 19.8
(baseline for her). She got a flu swab. EKG normal. Because she
spiked a fever 102.1 and respiratory distress she was admitted
to the ICU. The patient was subsequently more stable and
transferred to the floor. She has no history of sickle cell
crisis.
Review of sytems:
(+) Per HPI
(-) Denies recent weight loss or gain. Denied nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria.
Past Medical History:
- Breast DCIS s/p surgery and radiation at [**Hospital1 2177**] with surgeon Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. The patient refuses tamoxifen.
- Homzygous SS Sickle Cell Disease (followed by Dr.
[**Last Name (STitle) **]hematocrit range 19.5-23.1 and never been symptomatic per
Dr. [**Last Name (STitle) **] note [**9-17**]
- Hyposplenism with "diminutive" spleen on CT Abd [**2159**]
- S/p appendectomy
- Biliary colic
- S/p tubal ligation
- Ovarian cyst - never had repeat u/s
- Shoulder injury
Social History:
Ms. [**Known lastname **] works at the [**Hospital1 18**] on CC7. She is s/p tubal ligation
and currently sexually active with her husband. She has no
history of STDs, no history of
abnormal Pap smears. Her last Pap smear was approximately two
years ago. She reports that her periods are currently regular
occurring one time a month. She does not report heavy or
uncomfortable menses. She has one daughter.
Family History:
The patient believes that both of her parents had sickle cell
trait. She has 3 brothers, none of whom have sickle cell trait
or disease. She also has 3 sisters, one of which does not have
sickle cell trait or disease, one of which
has sickle cell trait, and one of which had sickle cell disease
and has subsequently passed away. The patient has no family
history of breast cancer. She also reports that her niece
recently died of sickle cell disease. Per OMR, the patient
reports that her father recently died of TB, although the
patient seems doubtful of this diagnosis. She reports that she
has been PPD tested on a yearly basis, and her most recent PPD
was negative. She had not been with her father who lived in
[**Country 2045**] while he was alive since her last PPD testing, so no
recent exposure to a patient with active TB that she knows of.
Physical Exam:
Vitals: T:99.5 BP:112/58 P:81 R: 26 O2:95% 2LNC
General: Alert, oriented, in pain and slightly tachypneic from
pain
HEENT: Sclera anicteric, dry MM, 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, [**1-15**] SM LLSB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2163-2-18**]
LACTATE-1.4
UREA N-11 CREAT-1.1 SODIUM-138 POTASSIUM-4.3 CHLORIDE-108 TOTAL
CO2-23
ALT(SGPT)-24 AST(SGOT)-35 LD(LDH)-216 ALKP-70 TBILI-2.3*
DBILI-0.5* INDIR BIL-1.8
LIPASE-25
WBC-13.4*# RBC-1.79* HGB-6.7* HCT-19.8* MCV-111* RDW-17.4*
NEUTS-89* BANDS-1 LYMPHS-3* MONOS-7 EOS-0 BASOS-0 ATYPS-0
METAS-0 MYELOS-0 NUC RBCS-2*
calTIBC-138* VitB12-221* Hapto-19* TRF-106*
EKG: NSR with normal axis and intervals, wavy baseline but no
significant ST/TW changes
CXR [**2163-2-19**]: No acute cardiopulmonary process.
CTA [**2163-2-19**]: No PE, although motion limits assessment of distal
subsegmental vessels. Multiple small peripheral opacities
consistent with infarcts typical for sickle disease; acuity of
these unknown without prior exam. No pneumonia. Tiny right
pleural effusion. Enlarged pulmonary artery indicating pulmonary
arterial hypertension.
LE U/S [**2163-2-19**]: No evidence for DVT in the bilateral lower
extremities. Visualization of the distal superficial femoral
veins was limited.
ECHO [**2163-2-21**]: The left atrium is mildly dilated. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). The right ventricular cavity is
mildly dilated with mild global free wall hypokinesis. 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
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2162-9-29**],
the right ventricle is mildly dilated/hypokinetic with moderate
pulmonary artery systolic hypertension. These findings are
consistent with hemodynamically significant pulmonary embolism.
Brief Hospital Course:
44 year-old woman history of SS sickle cell disease admitted
with flu-like illness and first sickle cell crisis that was
likely triggered from a respiratory infection and dehydration.
# Flu-like Illness: Symptoms consistent with acute flu-like
illness. Given her asplenism and risk for fulminant infection
she was started on abx while awaiting culture results including
vancomycin, ceftriaxone, azithromycin, and tamiflu. Nasal swab
returned negative on hospital day #1 and tamiflu was
discontinued. She was symptomatically treated with IVF, tylenol,
and oxygen supplementation. MRSA screen was negative, so Vanco
discontinued. Pt treated empirically for PNA with
Ceftriaxone(changed to Cefpodoxime on discharge) and
Azithromycin for 7 days.
# Sickle Cell Crisis: Hematology was consulted given question
of acute chest syndrome and potential need for exchange
transfusion or hydroxyurea. CT chest was reviewed with
hematology and consensus was that findings were chronic and not
consistent with acute chest syndrome. She received two units of
PRBCs in order to return to near baseline HCT. Crisis continued
to be treated with IVF, oxygen therapy and good pain control.
Patient is not up to date on appropriate immunizations and
received H1N1, seasonal influenza, and pneumovax prior to
discharge. She is due for menigicoccal and HiB as an outpatient.
The patient was pain free and with good oxygen saturation when
breathing room air both at rest and with ambulation on the day
of discharge.
# Pulmonary artery hypertension: CT Chest and Echocardiogram
both confirm PA hypertension. PA hypertension is a common
complication seen in Sickle Cell Crisis from chronic hemolysis.
Pt will have follow up with Pulmonary as outpatient. A repeat
Echocardiogram should be performed as an outpatient to evaluate
for interval change after sickle cell crisis has resolved.
# Echo report read as consistent with pulmonary embolism, but
the findings of RV failure and pulmonary hypertension is also
consistent with vaso occlusive crisis from sickle cell crisis.
CTA did not reveal central or segmental PEs. The small filling
defect seen in the right posterior lower lobe subsegmental
vessel would be too small of a PE to cause such profound
pulmonary HTN. LE dopplers negative for DVT.
# Vitamin B12 deficiency: Pt started on Cyanocobalamin
Medications on Admission:
Reports not taking any medications although was prescribed
folate.
Discharge Medications:
1. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
2. Folic Acid 1 mg Tablet Sig: Five (5) Tablet PO once a day.
Disp:*150 Tablet(s)* Refills:*0*
3. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 3 days: Take on [**3-25**], and [**2-25**] to complete 7 days of
antibiotics.
Disp:*6 Tablet(s)* Refills:*0*
4. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days: Take on [**3-25**], and [**2-25**] to complete a 7-day
course of antibiotics.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Sickle Cell Crisis
- Sickle Cell Anemia
- Vitamin B12 Deficiency
- Pulmonary Hypertension
SECONDARY DIAGNOSES:
- Hyposplenism with "diminutive" spleen on CT Abd [**2159**]
- History of Breast DCIS s/p surgery and radiation
- S/p appendectomy
- S/p tubal ligation
- Ovarian cyst
- Shoulder injury
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted with the diagnosis of Sickle Cell Crisis.
This was likely caused by possible viral illness and
dehydration. You were checked for Influenza with a nasal swab.
You do not have Influenza. You were treated with IV fluids,
antibiotics to cover for pneumonia, 2 units of blood
transfusions, and supplemental oxygen. You had total body pain
which resolved over the hospital course.
On the day of discharge, you were pain free with good oxygen
levels on room air. You received 3 vaccinations on the day of
discharge:
1. H1N1 Influenza Vaccine
2. Seasonal Influenza Vaccine
3. Pneumovax Vaccine
MEDICATIONS:
You should take the following two vitamins for your Sickle Cell
Anemia and Vitamin B12 Deficiency
1. Folic Acid 5mg daily
2. Cyanocobalamin (Vitamin B12) 1000mcg daily
To complete treatment for possible pneumonia, take the following
antibiotics for 3 more days:
1. Cefpodoxime 200mg one tablet twice a day
2. Azithromycin 250mg one tablet a day
Followup Instructions:
Appointment #1
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2163-3-8**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], 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
Appointment #2
Department: [**Hospital3 249**]
When: TUESDAY [**2163-3-22**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 26**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Appointment #3
Department: PULMONARY FUNCTION LAB
When: MONDAY [**2163-4-4**] at 1:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Appointment #4
Department: MEDICAL SPECIALTIES
When: MONDAY [**2163-4-4**] at 1:30 PM
With: DR. [**First Name (STitle) **] & DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 486, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1304
} | Medical Text: Admission Date: [**2181-5-22**] Discharge Date: [**2181-5-24**]
Date of Birth: [**2133-4-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2817**]
Chief Complaint:
Nausea/Vomiting, DKA.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
48F h/o DM1 who presents with DKA. Per the patient, she in USOH
until 2d ago, when she quit smoking. Since then she reports
increased intake of sweets. She has also been "running out of
insulin and trying to make it last." She took 24U of lantus
yesterday, and describes increased n/v yesterday night prompting
her to present to the ED.
.
In ED VS= 98.5 89 140/72 16 100%RA. Labs were notable for
critical high finger stick, HCO3 of 6, pH 7.10/26/61, lactate
5.0, CRE 1.5 (baseline 0.8), GAP 29, corrected NA 146. UA with
rare bacteria, 0 WBC, 0-2 epi. CXR unremarkable. ECG with
?twi/std in 2,3,avf and ?j-point elevation v1-2, was faxed to
cardiology who felt c/w strain. Exam notable for gingival
hyperplasia, otherwise, clinically dry.
.
He received CTX empirically for elevated lactate, and
leukocytosis. 2 PIVs were placed, and he was given 3L IVF, 10U
regular, and insulin gtt started and increased to 6U/hr. She is
awake, mentating well. At the time of transfer, VS= 154/74
100 20 100%RA.
.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
1. DM1 - A1C 10.2 [**1-8**]; multiple ED visits for hypoglcyemia
2. HTN
3. depression
4. bartholin gland abscess s/p I&D
Family History:
History of HTN; no DM, CAD or cancer.
Physical Exam:
Vitals: 98.9 96 161/78 18 100%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2181-5-23**] 02:23AM BLOOD WBC-12.4* RBC-3.66* Hgb-10.7* Hct-31.4*#
MCV-86# MCH-29.3 MCHC-34.1# RDW-16.0* Plt Ct-230
[**2181-5-22**] 11:00AM BLOOD WBC-16.2*# RBC-4.79 Hgb-13.5 Hct-45.8#
MCV-96# MCH-28.2 MCHC-29.5* RDW-15.4 Plt Ct-332
[**2181-5-22**] 11:00AM BLOOD Neuts-89.0* Lymphs-7.8* Monos-2.8 Eos-0.1
Baso-0.3
[**2181-5-23**] 02:23AM BLOOD Plt Ct-230
[**2181-5-23**] 02:23AM BLOOD PT-12.6 PTT-30.7 INR(PT)-1.1
[**2181-5-23**] 02:23AM BLOOD Glucose-146* UreaN-13 Creat-0.9 Na-142
K-4.1 Cl-116* HCO3-16* AnGap-14
[**2181-5-22**] 09:36PM BLOOD Glucose-181* UreaN-12 Creat-0.9 Na-141
K-4.4 Cl-114* HCO3-18* AnGap-13
[**2181-5-22**] 05:33PM BLOOD Glucose-145* UreaN-13 Creat-0.9 Na-142
K-3.8 Cl-114* HCO3-16* AnGap-16
[**2181-5-22**] 02:00PM BLOOD Glucose-586* UreaN-19 Creat-1.4* Na-139
K-4.9 Cl-115* HCO3-8* AnGap-21*
[**2181-5-22**] 11:00AM BLOOD Glucose-880* UreaN-22* Creat-1.5* Na-134
K-5.4* Cl-99 HCO3-6* AnGap-34*
[**2181-5-22**] 09:36PM BLOOD CK(CPK)-98
[**2181-5-22**] 11:00AM BLOOD CK(CPK)-101
[**2181-5-22**] 11:00AM BLOOD CK-MB-4 cTropnT-<0.01
[**2181-5-22**] 09:36PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2181-5-23**] 02:23AM BLOOD Calcium-8.7 Phos-1.1*# Mg-1.9
[**2181-5-22**] 02:04PM BLOOD Type-[**Last Name (un) **] pO2-61* pCO2-26* pH-7.10*
calTCO2-9* Base XS--20 Comment-GREEN TOP
[**2181-5-22**] 06:29PM BLOOD Type-[**Last Name (un) **] Temp-38.3 Rates-/18 pO2-54*
pCO2-31* pH-7.32* calTCO2-17* Base XS--8 Intubat-NOT INTUBA
[**2181-5-22**] 12:44PM BLOOD Glucose-GREATER TH Lactate-5.0*
[**2181-5-22**] 06:29PM BLOOD Lactate-3.0*
.
.
STUDIES:
Brief Hospital Course:
# DKA - The trigger was felt to be likely medication
non-compliance. CXR and UA were not consistent with infection.
She was started on an insulin drip in ED, and arrived on the
floor receiving 6U/hr. She received 3L IVF in ED. Upon arrival
to ICU she was switched to 1/2 NS x 1L given rising corrected
Na. Serial CHEM7 obtained Q4HR revealed gap closed ~11PM on the
night of admission, with FSBS < 250. She was transitioned to
D51/2 NS @ 100/hr, and the insulin drip was discontinued after
she was given 30U of lantus. Gap remained closed, repeat FSBS
up to 273, for which she received 10U, with FSBS down to 70s.
CE negative x2. She was seen by [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] consultant the next
day. Also, on the day following her admission, the patient's
anion gap reopened. She was restarted on the insulin drip. On
the following day, he anion gap closed and the insulin drip was
stopped. She was also seen by the [**Last Name (un) **] consultant, who
increased her Lantus dose and her sliding scale insulin. She
was then discharged home with a prescription for insulin and
follow-up appointments.
# Leukocytosis - This was felt likely to be a stress response.
The urinalysis was unremarkable, the CXR was without focal
infiltrate, and the ECG was without active evidence of ischemia.
# HTN - The patient was continued on her home regimen.
# Depression - The patient was continued on her home regimen of
fluoxetine.
# Smoking - The patient declined a nicotine patch.
Medications on Admission:
- Aspirin 81 mg PO DAILY (Daily).
- Metoprolol Tartrate 100 mg PO BID
- Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
- Nifedipine 30 mg SR PO DAILY.
- Insulin Humalog sliding scale.
- Insulin Lantus 27 UNITS QDAILY.
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
4. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
5. Lantus 100 unit/mL Solution Sig: Thirty Five (35) units
Subcutaneous once a day.
Disp:*QS ml* Refills:*2*
6. Humalog 100 unit/mL Solution Sig: as directed units
Subcutaneous QACHS: as per sliding scale.
Disp:*6 bottle* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Ketoacidosis
Type I diabetes
Discharge Condition:
Hemodynamically stable with blood sugars controlled on
subcutaneous insulin.
Discharge Instructions:
You were admitted for diabetic ketoacidosis in the setting of
not taking enough insulin. It is essential that you continue to
follow your finger sticks four times per day and dose your
insulin appropriately. We have increased your lantus to 35 units
daily and you have a new sliding scale. Please follow up with
your doctors [**First Name (Titles) **] [**Last Name (Titles) **] at [**Last Name (un) **] for further management of
your diabetes.
Please return to the emergency department or call your [**Last Name (un) **]
physician if you blood sugar rises above 400, you feel confused,
or have any other new concerns.
Followup Instructions:
Please call [**Last Name (un) **] and your primary care physician to schedule [**Name Initial (PRE) **]
follow up appointment with your physician in the next week.
Please also follow up with your therapist as soon as possible.
ICD9 Codes: 4019, 311, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1305
} | Medical Text: Admission Date: [**2145-11-19**] Discharge Date: [**2145-11-22**]
Date of Birth: [**2112-11-14**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Watermelon / Almond Oil / Hydralazine
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 21822**] is a 33 yo M with DM Type I, ESRD on HD (T/Th/S),
HTN with multiple past admissions for DKA, who self-presented to
the ED on [**2145-11-19**] with recurrent nausea and vomiting. He had
been in his usual state of health until Thursday evening,
[**2145-11-18**], when he suddenly developed nausea and multiple
episodes of vomiting of a non-bloody, non-bilious emesis that
lasted throughout the night. He also experienced progressively
worsening abdominal pain, describing it as a "fire" diffusely
located within his abdomen that was accompanied by new onset
back pain. Mr. [**Known lastname 21822**] reported that his presenting nausea and
vomiting feels distinct from those associated with his past
admissions for DKA in severity and acuity. He denied any fever
or chills at home, but did experience diffuse sweating. He
denied recent cough or dyspnea; denied any constipation,
diarrhea and change in bowel habits; denied dysuria and change
in his urination.
.
Mr. [**Known lastname 21822**] initially denied any significant changes in his oral
intake prior to the onset of his symptoms, but upon further
discussion mentioned that his refrigerator had stopped working
in the middle of the week and he and his girlfriend had been
eating out for most of their meals. Additionally, on Thursday
evening he drank some juice that had been in the refrigerator
and stated that he believes his symptoms are likely due to
ingestion of juice "that had something growing in it,"
particularly as he had his first episode of vomiting soon after
he drank the juice.
.
Over the course of the night, Mr. [**Known lastname 21822**] felt too ill to check
his blood glucose level and administer his insulin. His symptoms
became progressively worse, without any relief the next morning.
He did not take his morning dosage of glargline or
anti-hypertensives, and instead self-presented to the ED.
.
Mr. [**Last Name (Titles) 40896**] insulin regimen consists of glargine 15 units in
the morning with breakfast and lispro sliding scale injections.
He reported that his blood sugars have been under reasonable
control (~140s) over the past few days. His last HD prior to
presentation (on Thursday [**2145-11-18**]) had been uneventful. After
dialysis is blood glucose levels were in the 70s and he received
some [**Location (un) 2452**] juice. He denies experiencing any recent dizziness,
lightheadedness, or sensation that the room is spinning.
.
<I>Per MICU signout</I>: In the ED, initial VS T 100.8, BP
203/110, HR 112, RR 18, O2 100% RA. He was later febrile to
101.9 and was given 1 g vancomycin. His AST/ALT/AP were elevated
at 73/42/165 respectively. Finger stick blood glucose (FSBG) was
initially 712, with an AG of 25. He was given 10 units of
regular insulin IV after which FSBG decreased to 583. He was
then given another 10 units IV regular insulin followed by 10
units SC insulin. A R external jugular line was placed for
access. He received a total 2L IVF.
.
While in the MICU, Mr. [**Known lastname 21822**] was initially placed on insulin
gtt and later transitioned to glargine and lispro sliding scale
as his diet was advanced. His AG (25 at presentation) decreased
to 15. He was given oxycodone prn for pain and compazine for
nausea. His ALT and AP have decreased from their values at
presentation, yet were still elevated on [**11-20**] at 55 and 135
respectively. His AST normalized at 31. His LDH was elevated at
266.
.
Currently, on the floor the patient has no acute complaints. He
denies any nausea, vomiting or abdominal pain and reports
feeling ready to go home.
.
ROS:
(+) Per HPI as above.
(-) Per HPI as above, and denies recent weight loss or gain.
Denies sinus tenderness, rhinorrhea or congestion. Denies cough,
shortness of breath. He denies any sick contacts or recent
travel.
Past Medical History:
# DM I since age 19, seen at [**Last Name (un) **].
-- Complicated by nephropathy, gastroparesis (patient denies),
and retinopathy.
-- Followed at [**Last Name (un) **] HgbA1C of 10.2% on [**2145-8-19**].
# ESRD/CKD: secondary to HTN and DM1
-- Hemodialysis T/Th/Sat at [**Location (un) **] [**Location (un) **].
-- On kidney/pancreas transplant wait list since 4/[**2144**].
# Hypertension
# Anemia on Epo with dialysis
# Depression
# s/p appendectomy in [**7-/2144**]
.
Social History:
Lives in [**Location 686**] with girlfriend of 4 years; no children.
Recently lost his job and concerned about current financial
situation. Currently smokes 1-1.5 packs/week. Denies recent EtOH
use and illicit drug use.
Family History:
Grandfather with DM and CAD.
Physical Exam:
VS: 98.8 142/98 82 16 95RA
General: Sitting upright in bed, eating. Appears to be in no
acute distress. Poor eye-contact throughout history and
physical.
HEENT: Sclerae anicteric, EOMI, MMM, oropharynx clear without
erythema or exudate. Neck supple. No cervical lymphadenopathy.
No thyromegaly.
Lungs: No use of accessory muscles. Able to complete full
sentences. CTAB, no wheezes, rales, rhonchi. No dullness to
percussion. No CVAT.
CV: RRR. nl S1 and S2. No murmurs/rubs/gallops. No elevated JVP.
Abdomen: +BS, soft, nontender. Appeared slightly distended. No
rebound tenderness or guarding. No HSM.
Ext: Warm, well perfused, 2+ DP and radial. No clubbing,
cyanosis, edema. R LUE AV fistula with palpable thrill, not
tender or erythematous .
Neuro: AOx3. Answers questions appropriately with good fund of
knowledge of recent events. CNIII-XII intact. No abnormal
movements noted.
Pertinent Results:
[**2145-11-19**] 12:15PM BLOOD WBC-10.3# RBC-4.33*# Hgb-12.9*#
Hct-39.7*# MCV-92 MCH-29.8 MCHC-32.5 RDW-14.2 Plt Ct-201
[**2145-11-19**] 12:15PM BLOOD Neuts-89.2* Lymphs-6.7* Monos-3.5 Eos-0.4
Baso-0.2
[**2145-11-19**] 12:15PM BLOOD Glucose-712* UreaN-45* Creat-8.5*#
Na-129* K-6.6* Cl-82* HCO3-22 AnGap-32*
[**2145-11-19**] 12:15PM BLOOD ALT-73* AST-42* AlkPhos-165*
[**2145-11-20**] 06:01AM BLOOD ALT-55* AST-31 LD(LDH)-266* AlkPhos-135*
TotBili-0.4
[**2145-11-19**] 01:30PM BLOOD Lipase-122*
[**2145-11-20**] 12:58PM BLOOD Lipase-51
[**2145-11-19**] 12:15PM BLOOD cTropnT-0.15*
[**2145-11-19**] 02:50PM BLOOD cTropnT-0.14*
[**2145-11-19**] 05:47PM BLOOD Calcium-8.6 Phos-5.6* Mg-1.7
[**2145-11-19**] 02:50PM BLOOD Osmolal-324*
[**2145-11-19**] 01:30PM BLOOD Acetone-SMALL
[**2145-11-19**] 05:47PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2145-11-19**] 01:37PM BLOOD Type-[**Last Name (un) **] pO2-105 pCO2-40 pH-7.43
calTCO2-27 Base XS-1
[**2145-11-19**] 05:48PM BLOOD Type-ART pO2-67* pCO2-42 pH-7.44
calTCO2-29 Base XS-3
[**2145-11-19**] 12:55PM BLOOD Glucose-GREATER TH Lactate-2.9* K-7.4*
[**2145-11-19**] 05:48PM BLOOD Glucose-459* Lactate-1.7 Na-130* K-4.2
Cl-86*
.
DISCHARGE LABS:
[**2145-11-22**] 05:50AM BLOOD WBC-5.3 RBC-4.31* Hgb-12.9* Hct-38.0*
MCV-88 MCH-30.0 MCHC-34.1 RDW-13.7 Plt Ct-214
[**2145-11-22**] 01:10PM BLOOD Glucose-108* Na-134 K-4.2 Cl-88* HCO3-29
AnGap-21*
.
Imaging:
# KUB [**11-19**]: Nonspecific bowel gas pattern and no evidence of
acute abnormality.
.
# TRANSTHORACIC ECHO [**11-22**]: The left atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is moderately depressed (LVEF=
30-35 %) with global hypokinesis and regional inferior akinesis.
No masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. RV with mild global free wall
hypokinesis. 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
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. The pulmonary artery systolic
pressure could not be determined. There is a small pericardial
effusion. There are no echocardiographic signs of tamponade.
Brief Hospital Course:
Mr. [**Known lastname 21822**] is a 33 yo M with DM Type I, ESRD on HD (T/Th/S),
HTN with multiple past admissions for DKA, who self-presented to
the ED on [**2145-11-19**] with recurrent nausea and vomiting and FSBG
of 712.
.
# DKA: It is likely that Mr. [**Known lastname 21822**] had a viral gastroenteritis
or episode of food poisoning, leading to his nausea and
vomiting, which in the absence of his regular insulin
administration, triggered DKA. Though he denied any diarrhea or
change in bowel habits, or subjective fever, Mr. [**Known lastname 21822**]
experienced diffuse sweats prior to his presentation and later
became febrile following admission suggesting that infection is
a likely precipant of DKA. He received vancomycin in the ED,
after which he was afebrile. His CXR did not demonstrate any
acute pulmonary process, and on physical exam, his AVF was
neither tender or erythematous making PNA and fistula infection
a less likely cause of his symptoms. KUB demonstrated no
evidence of an acute abdominal process. Urine culture
demonstrated <10,000 organisms/ml. Blood cultures were sent with
no growth to date.
.
At presentation, patient's AG was 25 in the setting of FSBG
>600. He was started initially on an insulin gtt at 7 U/h. FS
were checked q1h and fell from 700s into the 100s over several
hours. D5 1/2 NS was started, and insulin drip down-titrated to
[**1-9**] U/h. Electrolytes were checked every four hours, and gap
went from 25 on admission to 15, his baseline, during the first
hospital night. His diet was advanced. Upon transfer to the
floor from the MICU, his AG was 15. However at discharge, his AG
was elevated to 17 with a BG of 108. His fs's had improved with
increase of his lantus to 20 units. The patient insisted on
discharge. Prior to his discharge, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] diabetes consult
was called and recommended he keep his outpatient insulin dosing
after discharge. He was instructed to make a follow-up
appointment with Dr. [**Last Name (STitle) 20502**], his [**Last Name (un) **] diabetologist.
.
# Systolic Heart Failure: During this admission, patient
obtained an ECHO notable for mild LVH with moderate dilation and
LVEF = 30-35 % with global hypokinesis and regional inferior
akinesis. Of note, his LVEF from prior ECHO in [**3-/2145**] was 52%.
He was switched from labetalol to carvedilol for known
improvement in morbidity and mortality. He was informed of this
new change in his cardiac function. He was set-up with
outpatient cardiology follow-up for both his systolic heart
failure and hypertension.
.
# Hypertension: Patient was initially hypertensive in the
setting of not having taken any of his meds since yesterday
morning. Home doses of lisinopril amlodipine, and labetalol were
restarted. His blood pressure has historically been difficult
to control and should be monitored closely as his labetalol was
changed to carvedilol in consideration of his heart failure.
.
# ESRD on HD: Patient was continued on dialysis schedule
(T/Th/S) via LUE fistula and maintained on his home dosage of
sevelamer during the course of his hospitalization. There was no
acute indication for HD on admission (although his potassium was
elevated, it improved with insulin administration).
.
# Transaminitis: Patient had elevated AST/ALT upon presentation
that is likely due to elevated glucose and triglycerides
secondary to DKA. With treatment of DKA, transaminases have
trended downwards and approached their baseline levels. No acute
intervention was required.
.
# Anemia: Patient's anemia is Likely secondary to ESRD. Has been
stable throughout his admission and required no acute
interventions.
.
# Code Status: FULL CODE.
Medications on Admission:
1. Amlodipine 10 mg daily
2. Insulin glargine 15 units daily
3. Insulin lispro sliding scale
4. Labetalol 200 mg tid
5. Lisinopril 40 mg daily
6. Omeprazole 20 mg [**Hospital1 **]
7. Ondansetron 4 mg q8h prn nausea
8. Sevelamer 800 mg TID ac for control of serum phosphorus
9. Sumatriptan prn
Discharge Medications:
1. amlodipine 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
Tablet(s)
2. lisinopril 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. sevelamer carbonate 800 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
6. carvedilol 25 mg Tablet [**Hospital1 **]: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
7. insulin glargine 100 unit/mL Solution [**Hospital1 **]: Twenty (20) Units
Subcutaneous once a day.
8. Humalog 100 unit/mL Solution [**Hospital1 **]: One (1) injection
Subcutaneous four times a day: please check finger sticks at
breakfast, lunch, and dinner. please take humalog as directed
by sliding scale.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses: Diabetic Ketoacidosis, Systolic Heart Failure
Secondary Diagnoses: End Stage Renal Disease
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 for very high blood sugars
(diabetic ketoacidosis). You initially went to the intensive
care unit for IV fluids and an insulin drip. When your lab
tests were improving, you were switched to subcutaneous insulin
and transferred to the general medicine floor. You also had an
ultrasound of your heart which showed that it is not squeezing
as well as it should. You will need to follow-up with
cardiologist regarding your heart function. You were dialyzed
by the renal team.
.
The following changes were made to your medications:
Your labetalol was STOPPED.
You were STARTED on Carvedilol.
Your insulin regimen was CHANGED.
Followup Instructions:
Department: HEMODIALYSIS
When: TUESDAY [**2145-11-23**] at 7:30 AM
Department: [**Hospital3 249**]
When: WEDNESDAY [**2145-12-1**] at 9:30 AM
With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2145-12-13**] at 3:20 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], 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: 5856, 4280, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1306
} | Medical Text: Admission Date: [**2157-7-22**] Discharge Date: [**2157-8-8**]
Date of Birth: [**2082-2-27**] Sex: F
Service: VASCULAR
CHIEF COMPLAINT: Ruptured abdominal aortic aneurysm.
HISTORY OF THE PRESENT ILLNESS: This is a 75-year-old female
who was evaluated in an [**Location (un) 8641**], [**Hospital 3844**] Hospital for
acute onset of back pain. CT was obtained, which showed a
ruptured aneurysm. The patient has had a known aneurysm for
greater than two years, but has not had surgery due to high
surgical risk. She was transferred here for emergent
surgery.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS:
1. Isordil.
2. Zocor.
3. Nitroglycerin.
4. Diltiazem.
PAST MEDICAL HISTORY:
1. Myocardial infarction times four; last MI, [**2155**].
2. Gastroesophageal reflux disease.
3. Arthritis.
PAST SURGICAL HISTORY:
1. Appendectomy, remote.
2. Cataract surgery.
HABITS: The patient is a smoker of greater than 55 packs per
year. She denies alcohol use.
PHYSICAL EXAMINATION: Examination revealed the blood
pressure of 130/70; pulse 85; respirations 10. This is an
elderly female, who was awake, unable to communicate because
of pain. HEART: Regular rate and rhythm. LUNGS: Clear to
auscultation. ABDOMEN: Unremarkable. EXTREMITIES:
Examination shows warm extremities, palpable femoral pulses
bilaterally.
HOSPITAL COURSE: The patient was taken to the operating room
and under abdominal aortic repair with exploration of the
right femoral artery. She then was transferred to the SICU
for continued monitoring and care. The Department of
Cardiology was requested to see the patient because of a low
cardiac index in a patient with known coronary artery
disease. Intraoperative transesophageal echocardiogram
showed an ejection fraction of 44%.
Recommendations were to initiate ACE inhibitor for post-load
reduction. Captopril 0.25 mg for a goal dosing of 25 to 50
t.i.d.. Continue to monitor cardiac output index PA and
wedge pressures. Ultimately will need a beta blocker as
well. Continue nitroglycerin for afterload.
On postoperative day #1, there were no overnight events. The
patient remained intubated. She follows commands. She
remained tachycardiac with a V rate of 100. Lungs were clear
to auscultation. Abdominal examination was unremarkable.
Extremities were warm. She was continued on perioperative
Kefzol. The postoperative hematocrit was 24.7. The BUN and
creatinine were 10 and 0.6. Potassium was 3.6. Lopressor
was begun. She was weaned to be extubated. She remained
NPO. She was transfused two units of packed red blood cells.
On postoperative day #2, the patient continued to have
tachycardia, reported secondary to Lopressor. She was
attempted to be weaned to extubate. Post transfusion
hematocrit was 31.8. BUN and creatinine remained stable at
9 and 0.5, potassium 4.6.
On postoperative day #3, the patient remained in the SICU.
She required Lasix times two doses for diuresis and
nitroglycerin 7 mcg per kilogram per minute for afterload
reduction. She did show tiring postextubation with
respiratory effort. Blood gases was 7.4, 749, 134, 34 + 11.
CPAP was at 40%. Hematocrit remained stable at 31.6.
Electrolytes were unremarkable. She had coarse breath sounds
bilaterally. Abdominal incisions were clean, dry, and intact
with mild abdominal distention. Extremities were warm,
showing palpable DP and PT bilaterally.
On postoperative day #4, the patient was weaned off
nitroglycerin. She continued to require diuresis and she was
off BiPAP. Gases were 7.4, 47, 173, 33, 98%. Hematocrit was
33.3. BUN and creatinine remained stable. Calcium,
magnesium, and phosphatase were stable. The patient
continued to show decreased breath sounds at the bases
bilaterally. There were no bowel sounds ausculted or flatus
passed. Neurologically, she remained intact. Diuresis was
continued. She remained in the SICU.
On postoperative day #5, the patient was transferred to the
VICU.
On postoperative day #6, there were no overnight events. She
remained hemodynamically stable. Hematocrit and electrolytes
were unremarkable. Abdominal examination was unremarkable.
NG was discontinued and clear liquids were begun. She was
"delined" and transferred to the regular nursing floor. The
Department of Physical Therapy was requested to see the
patient to assess for discharge planning. On postoperative
day #6 she had an episode of left-sided chest discomfort
without associated symptoms. EKG was obtained, which was
unchanged from his preoperative EKG. She was given morphine
for pain and monitored.
On postoperative day #7, the patient remained afebrile, but
the patient had a leukocytosis from 9.2 to 15.3. Lung
examination was unremarkable. Incisions were clean, dry, and
intact. Foley was discontinued and central line was
discontinued. A peripheral line was placed.
On postoperative day #8 she ran a low grade 99. White count
showed a downward trend of 14.2. She continued on a diet as
tolerated. Urinalysis was negative. Chest x-ray was
unremarkable. She required an increase in her Lopressor
dosing to 100 b.i.d. She remained in the VICU. White count
on postoperative day #9 showed an increase to 19.6. Blood
cultures were obtained. The CBL cultures were negative. She
was transferred to the regular nursing floor on postoperative
day #10. Sputum was obtained and results were negative. The
Department of Physical Therapy continued to follow the
patient and recommended [**Hospital 3058**] rehabilitation. The
patient wanted to go home. This was discussed with
Dr. [**Last Name (STitle) 1476**] and he felt rehabilitation would be more
appropriate.
All blood and urine cultures obtained were no growth. The
remaining hospitalization was unremarkable. The patient was
discharged in stable condition. Skin clips of the abdominal
and femoral wounds were removed prior to discharge. The
patient is to followup with Dr. [**Last Name (STitle) 1476**] in one to two weeks'
time.
DISCHARGE MEDICATIONS:
1. Levofloxacin 500 mg q.24h. times seven days.
2. Metoprolol 125 mg b.i.d., hold for systolic blood
pressure less than 90, heart rate less than 60.
3. Lasix 20 mg q.d.
4. Nitroglycerin sublingual 0.3 mg p.r.n. for chest pain,
may be repeated times two q.10 minutes until pain free.
5. Imdur 30 mg q.d., hold for systolic blood pressure less
than 90.
6. Cilastatin 80 mg q.d.
7. Amitriptyline 10 mg h.s.
8. Pantoprazole 40 mg q.d.
9. Percocet tablets one to two q.4h.p.r.n. pain.
10. Heparin 5000 units subcutaneously q.12h.
11. Nicotine patch 21 mg q.d.
12. Aspirin 81 mg q.d.
DISCHARGE DIAGNOSES:
1. Rupture abdominal aortic aneurysm with femoral artery
embolism, status post triple A repair and right femoral
embolectomy.
2. Decreased cardiac index treated.
3. Postoperative fever secondary to atelectasis, treated.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**], M.D. [**MD Number(1) 1478**]
Dictated By:[**Last Name (NamePattern1) 1479**]
MEDQUIST36
D: [**2157-8-3**] 10:41
T: [**2157-8-3**] 11:31
JOB#: [**Job Number 9634**]
1
1
1
R
ICD9 Codes: 5180, 496, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1307
} | Medical Text: Admission Date: [**2123-10-18**] Discharge Date: [**2123-10-22**]
Date of Birth: [**2044-1-17**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Clindamycin / Seroquel / Compazine
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
79 yo woman with CAD, h/o TIA, sick sinus SSS s/p PPM, AF on
coumadin, macular degeneration, hearing loss p/w AMS. She
complained of severe right-sided tooth pain last night. The
patient's daughter arranged for the patient to see a dentist
today. At 0930 [**10-18**] while at her [**Hospital3 **], the patient
received erythromycin (reportedly [**2113**] mg, but this dose does
not make sense) as prophylaxis. At around 1015 the patient was
found in bed, difficult to arouse, would not talk. The patient's
daughter was present thought that the patient looked "out of
it", "off-balance". The patient reportedly fell back in bed and
lay there with vacant look. Face white, lips blue. There were no
abnormal movements or focal weakness. Then patient's mental
status subsequently improved. EMS was called, and the patient
was brought to the ED.
In the ED, initial vitals signs were T 96.9, BP 90/60, HR 100,
RR 17, Sat 100%/RA. Blood sugar was 56. The patient was treated
with 1/2 amp D50 and 1 L NS wide open. Lethargic on exam w/
minimally reactive pinpoint pupils, but responding to verbal
commands. Labs were notable for WBC 18.6, INR 3, lactate 3.5.
U/A showed positive nitrites and trace leukocyte esterase but no
WBCs. Urine and blood cultures were sent. Serum tox screen was
negative. CXR and head CT were negative for acute process. The
patient was given vancomycin 1 gm IV, acyclovir 300 mg IV,
Bactrim 225 mg IV, and moxifloxacin 400 mg IV due to concern
about bacterial meningitis given change in MS. She was noted to
have BG of 56 in the ED treated with glucose and improvement in
her lethargy.
She was admitted to the MICU [**10-18**] with HR 84 BP 117/89 RR 20
Sat 96%/RA. In the MICU, the patient was alert and able to
converse. She complained of right-sided tooth pain and
discomfort associated with her urinary catheter, but was
otherwise asymptomatic. Denied headache, head trauma, dizziness,
lightheadedness, neck pain, stiffness, focal weakness, numbness,
or tingling.
Collateral information was obtained from the patient's daughter
[**Name (NI) **] and the patient's son [**Name (NI) 4468**]. According to [**Doctor First Name **], the patient
has not started any new medications recently. The only
medication change is that the patient's Zyprexa dose was
decreased from 2.5 mg [**Hospital1 **] to 2.5 mg QAM and 1.25 mg QPM last
Friday.
[**Doctor First Name **] notes that the patient has been depressed recently. She
spends most of the day sleeping. [**Doctor First Name 4468**] notes that right-sided
facial pain has been a chronic complaint for the patient.
She was given 2L IVF and noted to have one episode of a.fib with
RVR up to the 130's, improved with iv metoprolol. Currently she
feels much improved. She does acknowledge being confused on
admission but feels this is improved at this point. She
continues to have right sided facial pain and swelling but
denies tooth pain. She notes chills in the ER but none since and
no fevers. She had nausea in the ER but none since and has a
good appetite. She denies dysuria but had significant pain with
the foley catheter that is now removed. She has not been out of
bed to ambulate much. She notes significant constipation with no
bm in 5 days, and though she chronically is constipated this is
long for her. She denies HA, visual change, cough, sore throat,
sob, cp, palpitations, vomitting, leg swelling, rash, myalgias,
arthralgias.
ROS:
(+) Per HPI. Chronic vague abdominal pain. Chronic hearing and
vision loss.
(-) Denies fever, chills, sinus congestion, coryza, nasal
congestion, cough, shortness of breath, chest pain, nausea,
vomiting, diarrhea, urinary symptoms, blood in urine or stool,
myalgia, or arthralgia.
Past Medical History:
Atrial fibrilation with SSS s/p pacer
macular degeneration
deafness: s/p cochlear implant (scarlet fever causing marked
hearing impairment)
CAD s/p MI in [**2106**]
TIA
colitis
h/o C. diff
peptic ulcer disease
blind OD, wears patch over that eye
PSH:
s/p cochlear implant placement on right 20 years ago
s/p cochlear implant on right side replaced 6 years ago
Social History:
Was living in [**State 108**] up until 4 years ago. Now lives in
[**Hospital3 **] in [**Location (un) 86**] area. Denies past/current tobacco,
etoh, illicit drug use.
Family History:
hypercholesterolemia, heart disease
Physical Exam:
VS: T 95.4 HR 69 BP 106/68 RR 34->my count 20 Sat 100% RA
Gen: Well appearing elderly woman in NAD
Eye: extra-occular movements intact, pupil OS round, reactive to
light, NLP OD, sclera anicteric, not injected, no exudates
ENT: mucus membranes moist, no ulcerations or exudates; right
cheeck slightly full, mildly tender to palpation, mild erythema,
mouth with multiple carries, no obvious gum inflammation
Neck: no thyromegally, JVD: flat
Cardiovascular: regular rate and rhythm, normal s1, s2, no
murmurs, rubs or gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales or rhonchi
Abd: Soft, non tender, non distended, no heptosplenomegally,
bowel sounds present
Extremities: No cyanosis, clubbing, edema, joint swelling
Neurological: Alert and oriented x3, CN III-XII intact, normal
attention, sensation normal, speech fluent
Integument: Warm, moist, no rash or ulceration
Psychiatric: appropriate, pleasant, not anxious
Hematologic: no cervical or supraclavicular LAD
Pertinent Results:
Admit labs:
CBC: WBC-18.6*->18.0 HGB-10.7* HCT-33.0 (baseline 35) PLT
COUNT-262; diff: NEUTS-94.1* LYMPHS-3.7* MONOS-1.8* EOS-0.2
BASOS-0.2
coags: PT-30.4* PTT-32.2 INR(PT)-3.0*
bmp: UREA N-24* CREAT-1.1 (baseline 0.9)->0.7 SODIUM-135
POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-19* CK(CPK)-74
CK-MB-NotDone
Serum tox: ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
LACTATE-3.5->4.1
UA: URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG GLUCOSE-250
KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM RBC-[**1-28**]*
WBC-[**1-28**] BACTERIA-MANY YEAST-NONE EPI-0-2
Micro: [**2123-10-18**]: Blood cx x2 pending
[**2123-10-18**]: Urine cx: ESCHERICHIA COLI. >100,000 ORGANISMS/ML.
[**2123-10-18**]: Urine cx pending
[**2123-10-19**]: MRSA screen pending
CT Head [**2123-10-18**]: wet read: no acute intracranial process
CXR [**2123-10-18**]: final-No acute intrathoracic process.
Brief Hospital Course:
79 yo woman admitted with urinary tract infection, parotitis,
altered mental status, hypoglycemia and atrial fibrilation with
rapid ventricular response.
1. Urinary tract infection: hemodynamically significant with
hypotension, elevated lactate, leukocytosis. Urine cx with e.
coli, on cipro with good sensitivities. Cipro to be continued
through 11.29/09
2. Altered mental status: Likely related to acute infection with
hypotension and hypoglycemia, now improved, no evidence of
delerium currently, monitor.
3. Atrial fibrillation with RVR: in the setting of acute
infection, improved with additional beta blockade. Dilt and
metoprolol (has pacer for back up) were continued with good rate
control. Coumadin initially high (likely due to flagyl
interaction) so former was held. Because no indication for
flagyl, it was discontinued, and coumadin was restarted at
outpatient dose. INR on discharge ws 1.6. This should be
checked [**2123-10-25**] at rehab.
4. Parotitis: reportedly long-standing per family. ICU team
using hot packs and massage. Communication with ENT consult team
suggested outpatient follow-up. Appointment will be made with
daguther next week. Panorex films done but results were not back
prior to discharge. These will be followed up. No current
suspicion for odontologic infection.
5. Hypoglycemia: Patient had one episode in ICU, likely
infection related. No recurrences on the floor.
6. CAD, native vessel: cont. aspirin, statin, bb.
7. Hyperlipidemia: cont. statin.
8. Anxiety: zyprexa restarted
Code: DNR/DNI-confirmed with daughter.
Will go to [**Hospital 100**] Rehab.
Medications on Admission:
Medications at home:
Ativan 0.25 mg QID
Cardizem 240 mg daily
metoprolol XL 100 mg PO daily
Zyprexa 2.5 mg QAM, 1.25 mg QPM
simvastatin 10 mg PO QPM
Coumadin 1 mg PO daily, except Saturdays
Coumadin 2 mg Saturdays
Tylenol 500 mg PO BID, with 250 mg in mid day
Vitamin D 800 IU daily
Ocuvite 1 tab [**Hospital1 **]
Leutin 20 mg daily
Senna 1 tab [**Hospital1 **]
Colace 100 mg [**Hospital1 **]
Artificial tears
Medications on transfer:
Metoprolol Tartrate 50 mg PO/NG [**Hospital1 **]
Acetaminophen 500 mg PO/NG [**Hospital1 **]
MetRONIDAZOLE (FLagyl) 500 mg PO/NG Q8H
Acetaminophen 325-650 mg PO/NG Q6H:PRN pain
Morphine Sulfate 1-2 mg IV Q6H:PRN pain
Artificial Tears Preserv. Free 1-2 DROP BOTH EYES PRN dryness,
irritation Senna 1 TAB PO/NG [**Hospital1 **]
Ciprofloxacin HCl 500 mg PO/NG Q24H
Simvastatin 10 mg PO/NG QPM
Diltiazem Extended-Release 240 mg PO DAILY
Vitamin D 800 UNIT PO/NG DAILY
Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
4. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-27**]
Drops Ophthalmic PRN (as needed) as needed for dryness,
irritation.
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): through [**2122-10-24**]. Tablet(s)
10. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
11. Olanzapine 2.5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for stomach
upset.
14. Warfarin 1 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
15. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO EVERY OTHER DAY
(Every Other Day).
16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
UTI with urosepsis
Parotid gland swelling
Atrial Fibrillation
Discharge Condition:
Improved
Discharge Instructions:
You were admitted with significant urinary tract infection which
is susceptible to Ciprofloxacin which you are taking. You had a
rapid heart rate with atrial fibrillation, but medicines were
given to keep your heart rate well controlled. Coumadin was
restarted in hospital and will need to be followed at your rehab
facility to make sure it gets to a therapeutic level. The [**Hospital **]
clinic was informed of your parotid gland swelling and they have
agreed to call your daughter next week ([**Name (NI) 766**]) to schedule a
future appointment in their clinic. Xrays of your teeth were
done and the report is still pending. I do not suspect a tooth
infection, but will follow up on these results.
Followup Instructions:
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 1125**] Date/Time:[**2123-11-22**] 12:45
Outpatient ENT appointment to be coordinated next week with
patient's daughter.
ICD9 Codes: 5990, 4589, 2724, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1308
} | Medical Text: Admission Date: [**2186-5-16**] Discharge Date: [**2186-5-23**]
Date of Birth: [**2118-11-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Iodine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2186-5-19**] Coronary Artery Bypas Graft x 5 (Left internal mammary to
left anterior descending, Saphenous vein graft to diagonal,
Saphenous vein graft to Ramus, Saphenous vein graft to Obtuse
marginal, Saphenous vein graft to left posterior descending
artery)
[**2186-5-16**] Cardiac Cath with IABP insertion
History of Present Illness:
67 yo DM with history of type 2 diabetes, coronary disease,
status post renal transplant, sciatica, atrial fibrillation, and
chronic renal insufficiency and previous DES in the LAD presents
with CP and STEMI. Pt had a cardiac cath with reopening of LAD.
He has 60% LM and 3 vessel CAD and had IABP placed at the cath
lab.
Past Medical History:
Coronary Artery Disease, s/p Non-ST Elevation Myocardial
Infartcion, s/p atherectomy LAD in [**2176**], s/p 2.5 x 13 mm
Cypher DES to mid LAD in [**6-/2180**], s/p 2.75 x 28 mm Taxus DES for
ISR in [**5-/2181**], s/p POBA for ISR in 2/[**2185**].
End-stage renal disease s/p renal transplant in [**2180**]
Hypertension
Hyperlipidemia
Gastroesophageal reflux disease
Gout
Diabetes-type II
HSV meningitis in [**2184**]
Cardiomyopathy-EF 35-40%
Spinal stenosis
Sciatica chronic back pain and left hip pain
s/p AV fistula for HD in the past
Tonsillectomy as a child
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. He is a semi-retired
yaught charter organizer. He lives in [**Location 2312**] with his wife.
[**Name (NI) **] is married with 4 children.
Family History:
Father died of MI in early 60s, brother died of MI age 53.
Mother with diabetes.
Physical Exam:
Weight is 198 pounds, blood pressure is 140/60,pulse is 70
GENERAL: Gait is stable.
HEENT: PERRLA, EOMI, oropharynx is clear
NECK: Supple, full range of motion
HEART: RRR, S1, S2, no gallop
CHEST: Clear to auscultation, no rales or wheezes
ABDOMEN: Soft and nontender, non-distended
EXTREMITIES: He does have a large ecchymosis, which is improving
by his report in the left hip. Extremities, mild peripheral
edema.No varicosities
Neuro: non-focal, alert and oriented x 3
Pertinent Results:
[**2186-5-16**] Cath: 1. Selective coronary angiography of this left
dominant system with known occluded right coronary artery
revealed three vessel disease. The LMCA had a 60% calcified
stenosis. The LAD had a total occlusion in the mid segment at
the previously placed stents (Taxus within a Cypher). There were
no collaterals supplying the LAD territory. The LCX had a 40%
stenosis at the proximal segment and the origin of the OM1 had a
70% stenosis. The OM@ had mild disease. The OM3 had a proximal
50% stenosis. The OM4 had a 70% stenosis at its origin, which
was focal in nature. The LPDA had mild disease. 2. Angiography
of the LIMA revealed a patent vessel. This was done in
anticipation of likely upcoming surgery. 3. Resting hemodynamics
demonstrated systolic arterial hypertension with central aortic
pressure of 163/78 mm Hg.
[**5-17**] CT: 1. No evidence of retroperitoneal bleed. 2. Stable
splenic and lung calcifications likely represent the sequela of
prior granulomatous disease. 3. Extensive atherosclerotic
calcifications are similar to [**2186-1-12**]. 4. Cholelithiasis without
evidence of cholecystitis.
[**5-17**] Carotid U/S: There is less than 40% stenosis within the
internal carotid arteries bilaterally.
[**2186-5-19**] Echo: 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 interatrial septum is
aneurysmal. No atrial septal defect is seen by 2D or color
Doppler. Right ventricular chamber size and free wall motion are
normal. The ascending, transverse and descending thoracic aorta
are normal in diameter and free of atherosclerotic plaque to 40
cm from the incisors. 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. No mitral regurgitation is seen. There is no
pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the
results on Mr. [**Known lastname **] at 8AM. Post_Bypass: Normal RV systolic
function. Mild improved in the mid and apical anterior walls of
LV. LVEF 40% to 45% Intact thoracic aorta. Trivial MR [**First Name (Titles) **] [**Last Name (Titles) **].
IABP is in place approx 4 cm below the left subclavian artery.
[**2186-5-21**] CXR: NG tube, ET tube, left chest tube, and mediastinal
drains have been removed. The Swan-Ganz catheter was replaced by
right internal jugular line with its tip being at the level of
mid SVC. There is no pneumothorax, pulmonary edema, or increased
pleural effusion. The left retrocardiac atelectasis is
unchanged.
[**2186-5-16**] 04:15PM BLOOD WBC-8.7 RBC-3.82* Hgb-10.4* Hct-32.9*
MCV-86 MCH-27.3 MCHC-31.7 RDW-17.2* Plt Ct-220
[**2186-5-23**] 05:40AM BLOOD WBC-10.3 RBC-2.82* Hgb-8.3* Hct-24.8*
MCV-88 MCH-29.6 MCHC-33.6 RDW-17.5* Plt Ct-161
[**2186-5-16**] 04:15PM BLOOD PT-20.9* PTT-27.6 INR(PT)-2.0*
[**2186-5-23**] 05:40AM BLOOD PT-14.7* INR(PT)-1.3*
[**2186-5-16**] 04:15PM BLOOD Glucose-131* UreaN-46* Creat-1.7* Na-138
K-4.3 Cl-104 HCO3-25 AnGap-13
[**2186-5-23**] 05:40AM BLOOD Glucose-65* UreaN-86* Creat-2.1* Na-136
K-4.1 Cl-104 HCO3-26 AnGap-10
[**2186-5-21**] 01:04AM BLOOD Calcium-8.4 Phos-5.2* Mg-2.6
[**2186-5-17**] 04:10AM BLOOD %HbA1c-6.3*
Brief Hospital Course:
As mentioned in the history of present illness, Mr. [**Known lastname **]
presented to [**Hospital1 **] with chest pain. He was ruled in for ST segment
myocardial infarction and was brought for a cardiac cath. Cath
revealed occluded LAD at previous stent placement along with 60%
left main disease. Balloon angioplasty was performed to LAD and
a Intra-aortic balloon pump was placed. Post-cath he was brought
to the ICU for further management. Hematocrit dropped after cath
and he received a blood transfusion along with CT to rule-out
retroperitoneal bleed (CT was negative). He remained stable in
the ICU while awaiting surgery and required other diagnostic
studies prior to bypass surgery. On [**5-19**] he was brought to the
operating room where he underwent a coronary artery bypass graft
x 5. Please see operative report for surgical details. Following
surgery he was transferred to the CVICU for invasive monitoring
in stable condition. On post-op day one the balloon pump was
removed and he was weaned from sedation, awoke neurologically
intact and extubated. On post-op day two he was transferred to
the telemetry for further care. Chest tubes and epicardial
pacing wires were removed per protocol. Physical therapy
followed patient during his post-op course and at time of
discharge felt he would require additional rehab due to weakness
and history of falls. On post-op day four he was discharged to
rehab with appropriate medications and follow-up appointments.
Medications on Admission:
ALENDRONATE 5 mg daily, ALLOPURINOL 100 mg daily, ATORVASTATIN
40 mg daily, CALCITRIOL 0.25 mcg daily, CARVEDILOL 3.125 mg
Tablet twice daily, ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit
Capsule monthly x 6, FENTANYL - 25 mcg/hour Patch 72 hr - apply
transdermally q72 hours, FUROSEMIDE 40 mg Tablet - 1 Tablet(s)
by mouth qd and takes [**12-16**] at hs prn, GLIPIZIDE 2.5 mg Tablet
Extended Rel 24 hr (2) - 1 Tab(s) by mouth twice a day [**First Name8 (NamePattern2) **]
[**Last Name (un) **], LISINOPRIL 5 mg daily, OXYCODONE - 5 mg Tablet - take
[**12-16**] Tablet(s) by mouth three times
a day as needed for pain (28 day supply), PREDNISONE 5 mg daily,
QUININE SULFATE - 324 mg nightly as needed for as needed for
cramps, TACROLIMUS[PROGRAF] 0.5 mg twice a day per transplant
clinic, TRIMETHOPRIM-SULFAMETHOXAZOLE [BACTRIM] - 80-400 mg 3
times per week per transplant clinic,
WARFARIN 1 mg - 4 Tablet(s) by mouth Daily as directed by
coumadin clinic, ASPIRIN 81 mg daily, COLACE 100mg Capsule daily
as needed, ISULIN REGULAR HUMAN[HUMULIN R] inject subcutaneously
per sliding scale as needed, OMEPRAZOLE MAGNESIUM 20 mg twice a
day
Plavix - last dose:600mg [**2186-5-16**]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
11. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
12. Alendronate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day:
[**12-16**] tablet (20mg) qPM.
15. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
16. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day:
Resume Coumadin per pre-op dose (4mg qd) and adjust for goal INR
around 2. Please check INR routinely.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 5
Myocardial infarction
Diabetes mellitus
Hypertension
Hyperlipidemia
Atrial fibrillation
Chronic renal insufficiency s/p renal transplant
Gastroesophageal reflux disease
Spinal stenosis and Sciatica - chronic back pain
HSV meningitis in [**2184**]
Gout
s/p left AV fistula
s/p Tonisllectomy
Discharge Condition:
Good
Discharge Instructions:
1)No driving for one month
2)No lifting more than 10 lbs for at least 10 weeks from the
date of surgery
3)Please shower daily. Wash surgical incisions with soap and
water only.
4)Do not apply lotions, creams or ointments to any surgical
incision.
5)Please call cardiac surgeon immediately if you experience
fever, excessive weight gain and/or signs of a wound
infection(erythema, drainage, etc...). Office number is
[**Telephone/Fax (1) 170**].
6)Call with any additional questions or concerns.
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks
Dr. [**Last Name (STitle) **] in [**12-16**] weeks
Dr. [**First Name (STitle) 437**] in [**1-17**] weeks
Completed by:[**2186-5-23**]
ICD9 Codes: 4280, 5859, 412, 2724, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1309
} | Medical Text: Admission Date: [**2120-7-7**] Discharge Date: [**2120-7-22**]
Date of Birth: [**2052-7-8**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Optiray 350 / Clindamycin / Aldactone / IV Dye,
Iodine Containing / pyridostigmine
Attending:[**Last Name (un) 2888**]
Chief Complaint:
Fall and increased weight gain
Major Surgical or Invasive Procedure:
[**2120-7-12**] Cardiac catheterization
[**2120-7-14**] Pulmonary arterial catheterization
[**2120-7-14**] Intra-aortic balloon pump insertion
[**2120-7-15**] Dialysis catheter placement
[**2120-7-15**] Arterial line placement
[**2120-7-17**] Intra-aortic balloon pump re-insertion
[**2120-7-17**] Intubation
History of Present Illness:
68 year old man with a history of coronary disease status post
cabg in [**2107**] and multiple PCIs since then presenting on the [**7-7**]
with weight gain at home and altered mental status resulting in
a fall at home. In the ED he had a possible seizure with
dilantin loading. He became hypotensive after that and went to
MICU. He was then sent to the medicine service for several days
working up neurologic issues and falls. Then the patient began
having chest pain, echo showed new acute decrease in the EF from
45->20% and some apical and septal akinesis. Cath showed severe
native disease with 2 BMS placed in RCA. RHC showed elevated
wedge at 30mmHg. RA pressures 25 and PAP 73. CI 1.5. Then
transferred to [**Hospital1 1516**] for further management.
.
Patient was given 80mg IV lasix given last night and this
morning still volume overloaded and given another 100mg IV lasix
and metolazone and lasix gtt. Team is concerned for poor forward
flow given LFTs have increased to >1000, creatinine to 3.3, INR
>2, and only 600mL UOP with 20mg/hr lasix gtt yesterday.
.
At this point, he was transferred to the HF service and admitted
to the CCU for inotropes, swan, and lasix drip. If
non-responsive to this will need IABP.
.
On arrival to the floor, patient appears somewhat lethargic and
uncomfortable but is conversant. He endorses discomfort around
his foley site but denies cough, chest pain, sob, abdominal
symptoms, fevers/chills.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
- CAD
- Chronic systolic & diastolic CHF, EF 40-50% [**5-/2119**]
- CABG: s/p CABG in [**2107**] (LIMA-LAD (patent), SVG-PDA (occluded),
SVG-OM(occluded))
- PERCUTANEOUS CORONARY INTERVENTIONS: multiple stents (s/p DES
to LMCA into LCx, RCA, r-PL)
- PACING/ICD:
- ?Afib
3. OTHER PAST MEDICAL HISTORY:
- Appendicitis (complicated by colectomy & mucocele [**2114**])
- Depression
- Erectile dysfunction
- Insulin dependent diabetes mellitus x 30+yrs
- ulcerative colitis
- Peyronie's disease s/p penile implant
- benign Prostatic Hypertrophy
- h/o C. Difficile colitis
- CKD
Social History:
A retired Optometrist.
-Tobacco history:he quit smoking about 40 years ago, only having
smoked for about 5 years,while in his 20's.
-ETOH: None.
-Illicit drugs: None.
Family History:
His mother had CAD and a CABG in her 60's. There is a strong
family history of premature coronary artery disease, diabetes
mellitus, hypertension, and hyperlipidemia.
Physical Exam:
Admission exam:
Vitals: T: BP: 86/62 P: 61 R: 15 O2: 100% on RA
General: Oriented, no acute distress, depressed mood and affect,
talking extremely slowly
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not visualized, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: B/L crackles at bases, no wheezes, rales, ronchi
Abdomen: Soft, non-tender, moderately distended, bowel sounds
present, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation to light touch
.
Discharge/Death exam:
HEENT: pupils fixed and dilated
CV: no heart sounds auscultated, no carotid pulse
RESP: no breath sounds
Pertinent Results:
ADMISSION LABS:
[**2120-7-6**] 10:16PM cTropnT-0.03*
[**2120-7-6**] 06:00PM LACTATE-1.4
[**2120-7-6**] 05:55PM GLUCOSE-173* UREA N-43* CREAT-2.2* SODIUM-133
POTASSIUM-4.8 CHLORIDE-95* TOTAL CO2-29 ANION GAP-14
[**2120-7-6**] 05:55PM estGFR-Using this
[**2120-7-6**] 05:55PM ALT(SGPT)-33 AST(SGOT)-36 ALK PHOS-61 TOT
BILI-0.8
[**2120-7-6**] 05:55PM cTropnT-0.05*
[**2120-7-6**] 05:55PM proBNP-7830*
[**2120-7-6**] 05:55PM ALBUMIN-4.5
[**2120-7-6**] 05:55PM WBC-7.6 RBC-4.08* HGB-10.7* HCT-34.5* MCV-85#
MCH-26.3* MCHC-31.1 RDW-15.5
[**2120-7-6**] 05:55PM NEUTS-68.8 LYMPHS-16.8* MONOS-12.1* EOS-1.9
BASOS-0.4
[**2120-7-6**] 05:55PM PLT COUNT-232
[**2120-7-6**] 05:55PM PT-14.7* PTT-30.0 INR(PT)-1.4*
.
STUDIES:
[**2120-7-6**] CT Head w/o contrast- No acute intracranial process
[**2120-7-6**] C Spine w/o contrast- No acute fractures or
malalignment
[**2120-7-6**] CXR Portable AP- Midline sternotomy wires are again
noted. Bilateral pleural effusions are noted with probable
basilar atelectasis. No overt pulmonary edema. Heart size is
top
normal. No pneumothorax. IMPRESSION: Bilateral pleural
effusions with basilar atelectasis.
[**2120-7-6**] CT Abd/Pelvis-IMPRESSION: 1. Nonspecific mesenteric
stranding and small amount of fluid in the abdomen could be
secondary to generalized third spacing. 2. Chronic loculated
left sided pleural fluid collection/chronic empyema is stable.
3. Gallstones and sludge within the gallbladder.
[**2120-7-8**] EEG- This is an abnormal waking EEG because of diffuse
polymorphic arrhythmic theta and delta activity. This background
activity improves to theta range activity on stimulation. These
findings are suggestive of moderate encephalopathy but of
nonspecific cause. There are no epileptiform discharges or focal
abnormalities seen.
[**2120-7-10**] MRI Head w and w/o contrast- 1. No acute intracranial
abnormality. 2. No pathologic focus of enhancement or anatomic
substrate for seizure. 3. Relatively mild global atrophy.
4. Chronic inflammatory changes in the paranasal sinuses;
correlate clinically.
.
[**2120-7-11**] Portable TTE: The left atrium is mildly dilated. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is severely depressed (LVEF= 20 %) secondary to severe
hypokinesis/akinesis of the septum and apex; the rest of the
left ventricle appears hypokinetic with regional variation. The
aortic valve leaflets are moderately thickened. The study is
inadequate to exclude significant aortic valve stenosis. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild to moderate ([**12-18**]+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion. Compared with the findings of the
prior study (images reviewed) of [**2119-5-19**], left ventricular
systolic function is significantly further compromised.
.
[**2120-7-12**] Cardiac Catheterization:
1. Selective coronary angiography demonstrated three vessel
disease in the right dominant system The LMCA had a patent stent
with mild in stent restenosis, there was a 30-40% distal LMCA
stenosis beyond the distal edge of the LMCA stent which was
unchanged from prior. The LAD had diffuse severe disease
proximally and occludes at the mid vessel after a tiny diagonal
branch. The Cx had diffuse disease throughout with serial focal
50% stenoses. The RCA had an ostial 80% stenosis which was
heavily calcified. There was also an 80% heavily calcified 80%
stenosis in the mid RCA. Diffuse mild to moderate disease was
seen throughout the rest of the RCA.
2. Limited resting hemodynamics revealed elevated right and left
sided filling pressure with an RVEDP of 24 mmHg and an LVEDP of
26 mmHg. There was pulmonary hypertension with PA pressures of
73/35 mmHg. The cardiac index was depressed at 1.55 L/min/m2.
The central aortic pressure was 120/73 mmHg. Upon careful
pullback of a pigtail catheter from the LV to the aorta no
pressure gradient was seen.
3. Arterial conduit angiography revealed a patent LIMA which
supplied a diffusely diseased LAD. The SVGs were not engaged as
they were known to be occluded.
4. Successful PTCA and stenting of the ostial RCA with a
3.5x26mm INTEGRITY stent which was postdilated proximally to
4.0mm. Final angiography revealed no residual stenosis, no
angiographically apparent dissection and TIMI III flow (see PTCA
comments).
5. Successful PTCA and stenting of the mid RCA with a 3.5x12mm
INTEGRITY stent which was postdilated to 3.5mm. Final
angiography revealed no residual stenosis, no angiographically
apparent dissection and TIMI III flow (see PTCA comments).
6. Successful closure of the 6 French right femoral arteriotomy
site with a 6 French ANGIOSEAL VIP device with good resultant
hemostasis.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Moderate to severe diastolic ventricular dysfunction.
3. Moderate pulmonary hypertension.
4. Successful PTCA and stenting of the ostial RCA with a BMS.
5. Successful PTCA and stenting of the mid RCA with a BMS.
6. Successful closure of the right femoral arteriotomy site with
an Angioseal device.
.
[**2120-7-15**] EEG:
Abnormal EEG due to a low voltage slow background throughout.
This indicates a widespread encephalopathy. Medications,
metabolic disturbances, and infection are the most common
causes. Ischemia or hypoxia are other possibilities. There were
no areas of prominent focal slowing, but encephalopathies may
obscure focal findings. There were no epileptiform features or
electrographic seizures.
.
[**2120-7-15**] CT abdomen & pelvis:
IMPRESSION:
1. No acute intra-abdominal or intrapelvic hematoma detected.
2. Circulatory assist device within the abdominal aorta.
3. Persistent bilateral nephrograms, compatible with severe
renal failure, as the last contrast-enhanced study was performed
on [**2120-7-10**].
4. Unchanged small left pleural effusion.
.
[**2120-7-19**] Echo:
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is moderate to severe regional left ventricular systolic
dysfunction with hypokinesis of the inferior septum, inferior,
and inferolateral walls and distal anterior, lateral and apical
walls. The remaining segments contract normally (LVEF = 25-30
%). No masses or thrombi are seen in the left ventricle. The
right ventricular cavity is moderately dilated with free wall
hypokinesis. 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. Mild (1+)
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
IMPRESSION: Normal left ventricular cavity size with extensive
regional systolic dysfunction most c/w multivessel CAD
(including proximal RCA). Right ventricular cavity enlargement.
Mild mitral regurgitation.
Compared with the prior study (images reviewed) of [**2110-7-11**],
global left ventricular systolic function is slightly improved.
.
[**2120-7-20**] KUB:
1) No dilated loops of large or small bowel to suggest
obstruction or ileus. No obvious free air identified.
2) Multiple clustered locules of air in the right mid abdomen
may represent stool within the colon in an area of prior surgery
and are similar to the appearance on the [**2120-7-7**] abdominal CT.
However, the differential diagnosis for this appearance includes
air within an abscess. If there is significant clinical
suspicion for intra-abdominal infection, then this area could be
further assessed with a CT scan.
Brief Hospital Course:
Hospital Course: 68 year old man with a history of coronary
disease status post cabg in [**2107**] and multiple PCIs, DM type II,
hypertension and depression who presented initially on [**2120-7-7**]
with weight gain at home and altered mental status. He had what
appeared to be a possible seizure in the ED, resulting in
dilantin loading and subsequent hypotension requiring transfer
to the MICU. He was then sent to the medicine service for
several days while work up continued on his neurologic issues
and falls (work up negative). Then on [**2120-7-11**], he began having
chest pain, and echo showed new acute decrease in the EF from
45->20% with some apical and septal akinesis. Cath the following
day showed severe native disease with 2 BMS placed in RCA, and
RHC showed elevated wedge at 30mmHg. He was intitially
transferred back to the cardiology service for management,
however he became increasingly volume overloaded with end organ
dysfunction (renal and liver failure) suggestive of cardiogenic
shock, necessitating transfer to the CCU under the heart failure
service.
.
CCU Course: On arrival patient was started on inotropes,
pulmonary artery catheter was placed, and intra-aortic balloon
pump was initiated for support for his cardiogenic shock. Given
his renal failure, CVVH was initiated (mostly for
ultrafiltration). Despite full support with intermittent
pressors, IABP, and CVVH, he failed to improve. On [**2120-7-17**], he
self-discontinued his balloon pump, leading to rapid
decompensation necessitating urgent intubation and transfer to
the cath lab for IABP re-placement. He was able to wean off the
balloon pump on [**2120-7-19**], however his hemodynamics then worsened
again, necessitating the use of pressors. Despite full pressor
support, his status continued to worsen. Upon frank discussion
with his family regarding his grim prognosis, they felt that he
would never want to continue with aggressive care if there was
little chance of full recovery. On [**2120-7-21**], they decided to
transition his care to comfort measures only. He died
peacefully on [**2120-7-22**].
.
Please see below for details on each of his major active issues:
.
ACTIVE ISSUES:
# [**Date Range 7792**]/Cardiogenic Shock: On [**2120-7-11**] while on medicine
service, experienced chest pain with troponin of 0.1, negative
MB, but echo with new anterior WMA and EF depressed at 25% (down
from 40-45%). Cath on [**7-12**] showed 80% ostial stenosis of the
RCA, which was stented with 2 bare metal stents. Following the
cath, he continued to decompensate. He appeared to be in
decompensated CHF by renal status, crackles on exam, and mild
peripheral edema. A TTE showed an EF of 20% from baseline of
40-45% in 6/[**2118**]. He had 2 BMS placed to his RCA, his LVEDP was
elevatd at 30, pulmonary pressures were also elevated so the
patient was transferred to the [**Hospital1 1516**] service. Despite aggresive
diuresis, patient continued to [**Last Name (un) 22977**] clinically, with high
filling pressures, low CI, low UOP and was transfered to CCU.
Patient was started on dobutamine for inotropic effect (could
not do milranone because of [**Last Name (un) **]). He was also on lasix drip.
Patient had an intra-aortic baloon pump to improve systemic
perfusion and coronary artery perfusion.
.
While in CCU a Swan-Ganz catheter was placed to monitor CO.
Dobutamine drip was started in setting of low CO. The patient
was also started on CVVH to remove fluid thought to be
contributing to decreased CO as renal failure persisted. On [**7-17**]
pt was increasingly delusional and removed his IABP partially.
Decision was made to remove pump at this time and heparin ggt
d/c and pressure held at site. The patient's o2 sats decreased
at this time and lactate increased to over 6. Decision was made
to intubate and transfer to cath lab for replacement of pump.
Ballon pump was weaned off of IABP on [**7-19**]. Howver he conintued
to have high pressor requirements.
.
#.Acute on Chronic [**Last Name (un) **]: Baseline creatinine 1.1-1.5, on
admission 2.2. However after the drop in his blood pressure and
after his cath his Cr continued to rise and he stopped making
urine. Renal was consulted who started CCVH to remove fluid to
help relieve strain on his heart. CCVH was stopped when patient
was made CMO by family on [**7-21**].
.
#Transaminitis - On transfer to [**Hospital1 1516**] service, patients LFTs had
noted to increase to ALT 117, AST 418. The day following cath,
his LFTs sharply rose to ALT 1200 and AST 1059, LDH 1900, TBili
1.9. Concern was for shock liver vs med effect, Hepatology was
consulted who felt this was due to shock liver - they rec'd to
hold atorvastatin, obtain RUQ U/S which showed possibly fatty
liver with patent vasculature. The following day, he developed
encephalopathy and lactulose was started. LFTs trended down
throughout his hospital course.
.
#.Fall at Home- His initial insult was a well-described
mechanical fall from slipping on mineral oil, and he did not
endorse symptoms consistent with vasovagal syncope. We also
considered orthostasis given history of same vs. arrhythmia vs.
seizure given possible seizure in CT scan. Patient was not found
to be orthostatic. Neurology consulted and had a low suspicion
of seizure. MRI with and without contrast was unremarkable.
Neurology continued to follow and did not recommend AED's.
.
IDDM: Patient was kep on insulin sliding scale and hi blood
surgars well well ontrolled in the CCU.
.
Goals of Care dicussion: On [**7-21**]: Family meeting was held with
Dr. [**Last Name (STitle) **]??????[**Doctor Last Name **], Dr. [**Last Name (STitle) 4402**], SW [**Doctor First Name **], and patient??????s family
including: wife [**Name (NI) **], daughter [**Name (NI) 12983**], daughter [**Name (NI) 22978**], and
sister [**Name (NI) **]. They were updated on the patient??????s grim
prognosis and his continued decline despite maximal support.
The family was in agreement that per past discussions they had
with the patient, he would not have wanted a prolonged death and
would rather be made comfortable at this juncture. In light of
this, Mr [**Known lastname **]??????s goal of care was focused on comfort only, with
cessation of all supportive measures including pressors, CVVH,
and the ventilator. After withdawal of all care he passed away
on [**2120-7-22**] at 7:10am.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. Atorvastatin 40 mg PO DAILY
2. Bumetanide 1 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Eplerenone 25 mg PO DAILY
5. Lisinopril 5 mg PO DAILY
6. Lorazepam 0.5 mg PO TID
7. Mesalamine DR 1200 mg PO Frequency is Unknown
8. Metoprolol Succinate XL 12.5 mg PO Frequency is Unknown
Frequency [**Hospital1 **]
9. ranolazine *NF* 1,000 mg Oral [**Hospital1 **]
10. Aspirin 81 mg PO DAILY
11. NPH 28 Units Breakfast
NPH 18 Units Bedtime
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Congestive Heart Failure
Cardiogenic Shock
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2120-7-22**]
ICD9 Codes: 5849, 2875, 5859, 311, 4280, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1310
} | Medical Text: Admission Date: [**2164-8-22**] Discharge Date: [**2164-8-30**]
Date of Birth: [**2094-12-16**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
confusion, speech arrest
Major Surgical or Invasive Procedure:
right knee aspiration
History of Present Illness:
69 yo M with hx HTN, HLD, afib not on anticoagulation, and [**Hospital 23051**]
transferred from OSH as a code stroke after episode of confusion
this afternoon followed by global aphasia.
Per his wife he was in his usual state of health this AM and
after lunch time (? 12:00) appeared confused after returning
home from the grocery store without groceries and was wandering
around the house. He kept saying "I don't know" in response to
questions. He went to an OSH and there underwent a noncontrast
CT head and then became globally aphasic and not responding to
any commands and he was transferred here.
Past Medical History:
[] Cardiovascular - Atrial fibrillation (not on anticoagulatin),
HTN, HL
[] Endocrine - DM2, s/p thyroid surgery
[] Renal - Chronic nephrolithiasis with CKD
[] Gout
Social History:
No tobacco or illicits. Occasional beers on weekends (not
daily).
Family History:
No strokes or seizures.
Physical Exam:
At admission:
Gen; lying in bed, awake
HEENT; jaw clenched
CV; irreg, no murmurs
Pulm; CTA anteriorly
Abd; soft, nt, nd
Extr; no edema
Neuro;
MS; Awake, but does not follow any commands or attempt to speak.
CN; PERRL 4mm-->3mm, does not reliably blink to threat on left.
Eyes conjugate in midposition. Does not track. Face appears
symmetric.
Motor; normal tone. able to maintain all limbs symmetrically
and
antigravity.
Sensory; withdraws to pain, but more grimace on right than left
with noxous arm stimulation
Reflexes; toes mute b/l
______________________________________________
At discharge:
awake, alert, intermittently confused, language fluent with
intact comprehension, moving all 4 with full power, DTRs 2 and
symmetric throughout
Pertinent Results:
[**2164-8-22**] 05:38PM WBC-9.7 RBC-4.13* HGB-12.9* HCT-36.3* MCV-88
MCH-31.1 MCHC-35.4* RDW-14.0
[**2164-8-22**] 05:38PM PLT COUNT-157
[**2164-8-22**] 05:38PM PT-12.6 PTT-25.9 INR(PT)-1.1
[**2164-8-22**] 05:38PM TSH-1.8
[**2164-8-22**] 05:38PM ALBUMIN-4.4 CALCIUM-8.7 PHOSPHATE-4.6*
MAGNESIUM-2.2
[**2164-8-22**] 05:38PM cTropnT-<0.01
[**2164-8-22**] 05:38PM LIPASE-44
[**2164-8-22**] 05:38PM ALT(SGPT)-32 AST(SGOT)-31 LD(LDH)-209 ALK
PHOS-91 TOT BILI-0.3
[**2164-8-22**] 05:38PM GLUCOSE-191* UREA N-39* CREAT-2.5* SODIUM-143
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-27 ANION GAP-16
[**2164-8-22**] 06:07PM URINE RBC-1 WBC-5 BACTERIA-FEW YEAST-NONE
EPI-0
[**2164-8-22**] 06:07PM URINE BLOOD-SM NITRITE-NEG PROTEIN-300
GLUCOSE-150 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-TR
[**2164-8-22**] 06:07PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2164-8-22**] 09:04PM PHENYTOIN-13.8
.
[**2164-8-27**]:JOINT FLUID
JOINT FLUID ANALYSIS WBC RBC Polys Lymphs Monos NRBC Macro
[**2164-8-27**] 14:44 [**Numeric Identifier 961**]* 3000* 88* 0 6 1* 5
Source: Knee
JOINT FLUID Crystal Shape Locatio Birefri Comment
[**2164-8-27**] 14:44 FEW NEEDLE I/E1 NEG c/w monoso2
.
[**2164-8-27**] 2:44 pm JOINT FLUID Source: Knee.
**FINAL REPORT [**2164-8-30**]**
GRAM STAIN (Final [**2164-8-27**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2164-8-30**]): NO GROWTH.
.
IMAGING
[**2164-8-22**]: CT Head without contrast:
FINDINGS: Encephalomalacic changes are present in the right
parietal and occipital lobes in the right MCA and PCA
territories. There is no acute intracranial hemorrhage.
[**Doctor Last Name **]-white matter differentiation remains preserved. The
ventricles are normal in size and configuration. Overall, there
is little change from the outside hospital CT performed three
hours prior. Visualized paranasal sinuses and mastoid air cells
are clear. Soft tissues of the orbits are within normal limits.
Scout images demonstrate the endotracheal tube ending 3.5 cm
above the carina and an OJ tube coursing towards the stomach
although the tip is excluded from view.
IMPRESSION: Encephalomalacic changes involving the right
parietal
and occipital lobes. No acute intracranial process identified.
Little change since the outside hospital CT performed three
hours
prior.
.
[**2164-8-23**]: MR [**Name13 (STitle) 430**] Without Contrast:
IMPRESSION: Acute infarcts in the distribution of the left
posterior cerebral artery. Chronic right posterior cerebral
artery infarct. Brain atrophy.
.
[**2164-8-22**]: Chest Radiograph:
FINDINGS: AP supine portable chest radiograph is obtained. An
endotracheal tube is seen with its tip located approximately 3.6
cm above the carina. The NG tube courses into the left upper
quadrant with its tip just beyond the GE junction. Lung volumes
are low with crowding of bronchovasculature, and no definite
sign
of pneumonia or CHF. No large pleural effusion or pneumothorax.
Bony structures appear grossly intact.
IMPRESSION: Appropriately positioned ET tube. OG tube may be
advanced slightly for more optimal positioning.
.
[**2164-8-23**]: EEG:
IMPRESSION: This 24 hour video EEG telemetry captured no
pushbutton activations and 2 electrographic seizures with no
clinical correlation on video. Occasional interictal sharp wave
discharges were seen over the left frontal temporal admixed with
theta and delta frequency slowing, consistent with a focus of
epileptogenicity. The background rhythm demonstrated an 8 Hz
maximal posterior predominant alpha rhythm intermixed with theta
and delta likely related to a mild to moderate encephalopathy.
.
[**2164-8-22**]: ECG:
Probable sinus tachycardia with first degree A-V block and
atrial
premature beats. Non-specific inferolateral ST segment
depression
and T wave changes. No previous tracing available for
comparison.
.
[**2164-8-24**]: TTE:
The left atrium is mildly dilated. The left atrium is elongated.
The right atrium is moderately dilated. No atrial septal defect
or patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 70%). There is considerable beat-to-beat variability of
the
left ventricular ejection fraction due to an irregular
rhythm/premature beats. Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic arch is mildly dilated. There are focal
calcifications in the aortic arch. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
[**2164-8-24**]: Carotid Studies:
Impression: Right ICA with stenosis <40%.
Left ICA with stenosis 0%.
.
[**2164-8-26**]: CT Head Without Contrast:
IMPRESSION:
1. Evidence of prior chronic infarction in the right
parietooccipital region.
2. Focal ill-defined hypodensities in the left occipital region
corresponding with areas of acute left PCA infarcts seen on
recent MR study.
3. No new large acute territorial infarction. No hemorrhage or
mass effect.
.
[**2164-8-26**]: Bilateral Knee Plain Films:
FINDINGS: Due to swollen joints the patient is unable to
internally rotate the knee. Mild soft tissue swelling. The
presence of small effusions is likely. Bilateral mild
degenerative changes in the femorotibial joint and severe
degenerative changes in the femoropatellar joint. No evidence of
fracture. No evidence of chronic inflammatory changes
.
[**2164-8-27**]: EEG:
IMPRESSION: This EEG gives evidence mainly for an
encephalopathic-
appearing abnormality with background slowing and bursts of
slowing with
suppressive bursts. This would suggest widespread diffuse
cortical, as
well as subcortical, neuronal dysfunction. There are some
asymmetric
features suggesting attenuation of background posteriorly on the
right
and increased epileptiform interictal activity from the left
temporal
posterior frontal region suggesting there may be more isolated
structural damage.
.
[**2164-8-27**]: ECG:
Atrial fibrillation with a controlled ventricular response.
Compared to the previous tracing of [**2164-8-23**] the ventricular
response has slowed. The lateral ST-T wave changes are less
prominent. Otherwise, no diagnostic interim change.
.
[**2164-8-28**]: EEG:
IMPRESSION: This EEG gives evidence for mild to moderate diffuse
encephalopathy with superimposed focal slowing over the right
posterior
quadrant and more significantly fairly continuously across the
left
temporal and, to a lesser degree, posterior lateral frontal
region. The
left temporal frontal area also exhibits intermittent interictal
epileptic activity spontaneously and two short runs of
unsustained but
increased frequency discharges. Cardiac monitor continues to be
abnormal.
Brief Hospital Course:
Brief Hospital Course:
69 yo M h/o AF (not on anticoagulation), HTN, HL, DM2, CKD from
chronic nephrolithiasis p/w confusion, speech arrest, and
convulsive seizure of unclear etiology.
[] Seizure - The patient had an episode of confusion (answering
"I don't know" to all questions) followed by speech arrest. He
was subsequently able to follow commands but would not
verbalize. While in the ED of an OSH and en route to a CT
scanner, his jaw clenched and he reportedly had a convulsive
seizure. He was sedated and intubated and transferred to [**Hospital1 18**]
for further care. He was loaded with phenytoin. He had no
lateralizing signs on his neurologic exam, and an EEG on [**8-23**]
showed no seizure activity but did show intermittent left
frontal and temporal sharp waves and intermittent diffuse
slowing of the background rhythm. On MRI he was found to have a
subacute left occipital-temporal ischemic stroke, likely the
etiology of his seizures. He has had no further witnessed
seizure activity but was monitored on LTM. He was extubated
without difficulty and his mental status has cleared. LTM showed
no seizures and it was stopped. On [**2164-8-26**] the patient was found
on the floor and was unable to tell how he got there. Out of
concern for seizure as the etiology, he was loaded with Keppra
and placed on EEG for another 24 hours. Again the EEG failed to
show any seizure activity. The phenytoin is slowly being tapered
off and the patient is being continued on Keppra 1 g po bid. The
patient's alertness level decreased initally when started on the
2 AEDs but has now improved since the phenytoin taper. He has
follow up in [**Hospital 878**] clinic.
[] Ischemic Stroke - The patient has evidence on his initial
NCHCT of an old ischemic stroke affecting the right parietal and
occipital lobes, but there were no signs of new areas of
infarction. He subsequently had a NC MRI Brain on [**8-23**] which
showed a left occipital-temporal ischemic stroke. He was started
on warfarin and bridged with a heparin infusion. He is to be
maintained at a goal INR of [**2-16**]. Currently his INR is 4.4 and
please hold his warfarin until his INR is 2.
[] Atrial Fibrillation - The patient was briefly bradycardic to
the 40s overnight on [**8-22**] but this resolved. He was on aspirin
but not on anticoagulation prior to this event. Throughout the
rest of his stay the patient was restarted on his home
medications but continued to have episodes of RVR. His diltiazem
was increased to 90mg po qid and metoprolol was increased to
25mg po bid. Digoxin 0.125mg po daily was continued as well. EP
was consulted and recommended that the digoxin be stopped as
they did not feel it was helping. The metoprolol can be
increased to tid if needed. The patient's heart rate remained
primarily in the 80s on this regimen. Please continue him on
telemetry at rehab to ensure he is stable on this regimen. He
has an outpatient appointment with cardiology.
[] Gout - After transfer to the floor the patient complained of
right knee pain as well as minor left ankle tenderness. His home
medication allopurinol had been held while he was in the ICU but
restarted at transfer. These joints as well as his left knee
were warm and swollen. Rheumatology was consulted who tapped the
right knee and confirmed crystal proven gout in the joint. Given
the large amount of pain the patient was in, we gave him IV
steroids x 1 followed by a po prednisone taper. His pain is much
improved. After he finishes the prednisone taper, please start
colchicine 0.6mg po every other day (renal dosing) to help
prevent future flares. He has follow up in [**Hospital 2225**] clinic.
[] Hyperglycemia - While on the steroids for his gout flare, his
blood sugars have been high. Please continue him on an insulin
sliding scale until the prednisone taper is over.
[] Chronic renal failure - we contact[**Name (NI) **] his PCP and confirmed
that his recent Cr values range around 2.3-2.5. After this we
restarted his previous dose of lisinopril per his PCP, 10mg po
daily.
Medications on Admission:
Levothyroxine 50 mcq daily
Indomethacin 50 mg TID PRN
Sildenafil 50 mg PRN
Doxazosin 2 mg daily
Metoprolol succinate 25 daily
Lisinopril 20 daily
Allopurinol 100 daily
Pravastatin 40 daily? (not clear which statin the patient was
taking)
Aspirin 81 daily
Digoxin 0.125 mg daily
Sodium Bicarbonate 650 TID
Diltiazem 90 mg [**Hospital1 **]
Atorvastatin 40 daily
Discharge Medications:
1. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
2. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) tab PO Q6H
(every 6 hours) as needed for pain/fever.
3. insulin regular human 100 unit/mL Solution Sig: One (1) unit
Injection ASDIR (AS DIRECTED): Insulin sliding scale.
4. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-15**]
Drops Ophthalmic PRN (as needed) as needed for dryness.
5. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
7. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
12. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
15. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
16. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
17. diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
18. prednisone 20 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily)
for 2 days: Please taper dose. Give 50mg po daily x 2 days, then
40mg x 2 days, then 20mg x 2 days, then 10mg x 2 days and stop.
19. phenytoin sodium extended 100 mg Capsule Sig: One (1)
Capsule PO QHS (once a day (at bedtime)) for 4 days.
20. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Please hold until INR is less than 2. Goal INR [**2-16**].
21. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
22. Metoprolol Tartrate 5 mg IV Q8H:PRN tachycardia > 120
hold if SBP<120. Please notify HO by text-page if givein IV MTP.
23. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO every other
day: Please start after prednisone is complete.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
left PCA stroke
seizures
crystal-proven gout
atrial fibrillation with RVR
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurological exam: awake, alert, intermittently confused,
language fluent with intact comprehension, moving all 4
extremities with full power.
Discharge Instructions:
It was a pleasure caring for you during your stay. You were
admitted to the hospital for evaluation of your shaking and
confusion episodes. These episodes turned out to be seizures.
These seizures were coming from the left side of your brain and
imaging shows that you had a stroke days to weeks prior on the
left side of your brain as well. This damage caused by the
stroke is likely the cause of your seizure events. Additionally
the [**Doctor Last Name **] imaging showed that you suffered a right sided stroke
months previously.
-Your seizures were controlled with the help of an anti-seizure
medicine. Please continue to take one of these medicines, Keppra
1 g by mouth twice a day. We are currently tapering off your
phenytoin. Please take 100mg by mouth at bedtime until (last
dose) [**2164-9-3**], then stop.
- We have you on a blood thinner, warfarin (coumadin) to
decrease the chances of stroke since you have atrial
fibrillation. Your INR will have to be measured frequently by
blood draws. Your goal INR is [**2-16**]. Currently your INR is high so
we are holding the warfarin. Please restart taking 2mg by mouth
at night once the INR is 2. Your dose of this medicine will
likely change as you are being tapered off phenytoin, which is a
medicine that affects your warfarin levels.
-During your stay, your hospital course was complicated by
atrial fibrillation with a difficult to control heart rate. We
consulted the cardiology team, who recommended stop digoxin and
continuing on diltiazem and metoprolol at this time. They do not
currently feel that you would benefit from any other
intervention at this time.
-You had knee pain while in the hospital as well. The
rheumatology team removed some fluid from your right knee and
confirmed crystals present, consistent with a gout flare. Given
the amount of pain you were in, we treated you with steroids to
decrease the inflammation. Please continue to prednisone taper
we have placed you on as written (50mg x2days, 40mg x2days, 20mg
x2days, 10mg x2 days, and then
stop). You should start taking colchicine 0.6 mg by mouth every
other day after finishing this taper to prevent recurrent
attacks. Please continue taking allopurinol 100mg by mouth
daily. For the long term, you need to be consistently on
allopurinol and your dose should be titrated as an outpatient to
reach a uric acid level <6. This can be done by rheumatology.
Please see them in clinic as scheduled.
-While you are on the steroids, your blood sugar has been high.
We have asked that you be monitored with a insulin sliding scale
while you are on steroids. This can be discontinued afterwards.
Followup Instructions:
[**Hospital 2225**] clinic: Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD
Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2164-10-4**] 3:00pm
Cardiology clinic: Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D.
Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2164-10-15**] 1:40pm, [**Hospital Ward Name 23**] Bldg, [**Location (un) **].
[**Hospital 878**] clinic: Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2164-11-9**] 10:30, [**Hospital Ward Name 23**] Bldg, [**Location (un) **]
ICD9 Codes: 2724, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1311
} | Medical Text: Admission Date: [**2157-1-22**] Discharge Date: [**2157-1-26**]
Date of Birth: [**2091-7-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
colonoscopy
History of Present Illness:
The patient is a 65 year old woman with a h/o CAD, CHF and AFib
presenting with bright red blood per rectum. She was watching
TV on wednesday when she felt a strong urge to go to the
bathroom and passed bright red blood, followed by maroon stools.
In the last several weeks, her INR had been low and she had
been instructed to take 5mg instead of 2.5 mg of coumadin
2/nights per week. Her INR remained low, and since [**1-7**] she
had been taking the double dose 3 nights per week. This
occurred 4 more times before she arrived at the OSH ED. She had
a similar episode one year ago when diverticulitis was noted on
colonoscopy. She denies hematochezia, no dizziness, no
vomiting. She has had some slight abdominal pain that has been
intermittent and sharp in the lower quadrants. No fever or chest
pain. She denies constipation.
.
At the OSH her INR was corrected with 2U FFP and a colonoscopy
was performed [**2157-1-21**] which showed blood in entire colon with
diverticulosis, active bleeding from diverticular opening
treated with epinephrine and endoclip. She says she has not had
a bloody BM since prior to her colonoscopy. She says she
received 3U of blood as well. When she was given FFP prior to
the colonoscopy she had a reaction, her entire face swelled up
and she had difficulty breathing. Her Hct fell after transfusion
and she was transferred here for further evaluation and
treatment of her unstable lower GI bleeding
Past Medical History:
1. Coronary Artery disease - multiple caths with stents, last
cath [**2156-3-5**], s/p MI X2
2. CHF EF 60-65%, nuclear test with small potential ischemia
3. A.fib, had been on coumadin. previously on amiodorone, but
d/c following deteriorating vision in last year.
4. CVA with left upper visual field cut occurred following one
of her stenting procedures.
5. Acid reflux
6. Diverticular disease
7. HTN
8. Hyperlipidemia
9. oral cancer, resection of mass on left side of tongue
Social History:
She does not smoke or drink EtOH. Breds and showed champion
[**Doctor Last Name 2031**] horses, retired. Single with no children. Healthcare
proxy is friend [**Name (NI) **] [**Name (NI) 30041**] [**Telephone/Fax (1) 30042**].
Family History:
sister died of CAD, had DM2
Physical Exam:
VS Temp 98.6, BP 105/54, Pulse 74, RR 17, O2 sat 98% on RA
Gen A&O3, lying in bed, NAD
HEENT: MM moist, OP clear, teeth absent on lower left. PERRL
Lungs: CTAB
CV: RRR, nl S1S2, systolic murmer at apex
Abd: + BS, overweight, soft, nontender, nondistended.
Ext: no edema, distal pulses 2+.
Neuro: CN2-12 intact, except mild upper left visual field
deficit on confrontational testing. strength 5/5 throughout,
sensation grossly intact. reflexes 1+ throughout.
Pertinent Results:
HCT at Outside Hospital 38 -> 32.7 -> 29.3 -> 23.7 -> 29.6 ->
22.9 ->20.6
OSH CXR: low lung volumes, atelectasis.
OSH CT Abd: No retroperitoneal hemorrhage, sigmoid
diverticulosis.
OSH EKG: a flutter 76, nl axis, nl intervals no ST T wave
changnes.
Brief Hospital Course:
The patient is a 65 year old woman with history of CAD and Afib
on coumadin transferred for treatment of an unstable GI bleed in
the setting of an elevated INR to ~3.5.
.
-GI Bleeding. The most likely source is recurrent bleeding from
the diverticuli visualized on colonoscopy at the outside
hospital. Prior to transfer to our institution, her coumadin
had been stopped and she had been given Vitamin K and 2U FFP to
reverse her INR, however she continued to have active bleeding,
was given 3U PRBCs, and was transferred here for further
evaluation and possible surgical intervention. After
stabilization in the MICU, she had no futher episodes of
bleeding, and following the transfusion of 2 additional units of
PRBC, her HCT was 29 and slowly trended upward to 33.5 over the
next 3 days. Repeat colonoscopy revealed several diverticuli in
the distal colon/sigmoid region, consistent with the previous
report, but none were actively bleeding and no interventions
were undertaken.
.
- Atrial Fibrillation. The patient remained in atrial
fibrillation during the admission with several episodes of rapid
ventricular response with heart rate elevations to the 140's.
Notably, this occurred while she was not receiving her
metoprolol because of concerns over possible hemodynamic issues
should her bleeding recur. Once her hemodynamics proved stable,
her metoprolol was restarted and titrated upwards to 50mg PO TID
in order to control her heart rate. Her coumadin was held
during the admission given the risk of recurrant bleeding.
However, she was restarted on her aspirin and plavix given her
multiple cardiac stents in place.
.
-CHF. Diuresis was held during most of the admission over
hemodynamic concerns, however, she ultimately began to have
signs of volume overload including pedal edema, pulmonary
crackles, and dyspnea on exertion so her home regimen of
furosemide 120 PO QD was restarted.
Medications on Admission:
Medications on transfer from ICU:
Zantac 50mg IV q6h
Nexium 40mg IV BID
Metoprolol 25mg PO BID
Lasix 120mg daily
Lipitor 80mg daily
Fish oil 1200mg daily
Tylenol prn
Plavix held, ASA (held in ICU)
Zofran prn
Discharge Disposition:
Home
Discharge Diagnosis:
Lower GI bleed
diverticulosis
blood loss anemia
supra-therapeutic anticoagulation
atrial fibrillation
history of coronary artery diesase
Discharge Condition:
stable, HR around 100 and normotensive and no longer
orthostatic, Hct stable at 33.
Discharge Instructions:
Please return if you experience any further blood in your bowel
movements, feel lightheaded or weak, or have difficulty
breathing, palpitations or chest pain.
Please followup with your cardiologist and PCP as below and take
your medications as prescribed.
Followup Instructions:
Please call your PCP and set up a follow up appointment in [**6-13**]
days.
Cardiologist, Dr. [**Last Name (STitle) 11863**], [**First Name3 (LF) 5871**] Hospital
[**Last Name (NamePattern1) 30043**].
[**Location (un) 5385**] [**Numeric Identifier 30044**]
[**Telephone/Fax (1) 30045**]
Thursday [**1-27**] 11AM
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
Completed by:[**2157-1-28**]
ICD9 Codes: 4280, 2851, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1312
} | Medical Text: Admission Date: [**2171-5-28**] Discharge Date: [**2171-5-31**]
Date of Birth: [**2098-6-13**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2840**]
Chief Complaint:
DKA, epigastric pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
72F with hx DM, ESRD on HD presenting with DKA, epigastric
abdominal pain. Pt was recently admitted on the surgical service
from [**Date range (1) 103093**] with an infected AV fistula. She was started on
vancomycin. She underwent debridement of skin and hematoma
cavity with closure of the skin defect with a rhomboid flap. She
developed bleeding post-op and a permacath was placed for
access. She also had a period of decreased responsiveness during
HD. Workup included a negative CT scan, negative CEs, CXR
revelaed CHF, EEG could not be obtained. She was discharged to
the [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **].
.
At HD today, she c/o N/V and ?coffee ground emesis. Heme
positive at HD. She also had epigastric abdominal pain. She was
transferred to the ED for evaluation. In the ED she was
hemodynamically stable, Hct stable. Guiac negative. Was found to
be in DKA with an anion gap 25. Started on an insulin gtt at 10
units/hr. Had a low grade temp to 99.8, mildly elevated WBC to
11 with a left shift. Started on Vanco/Levo/Flagyl. Left IJ line
was placed. Per CXR, tip in right brachiocephalic vein, was
pulled back and repositioned but still in brachiocephalic vein.
BP was high with systolics in 200s. Given Anzement for nausea.
Past Medical History:
PMH:
-ESRD on HD TThSat - left AV fistual s/p thrombectomy and
revision
-Type 2 diabetes c/b triopathy
-Hypertension
-CVA with vascular dementia
-Anemia
-congestive heart failure withejection fraction of 55%.
-Osteoarthritis
-Cataracts
Social History:
SH: no tob, ETOH, illicits, lives at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]
Family History:
noncontributory
Physical Exam:
PE: 98.7 90 208/71 16 99RA
GEN: French Creole speaking, NAD
HEENT: PERRL, EOMI, JVP not elevated
CV: RRR, no m/r/g
LUNGS: CTA B
ABD: soft, minimal BS, +tenderness to palpation over RUQ and
epigastrium
EXT: no edema, 1+DPs
NEURO: intact
Pertinent Results:
.
EKG: NSR, 88 bpm, LAD, LAFB, peaked T's across precordium, no ST
elevations or depressions, no change from previous
.
CXR [**5-28**]: Comparison is made to the study performed one hour
earlier.
Again seen is a right-sided central line with tip overlying the
right atrium. Left-sided subclavian line appears to have been
pulled back several centimeters. However, the distal tip is
again seen within the right brachiocephalic vein pointed
upwards.
.
CT Abd/Pelvis: preliminary read - c/w chronic pancreatitis with
atrophy, course calcifications, GB distention without gallstones
or ductal dilation.
.
TTE [**12-15**]: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and systolic function (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.
Mild to moderate ([**2-11**]+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
PMIBI [**12-15**]: no ischemic changes
[**2171-5-28**] 11:33PM TYPE-ART PO2-99 PCO2-30* PH-7.43 TOTAL CO2-21
BASE XS--2
[**2171-5-28**] 11:33PM LACTATE-2.4*
[**2171-5-28**] 08:15PM GLUCOSE-339* UREA N-70* CREAT-10.3*
SODIUM-140 POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-17* ANION GAP-28*
[**2171-5-28**] 08:15PM GGT-16
[**2171-5-28**] 08:15PM TRIGLYCER-33
[**2171-5-28**] 08:15PM CALCIUM-9.3 PHOSPHATE-6.2* MAGNESIUM-2.1
[**2171-5-28**] 02:46PM ACETONE-MODERATE
[**2171-5-28**] 02:46PM WBC-11.1* RBC-4.76 HGB-14.7 HCT-46.9 MCV-99*
MCH-31.0 MCHC-31.4 RDW-17.1*
[**2171-5-28**] 02:46PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ SCHISTOCY-1+ BURR-1+
[**2171-5-28**] 02:46PM PLT SMR-NORMAL PLT COUNT-213
[**2171-5-28**] 02:46PM PT-12.9 PTT-28.7 INR(PT)-1.1
[**2171-5-28**] 02:08PM ALBUMIN-4.5 CALCIUM-9.7
[**2171-5-28**] 02:08PM WBC-10.9 RBC-4.89# HGB-15.0# HCT-48.5*#
MCV-99* MCH-30.7 MCHC-30.9* RDW-16.6*
[**2171-5-28**] 02:08PM NEUTS-94* BANDS-0 LYMPHS-3* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-1*
[**2171-5-28**] 02:08PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-OCCASIONAL POLYCHROM-1+
[**2171-5-28**] 02:08PM PLT SMR-NORMAL PLT COUNT-222
Brief Hospital Course:
72 yo woman with h/o ESRD on HD, type II diabetes mellitus,
presenting with anion gap metabolic acidosis and abdominal pain.
During her hospitalization the following issues were addressed:
.
# AG metabolic acidosis: Labs revealed a positive acetone,
raising concern for DKA. DDx also included uremia. She was
initially admitted to the ICU and placed on an insulin gtt.
Hyperglycemia and acidosis resolved by day two. She was
dialyzed on day two, and chemistries remained within normal
range for the remainder of her hospitalization. She was
continued on her outpatient insulin regimen of 15units 70/30 at
breakfast and a regular insulin sliding scale.
.
# Abdominal pain: Pain resolved on admission. Abdominal CT
showed signs of chronic pancreatitis including stranding, and
lab studies revealed an elevated AST that resolved. DDx also
included diabetic gastroparesis.
.
# ?GIB/coffee ground emesis: There was a question of coffee
ground emesis on admission. Stool was guiaic negative, and
hematocrit remained stable throughout her hospitalization 40-45.
No further work-up was intiated. She will follow-up for
outpatient EGD.
.
HTN: BP initially elevated on admission as patient missed
hemodialysis. She was treated with iv lopressor and
hydralazine, and BP normalized. HTN remained stable on
outpatient regimen on metoprolol and lisinopril for remainder of
her hospitalization.
.
# Dispo: she was discharged back to the [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **].
Communication is with the patient and her daughter [**Name (NI) **] [**Name (NI) 103090**]
[**Telephone/Fax (1) 103094**]. She is a full code.
Medications on Admission:
- Tylenol prn
- Venofer (iron) 100 mg IV Qweek
- EPO [**Numeric Identifier **] u QHD
- Zemplar 5 mcg QHD
- Colace [**Hospital1 **]
- Humulin 70/30 30 units QD
- Lactulose 30 cc prn
- Nephrocaps 1 tab daily
- Percocet prn
- ASA 325 daily
- Phoslo 667 TID
- Toprol XL 50 mg daily
- Zestril 10 mg QHS
- Sensipar 60 mg daily
Discharge Medications:
1. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) injection
Injection ASDIR (AS DIRECTED): TIW at hemodialysis.
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
8. Insulin
Insulin 70/13; 30units at breakfast
9. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Hyperglycemia
Metabolic acidosis
Chronic pancreatitis
Type II diabetes mellitus
ESRD on hemodialysis
Discharge Condition:
stable
Discharge Instructions:
If you develop abdominal pain, chest pain, shortness of breath,
fever, or any other concerning symptom, please call your primary
care physician [**Name Initial (PRE) **]/or return to the emergency department.
Followup Instructions:
Please follow-up with your primary care physician within the
next 1-2 weeks to review your hospital course and medications.
ICD9 Codes: 5856 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1313
} | Medical Text: Admission Date: [**2161-8-20**] Discharge Date: [**2161-8-27**]
Date of Birth: [**2090-8-28**] Sex: F
Service: THORACIC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 70 year-old
female with exertional dyspnea times six months.
Echocardiogram in [**Month (only) 404**] showed an aortic stenosis with
valve area .8 cm square. Catheterization on [**2161-8-20**]
showed a left ventricular ejection fraction approximately
65%, OMCA 70% occluded, left anterior descending coronary
artery is normal. Left circumflex is normal, right coronary
artery is normal. It showed a severe aortic stenosis and
aortic regurgitation and left main disease.
PAST MEDICAL HISTORY: Significant for diabetes,
hypertension, hypercholesterolemia and history of aortic
stenosis, hysterectomy in [**2146**].
MEDICATIONS AT HOME: Glyburide 5 mg q.a.m. and q lunch,
Monopril 10 mg q.a.m., 5 mg q.p.m. and Premarin, Lipitor,
aspirin.
The patient was taken by Dr.[**Last Name (STitle) **] to the Operating Room on
[**2161-8-21**] and underwent coronary artery bypass graft
times two, left internal mammary coronary artery to left
anterior descending coronary artery, right saphenous vein
graft to obtuse marginal and AVR with bimechanical #19 valve.
HOSPITAL COURSE: The patient was extubated in the Intensive
Care Unit and weaned off all drips and discontinued chest
tube without any incidence. The patient was transferred to
the floor and postoperatively course was unremarkable. Upon
discharge the patient was able to ambulate at level three to
four with assistance.
DISCHARGE MEDICATIONS: Lasix 20 mg po b.i.d. times five days
and K-Ciel 20 milliequivalents po b.i.d. times five days,
Lopressor 25 mg po b.i.d., coumadin 3 mg po q.d., Lipitor 10
mg po q.d., aspirin 81 mg po q.d., Glyburide 5 mg q.a.m. and
q lunch.
DISCHARGE CONDITION: Upon discharge the patient's physical
condition was stable. Chest was clear. Incision was clean,
dry and intact. No pus or drainage. Sternum was stable.
The patient will be discharged to a rehab facility. The
patient was told to have the INR checked and results will be
reported to the patient's primary care physician. [**Name10 (NameIs) **] INR
will be cap at approximately 2.5. The patient was told to
follow up with Dr. [**Last Name (STitle) **] in three to four weeks.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 186**]
MEDQUIST36
D: [**2161-8-27**] 09:53
T: [**2161-8-27**] 10:03
JOB#: [**Job Number 36429**]
ICD9 Codes: 4241, 4280, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1314
} | Medical Text: Admission Date: [**2199-3-18**] Discharge Date: [**2199-3-22**]
Date of Birth: [**2153-5-26**] Sex: F
Service: MEDICINE
Allergies:
Latex / doxycycline
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
Chest pain and nausea for 5 days
Major Surgical or Invasive Procedure:
Cardiac Catherization [**2199-3-20**]
History of Present Illness:
Patient is a 45 yo F with PVD, DM, HL, HTN and OSA. no known
CAD, no history cath who presents with chest pain and pressure
for 5 days. Patient was last in her usual state of health 5 days
prior to admission when she began to feel an intense chest
pressure and heaviness in the left chest radiating up to the jaw
while walking to her car. At this time she also felt intense
nausea. The pain and nausea abated on its own but recurred more
intensely that night accompanied with vomiting. At home, she
took one of her boyfriend's nitroglycerin which brought about
partial relief of pain. She continued over the weekend to have
pain, nausea, and vomiting recurring which was relieved with her
boyfriend's nitroglycerin. In total, she reports taking 7 nitros
for these episodes over the weekend. She had progressive fatigue
as the days progressed, and on day of presentation took a
shower, after which she felt extreme pronounced fatigue which
prompted her to present to the hospital. She reports worsening
orthopnea and DOE. Also, while she was on full dose aspirin due
to PVD, has not taken it while being on coumadin.
.
In the ED, VS 98.4 83 104/64 16 100% RA, EKG was read as non
acute and CXR was normal. Troponin and ckmb were neg x2. Patient
underwent stress MIBI which showed new partially reversible
inferior wall mild perfusion defect.
Past Medical History:
PMH:
asthma
diabetes type 2
anxiety
LLE DVT
PVD
HLD
HTN
OSA
.
PSH:
b/l angiograms,
L knee surgery x2,
appendectomy,
tonsillectomy,
L fem-AK [**Doctor Last Name **] [**2198-6-11**], graft removal
[**7-17**],
vein patch angioplasty of L CFA/[**Doctor Last Name **] [**7-19**],
washout and complex wound closure [**7-26**].
Social History:
Moving in with her boyfriend. She has one child. She is
unemployed. Had a recent house fire and is currently living in
her daughter's house.
Tobacco history: 2ppd for past 25 yrs, former 1.5ppd, newly quit
on varenicline
Former cocaine use. (denies use for many years)
Drinks 5-6 drinks on weekends.
Hx of domestic violence.
Family History:
Mother had an abdominal aortic aneurysm status post repair, MI
in her mid 50s, carotid stenosis, cervical cancer, coronary
artery disease, other [**Month/Year (2) 1106**] lesions which were stented. She
died due to complications of a procedure. The patient's father
died young. The patient has one cousin with cervical cancer. Her
maternal grandmother had an MI in her 60s. Maternal grandfather
with MI, hypertension, and hypercholesteremia.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VS: T98.3, BP125/71, HR69, RR18, O2sat 99%RA
GENERAL: WDWN, in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVD
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas, no
arterial ulcers
PULSES:
Right: radial 2+ Popliteal 2+ DP 2+ PT 1+
Left: radial 2+ DP 2+ PT 2+
PHYSICAL EXAM ON DISCHARGE:
Unchanged from admission
Pertinent Results:
Labs on Admission:
[**2199-3-18**] 05:00PM BLOOD WBC-10.6 RBC-4.20 Hgb-12.4 Hct-36.5
MCV-87 MCH-29.4 MCHC-33.9 RDW-12.8 Plt Ct-228
[**2199-3-18**] 05:00PM BLOOD PT-21.4* PTT-40.4* INR(PT)-2.0*
[**2199-3-18**] 05:00PM BLOOD Glucose-126* UreaN-17 Creat-0.7 Na-141
K-4.4 Cl-104 HCO3-27 AnGap-14
[**2199-3-20**] 06:03AM BLOOD Calcium-8.6 Phos-4.7* Mg-2.0
Cardiac Enzymes:
[**2199-3-18**] 11:11PM BLOOD CK-MB-2 cTropnT-<0.01
[**2199-3-20**] 02:50AM BLOOD CK-MB-1 cTropnT-<0.01
[**2199-3-20**] 08:00PM BLOOD CK-MB-5 cTropnT-0.28*
[**2199-3-21**] 04:18AM BLOOD CK-MB-7 cTropnT-0.18*
STUDIES:
CTA [**3-18**]:
IMPRESSION:
1. No PE or acute aortic syndrome.
2. Extensive atherosclerotic disease of the aorta, coronary
arteries, and
splenic artery.
3. Stable pulmonary calcified granulomas.
STRESS MIBI [**3-19**]:
INTERPRETATION: This was a 45 year old DM2 woman with PVD, HTN
and
HLD who was referred to the lab from the ED after negative
serial
cardiac enzymes for an evaluation of chest discomfort. She
received
0.142mg/kg/min of IV Persantine infused over 4 minutes. She
complained
of mid-sternal chest pressure and nausea immediate post
Persantine
infusion, which was relieved with the administration of 125mg IV
Aminophylline. There were no changes in ST segments or T waves
noted
during the infusion or in recovery. The rhythm was sinus without
ectopy.
The heart rate and blood pressure responded appropriately to the
Persantine infusion. At 2:15 post infusion, 125mg IV
Aminophylline was
given to reverse the Persantine side effects.
IMPRESSION: No ischemic ECG changes. Persantine induced symptoms
reported. Appropriate hemodynamic response. Nuclear report sent
separately.
MIBI Report [**3-19**]:
IMPRESSION:
1. New partially reversible inferior wall mild perfusion defect.
2. Normal left ventricular wall motion and cavity size. LVEF
62%.
Cardiac Cath [**3-20**]:
COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated
single vessel coronary artery disease. The LMCA was patent. The
LAD had
a 30% mid segment stenosis. The Lcx was patent with no
angiographically
apparent disease. The RCA was tortuous with diffuse disease.
There was
a 40% proximal lesion and a 40% mid lesion. There was a 95% mid
to
distal lesion.
2. Limited hemodynamics revealed centralized systolic
normotension.
3. Successful PCI with 6 Integrity BMS to the RCA (from the
distal
bifurcation to the ostium) complicated by spiral dissection
which had
completely been treated with the stents; no residual dissection.
4. Terumo band to right radial artery.
5. Integrillin for 12 hours post-cath.
FINAL DIAGNOSIS:
1. Single vessel coronary artery disease.
2. Successful PCI to the RCA with six Integrity BMS.
3. No post-procedure complications.
4. Patient to remain on aspirin indefintely and clopidogrel for
at least
1 year, uniterrupted, however duration of coumadin to be
established.
Radiology Report BILAT LOWER EXT VEINS Study Date of [**2199-3-19**]
8:21 AM
IMPRESSION: No evidence of deep vein thrombosis in either leg.
Please note
to evaluate for an arterial graft, a dedicated study must be
ordered through the [**Date Range 1106**] lab.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2199-3-20**] 2:30
AM
No evidence of acute cardiopulmonary process.
[**Known lastname **], [**Known firstname 2671**] [**Hospital1 18**] [**Numeric Identifier 2881**]TTE (Complete)
Done [**2199-3-21**] at 2:12:25 PM FINAL
IMPRESSION: Mild focal left ventricular systolic dysfunction
consistent with one vesel CAD. No significant valvular
abnormality.
ECG's:
Cardiovascular Report ECG Study Date of [**2199-3-18**] 2:22:10 PM
Sinus rhythm. Consider prior anteroseptal myocardial infarction
as recorded
on [**2199-2-20**] without diagnostic interim change. Clinical
correlation is
suggested.
TRACING #1
Cardiovascular Report ECG Study Date of [**2199-3-18**] 4:49:58 PM
Sinus rhythm. Consider prior anteroseptal myocardial infarction
as recorded
on [**2199-3-18**] without diagnostic interim change.
TRACING #2
Cardiovascular Report ECG Study Date of [**2199-3-18**] 11:20:14 PM
Wandering baseline and baseline artifact. The recording is
similar to that
of [**2199-3-18**] consistent with prior anteroseptal myocardial
infarction. Clinical correlation is suggested.
TRACING #3
Cardiovascular Report ECG Study Date of [**2199-3-19**] 8:50:30 PM
Sinus rhythm. Normal tracing. Compared to the previous tracing
of [**2199-3-18**]
R waves are now present in the anterior leads.
TRACING #1
Cardiovascular Report ECG Study Date of [**2199-3-20**] 2:10:34 AM
Sinus rhythm. Normal tracing. Compared to the previous tracing
of [**2199-3-19**]
there is no significant change.
TRACING #2
Cardiovascular Report ECG Study Date of [**2199-3-20**] 3:16:46 PM
Sinus rhythm. Low limb lead voltage. Late R wave progression.
Since the
previous tracing of [**2199-3-10**] the rate is faster.
TRACING #1
Cardiovascular Report ECG Study Date of [**2199-3-20**] 7:50:36 PM
Sinus rhythm. Leftward axis. Late R wave progression. Since the
previous
tracing the rate is slower. Axis is more leftward. T wave
inversions in the
inferior leads are now present. Clinical correlation is
suggested.
TRACING #2
LAB RESULTS ON DISCHARGE:
[**2199-3-22**] 06:25AM BLOOD WBC-9.0 RBC-3.80* Hgb-11.1* Hct-33.0*
MCV-87 MCH-29.2 MCHC-33.7 RDW-13.0 Plt Ct-185
[**2199-3-22**] 06:25AM BLOOD PT-11.4 INR(PT)-1.1
[**2199-3-22**] 06:25AM BLOOD Glucose-93 UreaN-14 Creat-0.7 Na-139
K-4.6 Cl-102 HCO3-30 AnGap-12
[**2199-3-21**] 04:18AM BLOOD CK(CPK)-87
[**2199-3-21**] 04:18AM BLOOD CK-MB-7 cTropnT-0.18*
[**2199-3-22**] 06:25AM BLOOD Calcium-9.0 Phos-4.5 Mg-2.0
Brief Hospital Course:
Primary Reason for Hospitalization:
Patient is a 45 yo female with PMH of PVD, DM, HL, HTN and OSA
and no known h/o CAD who was admitted for unstable angina and
found to have new partially reversible inferior wall mild
perfusion defect on stress MIBI. She underwent PTCA [**3-20**] which
revealed diffuse RCA disease with 95% mid-distal lesion.
Catheterization was complicated by RCA dissection, and treated
with 6X BMS. She had trop peak to 0.28 post transfusion, was
observed in the CCU overnight with uncomplicated course, and
transfered back to the cardiology floor. She remained chest pain
free but had ongoing chronic right shoulder pain. She was
discharged home on aspirin, clopidogrel, metoprolol, ace
inhibitor, and a statin.
ACUTE CARE:
1. Unstable angina: Patient had chest pain and pressure for 5
days at home that was partially relieved by her boyfriend's
nitroglycerin. On presentation, she had normal cardiac enzymes
and no ecg changes. Stress MIBI showed new partially reversible
inferior wall mild perfusion defect. She received cardiac
catherization, where a 95% mid-to-distal RCA lesion was stented
with 6 BMS, complicated by spiral dissection that was completely
treated with the stents. Patient was on Integrilin for 12 hours
post-cath. Cardiac enzymes were followed to peak. She was
continued on Aspirin 325, plavix 75 daily, rosuvastatin 40mg,
metoprolol 12.5 PO BID.
2 DVT: Patient presented with DVT one month prior to admission.
On this admission, PE was ruled out by CTA. Per Dr. [**Last Name (STitle) **], her
[**Last Name (STitle) 1106**] surgeon, as this was a limited tibial vein DVT, can
stop coumadin now that she is on aspirin and plavix and patient
would have increased risk of bleeding. Coumadin was stopped and
coags trended until INR normalized. Bilateral lower extremity
ultrasound also showed no DVT. Workup for potential
hypercoagulable state was deferred to outpatient treatment.
CHRONIC CARE:
1. Shoulder pain: Patient is followed by rehabilitative services
for chronic right shoulder pain. Patient was treated for this
pain with oral opioid analgesics and was discharged on home
vicodin. She was scheduled for shoulder injection in the week
after discharge.
2. Diabetes type 2: Patient is on oral hypoglycemics at home.
A1c 7.2% at the end of [**2199-2-3**]. Patient was maintained on
home Lantus 28U at night plus Novolog ISS (humalog should not be
used in the setting of latex allergy). Home oral hypoglycemics
were held throughout admission and restarted on discharge.
3. PVD: Patient takes cilostazol at home, which was held in the
setting of dissection and 2 other antiplatelet agents: plavix
and aspirin. Per patient's [**Year (4 digits) 1106**] surgeon, Dr. [**Last Name (STitle) **], this
should be restarted later, as it does not add additional
bleeding risk. Patient was discharged on her home cilostazol.
4. HLD: Patient was continued on her home crestor.
5. HTN: Patient was continued on her home lisinopril, and
started on metoprolol.
6. OSA: Patient was noted to snore and have oxygen
desaturations overnight on the floor. She has never been
evaluated for OSA and is not on CPAP. Workup was deferred to
outpatient providers.
Transitions in Care:
1. CODE STATUS: FULL
2. MEDICATION CHANGES:
1. START Plavix 75mg tablet, please take 1 tablet by mouth
daily until instructed otherwise by your cardiologist (you will
need to be on this medication for at least one month).
2. START Metoprolol 25mg tablet, please take half (0.5) a
Tablet twice daily.
3. START Nicotine patch, please use one patch daily, start
with 21mg patches for the first six weeks, then use 14mg patches
on weeks seven to eight and 7mg patch for weeks nine to ten.
4. STOP taking Warfarin (Coumadin).
5. CHANGE Aspirin from 81mg daily to 325mg once daily.
6. STOP taking chantix, this medication may increase the risk
for heart attack.
7. START Miralax 17g packet. Take one packet in water [**2-4**]
times daily as needed for constipation
8. CHANGE vicodin to 1 tablet every four hours as needed for
right shoulder pain. Do not take more than 7 tablets in a day.
9. Start pantoprazole 20mg, one tablet once daily.
3. FOLLOW-UP:
Please call your PCP as soon as you get home to make a follow up
appointment with him within 1 week of your discharge.
.
Please also follow up with your [**Month/Day (2) 1106**] surgeon as planned.
.
Please also keep the following appointments.
Department: ORTHOPEDICS
When: TUESDAY [**2199-3-26**] at 12:40 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2199-4-3**] at 12:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
4. OUTSTANDING CLINICAL ISSUES:
-potential workup for hypercoagulability
-injection of right shoulder joint for pain control
-outpatient workup for OSA, sleep study
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 1-2 puffs po
q4-6hr as needed for cough/wheezing
CILOSTAZOL - 50 mg Tablet - 1 Tablet(s) by mouth twice a day
take 2 hours before eating on 1 hour after. No grapefruit juice.
FLUTICASONE [FLONASE] - 50 mcg Spray, Suspension - 1 (One)
per(s) inhaled twice a day
GABAPENTIN - 400 mg Capsule - 1 Capsule(s) by mouth three times
a day
GLUCAGON (HUMAN RECOMBINANT) - 1 mg Kit - Inject into the muscle
once as needed for for severe hypoglycemia
HYDROCODONE-ACETAMINOPHEN - 5 mg-500 mg Tablet - 2 Tablet(s) by
mouth at bedtime as needed for pain
INSULIN GLARGINE [LANTUS] - (Dose adjustment - no new Rx) - 100
unit/mL Solution - 28 at bedtime
INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - use three
times daily with meals as directed QAC as per sliding scale
LISINOPRIL - 10 mg Tablet - 1 Tablet(s) by mouth qdaily
METFORMIN - 1,000 mg Tablet - 1 Tablet(s) by mouth twice a day
PAROXETINE HCL - 30 mg Tablet - 1 Tablet(s) by mouth qday
ROSUVASTATIN [CRESTOR] - 40 mg Tablet - one Tablet(s) by mouth
daily
VARENICLINE [CHANTIX CONTINUING MONTH PAK] - 1 mg Tablet - 1
Tablet(s) by mouth twice a day
WARFARIN - ([**Hospital Ward Name **] by Other Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) - 5 mg
Tablet - Take up to 3 Tablet(s) by mouth daily or as directed by
coumadin clinic
ASPIRIN - (OTC) - 81 mg Tablet, Chewable - 1 Tablet(s) by mouth
once a day
LORATADINE - ([**Last Name (NamePattern1) **] by Other Provider) - Dosage uncertain,
taken prn
RANITIDINE HCL - 75 mg Tablet - 1 Tablet(s) by mouth qday, taken
prn
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation every 4-6 hours as needed for wheezing.
2. cilostazol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): take 2 hours before eating or one hour after. No
grapefruit juice .
3. gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
4. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO once a
day.
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
9. polyethylene glycol 3350 17 gram/dose Powder Sig: [**2-4**] PO
DAILY (Daily) as needed for constipation.
Disp:*60 doses* Refills:*0*
10. nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 6 weeks: use week [**2-8**].
Disp:*42 Patch 24 hr(s)* Refills:*0*
11. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Transdermal
once a day for 2 weeks: use on week [**8-11**]. .
Disp:*14 Patch 24 hr(s)* Refills:*0*
12. nicotine 7 mg/24 hr Patch 24 hr Sig: One (1) Transdermal
once a day for 2 weeks: week [**10-14**].
Disp:*14 Patch 24 hr(s)* Refills:*0*
13. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain: Do not drive or operate machinery
while taking this medication. Do not take more than 7 tablets
per day, and do not take other acetaminophen-containing products
while taking vicodin.
Disp:*30 Tablet(s)* Refills:*0*
14. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Nasal twice a day.
15. Insulin
Please continue your home insulin regimen without change:
SQ Insulin Glargine (lantus) 28 units QHS
SQ Insulin Lispro (Humalog) every breakfast, lunch and dinner
per sliding scale.
16. glucagon (human recombinant) 1 mg Kit Sig: Once Injection
as needed: Inject into the muscle once as needed for severe
hypoglycemia.
17. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
18. rosuvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
19. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day as needed for heartburn.
20. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
21. pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Non ST-Elevation Myocardial Infarction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking part in your care. You were admitted
for evaluation of chest pain was though to be due to narrowing
of your coronary arteries. You underwent stress test followed by
coronary catheterization which confirmed narrowing of your right
coronary artery. The catheterization of this artery was
complicated by dissection of the wall of the artery and a
temporary interuption of blood supply to the heart muscle which
was fixed with six bare metal stents. You are being discharged
with several medication changes and with cariology follow-up.
.
Please make the following changes to your medications:
1. START Plavix 75mg tablet, please take 1 tablet by mouth daily
until instructed otherwise by your cardiologist (you will need
to be on this medication for at least one month).
2. START Metoprolol 25mg tablet, please take half (0.5) a Tablet
twice daily.
3. START Nicotine patch, please use one patch daily, start with
21mg patches for the first six weeks, then use 14mg patches on
weeks seven to eight and 7mg patch for weeks nine to ten.
4. STOP taking Warfarin (Coumadin).
5. CHANGE Aspirin from 81mg daily to 325mg once daily.
6. STOP taking chantix, this medication may increase the risk
for heart attack.
7. START Miralax 17g packet. Take one packet in water 1-2 times
daily as needed for constipation
8. CHANGE vicodin to 1 tablet every four hours as needed for
right shoulder pain. Do not take more than 7 tablets in a day.
9. Start pantoprazole 20mg, one tablet once daily.
.
Please continue the rest of your home medications without
change.
Please keep all follow up appointments.
Followup Instructions:
Please call your PCP as soon as you get home to make a follow up
appointment with him within 1 week of your discharge.
.
Please also follow up with your [**Known lastname 1106**] surgeon as planned.
.
Please also keep the following appointments.
Department: ORTHOPEDICS
When: TUESDAY [**2199-3-26**] at 12:40 PM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2199-4-3**] at 12:00 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
ICD9 Codes: 4439, 2724, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1315
} | Medical Text: Admission Date: [**2136-6-26**] Discharge Date: [**2136-7-8**]
Date of Birth: [**2061-1-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2136-6-29**] Three Vessel Coronary Artery Bypass Grafting(left
internal mammary to diagonal, vein grafts to obtuse marginal and
PDA) and Mitral Valve Repair(28mm [**Doctor Last Name 405**] [**Doctor Last Name **] Annuloplasty
Band)
History of Present Illness:
Mr. [**Known lastname 23340**] is a 75 year old male with known coronary
disease, recently admitted to the [**Hospital1 18**] with unstable angina. He
ruled in for an acute myocardial infarction at that time and
underwent cardiac catheterization which revealed severe three
vessel coronary artery disease. Prior to cath, was loaded with
Plavix. He subsequently underwent cardiac surgical evaluation
and coronary revascularization surgery was delayed secondary to
Plavix load. He was eventually discharged on medical therapy.
Unfortunately, he presented one day after discharge with rest
angina. He was admitted for further evaluation and treatment.
Past Medical History:
- Coronary Artery Disease with history of recent MI
- Prior PTCA to RCA [**2119**], [**2120**]
- Hypertension
- Dyslipidemia
- Prostate Cancer, s;p Prostatecomy
- Appendectomy
- Ganglionic Cyst Removal, Right Hand
Social History:
He smokes cigars for about 30 years, but he quit 25 years ago.
He drinks socially, up to two drinks per day (usually [**1-3**]
glasses of wine/scoth at night). He is a retired [**Location (un) 86**] police
officer. He does not get any regular physical exercise.
Family History:
Denies premature coronary artery disease.
Physical Exam:
Vitals: T 96.4, BP 130/89, HR 73, RR 18, SAT 98 on room air
General: elderly male in no acute distress
HEENT: oropharynx benign, PERRL
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, no murmur or rub
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2136-6-25**] 07:00AM BLOOD WBC-10.3 RBC-4.66 Hgb-14.5 Hct-43.2
MCV-93 MCH-31.0 MCHC-33.5 RDW-13.4 Plt Ct-249
[**2136-6-25**] 07:00AM BLOOD Glucose-92 UreaN-21* Creat-1.0 Na-139
K-4.3 Cl-105 HCO3-25 AnGap-13
[**2136-6-26**] 04:30AM BLOOD CK-MB-8 cTropnT-1.57*
[**2136-6-27**] Carotid Ultrasound: There is a less than 40% right ICA
stenosis and a 40% to 59% left ICA stenosis with antegrade flow
in both vertebral arteries.
[**2136-6-28**] Echocardiogram: The left atrium is elongated. Left
ventricular wall thicknesses and cavity size are normal. There
is mild regional left ventricular systolic dysfunction with
basal and mid-inferior hypokinesis. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. Moderate (2+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
Brief Hospital Course:
Mr. [**Known lastname 23340**] was admitted and underwent further preoperative
evaluation which included a carotid ultrasound and a
transthoracic echocardiogram(please see result section). He
remained stable on intravenous Heparin and intravenous
Nitroglycerin. His preoperative course was otherwise
unremarkable and he was cleared for surgery. On [**6-29**], Dr.
[**Last Name (STitle) **] performed coronary artery bypass grafting and a mitral
valve repair. For surgical details, please see separate dictated
operative note. Following the operation, he was brought to the
CSRU for monitoring. Within 24 hours, he awoke neurologically
intact and was extubated without incident. He maintained stable
hemodynamics and weaned from intravenous therapy without
difficulty. His CSRU course was otherwise uneventful and he was
transferred to the SDU on postoperative day one. He experienced
brief episodes of paroxysmal atrial fibrillation. His atrial
fibrillation was treated with Amiodarone and he converted back
to normal sinus rhythm. As he developed significant conversion
pauses while on amiodarone, this was discontinued. He was
transfused 2 units PRBCs on [**7-4**] for postoperative anemia. As he
had no further pauses, his pacing wires removed on POD #5. He
experienced recurrent atrial fibrillation and he was restarted
amiodarone. Coumadin and heparin were started for
anticoagulation. The physical therapy service worked with him
daily for assistance with his postoperative strength and
mobility. Slowly his INR became within therapeutic range and his
heparin was discontinued. Mr. [**Known lastname 23340**] required steady
diuresis for fluid overload. He continued to make steady
progress and was discharged home on [**2136-7-8**]. He will follow-up
with Dr. [**Last Name (STitle) **], his cardiologist and his primary care physician
as an outpatient. Dr. [**First Name (STitle) **] will manage his coumadin dosing
for a target INR of 2.0-2.5 for atrial fibrillation.
Medications on Admission:
Lipitor 10 qd, Metoprolol 100 [**Hospital1 **], Imdur 60 qd, Aspirin 325 qd,
Lisinopril 20 qd
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*40 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Disp:*60 Tablet(s)* Refills:*0*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*1*
6. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Outpatient Lab Work
First INR check to be drawn within 24 hours. Please fax results
to ([**Telephone/Fax (1) 23341**], phone ([**Telephone/Fax (1) 1921**].
8. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
twice a day.
Disp:*60 Tablet(s)* Refills:*2*
9. Coumadin 4 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary Artery Disease, Mitral Regurgitation - s/p CABG and MV
repair
- Postoperative Atrial Fibrillation
- Postoperative Anemia
- Prior PTCA to RCA [**2119**], [**2120**]
- Mild to moderate Carotid Disease
- Hypertension
- Dyslipidemia
- Prostate Cancer
Discharge Condition:
Good
Discharge Instructions:
Patient should shower daily, no baths. No creams, lotions or
ointments to incisions. No driving for at least one month. No
lifting more than 10 lbs for at least 10 weeks from the date of
surgery. Monitor wounds for signs of infection. Please call
cardiac surgeon if start to experience fevers, sternal drainage
and/or wound erythema.
Followup Instructions:
Coumadin/ INR to be followed by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] via the
[**Hospital3 **].
First blood draw within 24 hours of discharge. Please fax
results to ([**Telephone/Fax (1) 23341**], phone ([**Telephone/Fax (1) 1921**].
Cardiac surgeon, Dr. [**Last Name (STitle) **] in [**4-5**] weeks.
Local PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in [**2-4**] weeks.
Local cardiologist, Dr. [**Last Name (STitle) 171**] in [**2-4**] weeks.
Completed by:[**2136-7-9**]
ICD9 Codes: 4240, 4280, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1316
} | Medical Text: Admission Date: [**2123-2-12**] Discharge Date: [**2123-2-16**]
Date of Birth: [**2070-11-18**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
52yo F presents s/p Gamma Nail L femur fx, tibial plateau ORIF
after removal of temporary external fixator, and body fx from
MVC dated [**2123-1-16**], now complaining of R knee wound infection.
Major Surgical or Invasive Procedure:
I&D R Knee
History of Present Illness:
Pt was seen by Dr [**Last Name (STitle) 1005**] three days prior to admission in
clinic with concern of an infected surgical wound. Denied fever,
chills, nausea, vomiting, numbness, tingling. Pt states her
coumadin was stopped 2 [**Last Name (un) 32460**] prior to admission. Pt has noticed
increased discharge from wound. The pt has remained afebrile.
Past Medical History:
s/p Gamma Nail L Femur, tibial plateau ORIF,and C2 body fx
Hypothyroidism
Hyrpertension
MRSA
Social History:
nc
Family History:
nc
Physical Exam:
98.8*96*148/50*14*93RA
AAOx3 NAD
PERRLA, EOMI, collar in place
Healing laceration to left forehead/temple
CTAB
RRR, S1 S2
Abd soft, non-tender
+2 radial and DP pulses
R knee immobilized with wound producing slight purulence
LLE has small healing lac
Pertinent Results:
[**2123-2-12**] 11:10AM PT-16.4* PTT-27.1 INR(PT)-1.7
[**2123-2-12**] 11:10AM PLT COUNT-386
[**2123-2-12**] 11:10AM HYPOCHROM-1+ POIKILOCY-1+
[**2123-2-12**] 11:10AM NEUTS-72.0* LYMPHS-21.3 MONOS-3.0 EOS-3.5
BASOS-0.2
[**2123-2-12**] 11:10AM WBC-6.3 RBC-4.09* HGB-11.8* HCT-35.5* MCV-87
MCH-28.9 MCHC-33.2 RDW-15.5
[**2123-2-12**] 11:10AM GLUCOSE-98 UREA N-14 CREAT-0.6 SODIUM-141
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-33* ANION GAP-11
[**2123-2-12**] 05:20PM VANCO-18.6*
[**2123-2-12**] 4:30 pm SWAB Site: KNEE R KNEE.
GRAM STAIN (Final [**2123-2-12**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary):
BACTERIA. RARE GROWTH.
BEING ISOLATED FURTHER IDENTIFICATION TO FOLLOW.
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
[**2123-2-9**] 4:20 pm SWAB RIGHT LEG.
**FINAL REPORT [**2123-2-11**]**
GRAM STAIN (Final [**2123-2-9**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2123-2-11**]):
STAPH AUREUS COAG +. SPARSE GROWTH.
Please contact the Microbiology Laboratory ([**6-/2424**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
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.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
RADIOLOGY Final Report
FEMUR (AP & LAT) LEFT [**2123-2-13**] 3:20 PM
FEMUR (AP & LAT) LEFT
Reason: eval for fracture
[**Hospital 93**] MEDICAL CONDITION:
52 year old woman with pain on extension
REASON FOR THIS EXAMINATION:
eval for fracture
HISTORY: A 52-year-old woman with pain on extension. Please
evaluate for fracture.
AP AND LATERAL VIEWS OF THE LEFT FEMUR: Comparison is made to
intraoperative films on [**2123-1-16**]. There is an intramedullary rod
and femoral neck screw in place, stabilizing a mid shaft
fracture. Fracture is comminuted, bony fragments in the soft
tissues lateral and anterior to the fracture site.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 32202**]
Approved: SUN [**2123-2-14**] 8:01 AM
RADIOLOGY Final Report
C-SPINE, TRAUMA [**2123-2-13**] 3:20 PM
C-SPINE, TRAUMA
Reason: eval for fx
[**Hospital 93**] MEDICAL CONDITION:
52 year old woman with pain on extension
REASON FOR THIS EXAMINATION:
eval for fx
HISTORY: 52-year-old woman status post trauma with pain on
extension. Please evaluate for fracture.
THREE VIEWS OF THE CERVICAL SPINE: The exam is technically
limited. No gross fracture or dislocation is seen. The
retropharyngeal soft tissues are normal. The cervical spine
appears straight, but the patient is recumbent.
IMPRESSION:
Technically limited exam but no gross fracture seen.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 32202**]
Approved: SUN [**2123-2-14**] 8:01 AM
Brief Hospital Course:
Pt was admitted to the Ortho/Trauma Service under Dr [**Last Name (STitle) 1005**]
and scheduled for a I&D washout of the R knee. The pt was
started on Vanco/Gent antibiosis in the ED and was subsequently
changed to Vanco only on admission. The pt tolerated the
procedure well withouut any apparent complications. On POD#2,
the drain was pulled and the wound was examined to be healing
satisfactorily. PT attempted to evaluate the pt, but the pt
refused. The Venous Access team evaluated the pt, was unable to
place a PICC at bedside and recommended placement via IR. Repeat
femur and c-spine were ordered and neither showed any
significant change and were reviewed by Dr [**Last Name (STitle) 1005**] prior to
discharge.
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Levothyroxine Sodium 25 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
5. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4-6H
(every 4 to 6 hours) as needed.
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
7. Enoxaparin Sodium 30 mg/0.3 mL Syringe Sig: One (1)
Subcutaneous Q12H (every 12 hours).
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
9. Vancomycin HCl 1,000 mg Recon Soln Sig: One (1) Intravenous
twice a day for 4 weeks.
10. Outpatient Lab Work
Vanco Trough Q Wednesday
Report results to Dr [**Last Name (STitle) 1005**]
617*667*5589
11. PICC Care
PICC line flush
As per protocol.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
R Knee Sx Site Infection
s/p Gamma Nail L femur, tibial plateau ORIF, and C2 body fx
HTN
Hypothyroidism
Discharge Condition:
Good.
Discharge Instructions:
Seek medical attention if you experience fever, chills, nausea,
vomiting, new or worsening, symptoms.
Place no weight on your right leg.
Use your crutches as directed.
Keep your leg elevated as much as possible.
Continue to wear your collar AT ALL TIMES for 12 weeks.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Where: [**Hospital6 29**]
ORTHOPEDICS Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2123-3-2**] 11:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12005**] Where: LM [**Hospital Unit Name 12006**] Phone:[**Telephone/Fax (1) 3666**] Date/Time:[**2123-2-23**] 10:40
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2123-2-15**]
ICD9 Codes: 4019, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1317
} | Medical Text: Admission Date: [**2124-4-10**] Discharge Date: [**2124-4-17**]
Date of Birth: [**2072-10-11**] Sex: F
Service: NEUROSURGERY
Allergies:
Vicodin / Codeine / Opium
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Ataxia,gait instability
Major Surgical or Invasive Procedure:
[**4-14**]: Right Posterior Fossa Craniotomy/craniectomy for mass
resection
History of Present Illness:
Ms. [**Known lastname 80652**] was well until last week or two when she had noticed
increasing headaches. The headaches were worse when she was
straining with bowel movements or laughing, but often it also
came with or without any precipitating factors. She was also
noticed being clumsy and having loosing her balance as well.
She has not had any visual disturbances. No other signs of
intracranial tensions like headache, nausea, vomiting, or other
motor, sensory, or neurological deficits. She had a head CT,
which showed right lateral CP angle mass
measuring about 4.8 x 4.7 cm. This was heterogeneously
enhancing. An MRI confirmed this mass also.
Past Medical History:
-s/p 4 left ovarian cystectomies
-reports that one cyst "fell out" into the toilet that was
greyish in appearance
-s/p hysterectomy and bilateral oophorectomies [**2107**]
-left foot cyst
-3 left hip lipomas removed
-kidney stones
-s/p cholecystectomy [**27**] years ago
-left shoulder ganglion cyst
-s/p "bladder sling" [**2123-9-13**]
-emphysema
-hypercholesterolemia
Social History:
Has several family members with her that are supportive, +
tobacco, has tried to quit 6 times
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAM Upon Admission:
T:97.5 BP:127/81 HR:74 RR:12 O2Sats:97% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:PERRL 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: [**3-21**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing 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 [**5-23**] throughout. No pronator drift.
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
Coordination: Slowed on finger-nose-finger. Normal rapid
alternating movements, heel to shin.
+ Rhomberg test
Upon Discharge:
Pertinent Results:
Labs on Admission:
[**2124-4-10**] 04:53PM BLOOD WBC-8.1 RBC-4.99 Hgb-14.6 Hct-41.7 MCV-84
MCH-29.2 MCHC-35.0 RDW-13.9 Plt Ct-330
[**2124-4-10**] 04:53PM BLOOD Neuts-70.3* Lymphs-25.4 Monos-2.1 Eos-1.6
Baso-0.7
[**2124-4-10**] 05:51PM BLOOD PT-12.4 PTT-26.0 INR(PT)-1.0
[**2124-4-10**] 04:53PM BLOOD Glucose-96 UreaN-20 Creat-0.7 Na-139
K-4.2 Cl-103 HCO3-24 AnGap-16
[**2124-4-11**] 05:01AM BLOOD Calcium-10.4* Phos-3.7 Mg-2.4
Labs on Discharge:
[**2124-4-16**]
07:25a
136 101 22 127 AGap=10
-------------/
4.6 30 0.7
Ca: 9.0 Mg: 2.4 P: 3.3
Wbc: 14.6 Hgb:11.7 PLT: 333 Hct:32.2
PT: 12.1 PTT: 22.8 INR: 1.0
CT head [**2124-4-10**]:
FINDINGS: Centered in the right lateral posterior fossa,
adjacent to the
cerebellopontine angle, there is an apparent extra-axial, 4.8 x
4.7 cm,
heterogeneous, avidly-enhancing mass with small foci of
calcification along
the rim. On non- contrast images, this lesion is slightly
hyperdense compared to brain parenchyma, particularly along the
rim, with central hypodense region. There is resulting mass
effect and compression of right cerebellar hemisphere. There is
no erosion or definite hyperostosis identified of the adjacent
bone. There is mass effect resulting in compression of the right
perimesencephalic cistern, and leftward displacement of the
fourth ventricle, which still appears patent. There is evidence
of tonsillar herniation. Overall, the ventricles have a slightly
enlarged appearance, which could reflect a mild degree of
outflow obstruction. The right jugular vein appears patent as
well as part of the sigmoid sinus. However, the tumor effaces
the sigmoid sinus within its groove at the level of the fourth
ventricle. The sigmoid and transverse sinus cephalad to this
region appear patent. Elsewhere, there is no intracranial
hemorrhage, edema, shift of normally midline structures or
evidence of major vascular territorial infarcts. The remaining
basilar cisterns are patent. The [**Doctor Last Name 352**]-white differentiation in
the cerebral cortex is preserved. There is no fracture. Mastoid
air cells and paranasal sinuses are well aerated. Soft tissues
are normal.
IMPRESSION: Large right posterior fossa extraaxial, enhancing,
heterogeneous mass resulting in tonsillar herniation,
compression of the right perimesencephalic cistern and
displacement of fourth ventricle, likely causing a mild degree
of outflow obstruction. The adjacent sigmoid sinus appears
effaced. The imaging findings are most consistent with a large
meningioma. A contrast-enhanced MRI could provide further
information, including the patency of the adjacent sigmoid
sinus.
MRI head [**2124-4-10**]:
FINDINGS: In comparison with a prior examination, again on the
right side of the posterior fossa, there is a large apparently
extra-axial mass lesion, measuring approximately 5.0 x 4.5 cm in
transverse dimensions x 4.5 x 4.5 cm in the coronal MP-RAGE
projection. This lesion demonstrates mild hyperintense signal in
comparison with the rest of the brain parenchyma on T1 without
contrast. No restricted diffusion is identified. Several
heterogeneous signal areas are visualized on the FLAIR sequence
within this mass lesion, possibly related with punctate
calcifications and hyperintensity signal areas on T2, possibly
related with small areas with cystic transformation. With
gadolinium contrast, this lesion enhance avidly, mild vasogenic
edema is identified and significant mass effect and shifting of
the fourth ventricle towards the left. The prepontine cistern
apparently is preserved, mild effacement of the inferior right
collicular cistern is demonstrated. Supratentorially, there is
no evidence of abnormal enhancement and both cerebral
hemispheres are grossly normal, no diffusion abnormalities are
detected. The ventricles are slightly prominent, however no
significant transependymal migration of CSF is demonstrated.
Multiple areas of hyperintensity signal are visualized in the
periventricular white matter, likely consistent with chronic
areas of gliosis or small vessel disease. Normal flow void is
identified in the major vascular structures, the right posterior
fossa mass lesion lesion is in close contact with the right
trasverse sinus. The coronal and sagittal images demonstrate
right tonsillar herniation, approximately 1.5 cm of tonsillar
herniation is demonstrated on the sagittal image. The orbits,
the paranasal sinuses, and the mastoid air cells appear within
normal limits.
IMPRESSION:
1. Large extra-axial right posterior fossa mass lesion, with
significant pattern of enhancement and areas of heterogeneous
signal, more
likely consistent with a large meningioma, resulting in right
tonsillar
herniation, mass effect, and compression of the fourth ventricle
as described in detail above.
2. Multiple areas of hyperintensity signal are visualized in the
periventricular white matter, likely consistent with chronic
areas of gliosis or small vessel disease, however, nonspecific.
No other lesions or areas with abnormal enhancement are
demonstrated.
CT Torso [**4-13**]:
CT OF THE CHEST WITH CONTRAST, FINDINGS: No pulmonary
parenchymal
abnormalities are appreciated. The aorta appears unremarkable as
well as its major branches. There is no hilar, mediastinal or
axillary adenopathy. No breast masses. Bone windows show no
abnormalities.
Initial wet read to raised the question of a filling defect
involving the left pulmonary artery which is felt to be
extrinsic to the artery or due to partial volume effect. Note of
a cyst involving the left pericardium.
CT OF THE ABDOMEN WITH CONTRAST AND WITHOUT CONTRAST, FINDINGS:
The patient
is status post cholecystectomy. The liver is unremarkable with a
patent
portal vein, no focal mass lesions, and no dilated ducts. The
kidneys,
adrenal glands, spleen, pancreas, and visualized loops of large
and small
bowel appear normal. The aorta as well as its branches also
appears
unremarkable.
CT OF THE PELVIS WITH CONTRAST, FINDINGS: The visualized loops
of large and
small bowel appear normal. There is no free fluid, no
adenopathy. The
patient is status post hysterectomy. Bone windows demonstrate no
suspicious lytic or blastic change.
IMPRESSION:
1. No findings to suggest a primary source of this patient's
intracranial
pathology.
2. Simple pericardial cyst.
3. No evidence of acute pulmonary embolism.
EKG [**4-13**]:
Normal sinus rhythm, rate 71. Normal tracing. No previous
tracing available
for comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
71 160 110 386/405 47 22 48
MRI [**4-15**]:
FINDINGS: Since the previous study, the patient has undergone
resection of
right-sided posterior fossa meningioma. Blood products are seen
with a large surgical cavity in the region. Mild surrounding
edema is identified. No acute infarcts are seen. No residual
enhancement is identified. There is no evidence of
hydrocephalus. The previously noted subtle periventricular
signal abnormalities are unchanged. Of concern is filling defect
within the right transverse sinus extending from torcula to the
region of the sigmoid sinus. The left transverse sinus as well
as the superior sagittal sinus, and deep venous system are
patent.
Fluid is seen within the soft tissues in the right parietal
region related to surgery. Inferior position of the cerebellar
tonsils is again identified and is unchanged.
IMPRESSION:
1. Postoperative changes in the posterior fossa with blood
products, air, and surrounding edema unchanged with a downward
position of the cerebellar tonsils as before. Mass effect on the
fourth ventricle is seen without hydrocephalus with a mass
effect decrease since the previous study.
2. Filling defect is seen in the right transverse sinus
concerning for
thrombosis within the sinus. Further evaluation with the MRV is
recommended.
CTA/V of Head [**4-16**]:
CTV OF THE BRAIN WITH CONTRAST
HISTORY: Suspected venous sinus thrombosis right transverse
sinus.
Comparison is made with study performed on [**2124-4-15**].
There is a post-operative cavity in the right cerebellum with a
hemorrhagic
focus along its margins. There is a mesh cranioplasty at the
operative site. Corresponding to the findings seen on the MRI,
there is lack of normal flow in the mid to distal transverse and
sigmoid sinus concerning for thrombosis. The remaining venous
structures are normally opacified.
IMPRESSION:
Findings suggestive of right distal transverse and sigmoid sinus
thrombosis.
Brief Hospital Course:
The patient was admitted to the ICU for Q 1 hour neuro checks
due to the large size of the posterior fossa mass and due to the
mass effect on the 4th ventricle. She was symptomatic such that
she was experiencing headaches and difficulty with balance. The
patient was scheduled to have a craniectomy with resection of
the mass which occurred on [**2124-4-14**]. She went to the ICU
post-operatively for observation. Her neuro exam was stable
without any focal deficit. She was continued on a decadron
medication with a every other day taper to off. She was given
arrangements to follow up with her PCP [**Last Name (NamePattern4) **] [**4-18**] for continued
monitoring of her blood sugars while the dosing is tapered. She
was further seen and evaluated by PT and OT who determined that
she would be appropriate for home discharge with the use of a
walker. She was discharged accordingly on [**4-17**] with follow up
instructions for a brain tumor apptointment and MRV of the head.
Medications on Admission:
Vytorin, Etodolac
Discharge Medications:
1. Docusate Sodium Oral
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
3. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*14 Patch 24 hr(s)* Refills:*0*
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Dexamethasone 4 mg Tablet Sig: Taper dose PO Q6H (every 6
hours): 4mg QIDx2 dys, 3mg QIDx2 dys, 2mg QIDx2dys, 1mg
QIDx2dys. then off.
Disp:*QS Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
TBA
Discharge Diagnosis:
Right Cerebellar Mass
Discharge Condition:
Neurologically stable
Discharge Instructions:
General Instructions/Information
?????? 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 staples have been
removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? 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.
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: increasing redness,
increased swelling, increased tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**7-28**] days (from your date of
surgery) for removal of your sutures and a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2124-5-15**] @
2:00pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of
[**Hospital1 18**], in the [**Hospital Ward Name 23**] Building. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You need an MRI/V of the brain (prior to your brain tumor
appointment). MRI Phone:[**Telephone/Fax (1) 327**] MRI/V is scheduled for
[**2124-5-15**] @ 11:55am
Completed by:[**2124-4-17**]
ICD9 Codes: 3051, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1318
} | Medical Text: Admission Date: [**2192-9-10**] Discharge Date: [**2192-9-18**]
Date of Birth: [**2140-1-28**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
s/p motorcycle crash
Major Surgical or Invasive Procedure:
Halo vest placement
History of Present Illness:
This is a 52 year-old man who was brought by EMS to the ED after
being in a motorcycle crash at approximately 30mph. He was
wearing a helmet and denied LOC. His blood alcohol at
presentation was 165. On arrival he complained of posterior neck
pain.
Past Medical History:
None
Social History:
EtOH
local firefighter
Family History:
Noncontributory
Physical Exam:
Pertinant PE on discharge:
VSS Afebrile
Gen: No distress. Alert and oriented, pleasant. Wants to go home
HEENT: Halo in place with good fit, no redness or pus at pin
sites.
Chest: Clear to auscultation bilaterally
CV: Regular rate and rhythm
Abd: Soft, nontender, nondistended
Ext: Warm and well-perfused. Healing abrasions on left knee and
shoulder, no signs of infection.
Pertinent Results:
[**2192-9-10**] 09:37PM TYPE-[**Last Name (un) **] PO2-48* PCO2-54* PH-7.29* TOTAL
CO2-27 BASE XS--1
[**2192-9-10**] 09:35PM GLUCOSE-110* UREA N-11 CREAT-0.7 SODIUM-144
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-25 ANION GAP-19
[**2192-9-10**] 09:35PM AMYLASE-44
[**2192-9-10**] 09:35PM ASA-NEG ETHANOL-165* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2192-9-10**] 09:35PM WBC-11.4* RBC-4.29* HGB-14.4 HCT-39.0* MCV-91
MCH-33.6* MCHC-36.9* RDW-13.7
[**2192-9-10**] 09:35PM PLT COUNT-283
[**2192-9-10**] 09:35PM PT-11.1* PTT-21.9* INR(PT)-0.8
[**2192-9-10**] 09:35PM FIBRINOGE-281
Pertinent radiology results:
CT C-spine: [**Location (un) 26524**] fracture of C1 vertebra with
displacement of the lateral masses.
MRA: Abnormal filling defect within the petrous portion of the
right internal carotid artery, likely representing a short
segment arterial injury such as intimal flap and/or nonocclusive
thrombus.
Brief Hospital Course:
The patient was admitted to the Trauma Service and followed by
Spine Orthopedics, Neurosurgery and Dr. [**Last Name (STitle) **]. He was
admitted briefly to the Trauma ICU and then transferred to the
floor with no major events. He remained hemodynamically stable
and his pain was well-controlled with IV and then oral
medications. He was fitted with a halo vest on the day of
admission with no complications. He was seen by Vascular Surgery
for the concern for a traumatic arterial dissection and/or
thrombus and was started on heparin for anticoagulation. When
his PTT was in the target range coumadin was begun, and he was
transitioned to lovenox for discharge on both lovenox and
coumadin.
He was seen by physical therapy, occupational therapy, and
social work and advanced well in his activity and independence
level. Given his strong level of support at home, it was felt he
could go home rather than going to a rehabilitation center.
Medications on Admission:
Allopurinol
Discharge Medications:
1. Lovenox 100 mg/mL Syringe Sig: One (1) ml syringe
Subcutaneous twice a day: d/c when INR [**2-23**].
Disp:*QS syringe* Refills:*0*
2. Coumadin 7.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. x-ray
AP and lateral film of C-spine prior to appointment with Dr.
[**Last Name (STitle) 363**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
C1 or [**Location (un) 5621**] fracture
Right ICA dissection
abrasions
Discharge Condition:
Good
Discharge Instructions:
You should call a physician or come to ER if you have worsening
pains, fevers, chills, nausea, vomiting, shortness of breath,
chest pain, redness or drainage about halo pin sites,
uncontrollable bleeding, excessive bruising, dark colored stool,
blood in your stool, or if you have any questions or concerns.
It is important you take medications as directed. You should not
drive or operate heavy machinery while on any narcotic pain
medication such as percocet as it can be sedating. You may take
colace to soften the stool as needed for constipation, which can
be cause by narcotic pain medication.
You will need to continue taking coumadin and lovenox until your
INR is between 2 and 3. At that point you will stop taking
lovenox and continue only on coumadin. Your primary care
physician may need to adjust the dose of coumadin to keep your
INR=[**2-23**].
Followup Instructions:
You have an appointment this [**Last Name (LF) 2974**], [**9-21**], at 11:30am
with Dr. [**Last Name (STitle) 8049**].
Call Dr. [**Last Name (STitle) **] (Vascular surgery) for a follow-up
appointment in 2 weeks ([**Telephone/Fax (1) 3121**]).
Call Dr. [**Last Name (STitle) 363**] (spine surgery; [**Telephone/Fax (1) 3573**]) for a follow-up
appointment in 2 weeks with AP and lateral x-rays.
ICD9 Codes: 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1319
} | Medical Text: Admission Date: [**2113-9-29**] Discharge Date: [**2113-10-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9853**]
Chief Complaint:
Shortness of Breath.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Name14 (STitle) 75755**] is a [**Age over 90 **] y.o. F from NH with CAD s/p MI, DM type 2,
CVA (nonverbal at baseline), presenting with respiratory
distress and shortness of breath. Pt noncommunicative at
baseline so history obtained from ED records, NH records and per
ED resident. Pt was found with labored breathing with RR 43 and
O2 sat 88% on 2 L NC. Ipratropium neb provided at NH without
any effect. Continued to have respiratory distress with sats in
70-81%. Nonrebreather improved sat to 81-84%. VS 132/109 and
tachy at 113. Noted to be clammy and sweating profusely. FS
223 at that time. Per NH notes, pt had similar episode earlier
in day. Gave mag citrate with 1 large BM and vomiting x 1.
.
In the ED: VS T 100 rectally BP 146/82 HR 99 RR 32 99% 15 L
NRB
Per ED notes, audible crackes. EKG done that did not show any
acute changes. Foley inserted. Portable CXR completed with
possible effusion/consolidation. CT head negative. Had already
been started on Keflex 500 TID at NH on [**2113-9-27**] for unknown
reason. Also on Valtrex for H. zoster since [**9-27**]. Given
ceftriaxone, vancomycin, and azithromycin. BCx and UCx drawn.
DNR status confirmed by ED resident with HCP, but intubation
acceptable. Per ED nurses, pt appears at her baseline as she is
frequently in ED.
.
On arrival to ICU, pt appears comfortable. Was initially on NRB
and now currently on 4 L NC with O2 sats in high 90s.
Past Medical History:
1. Coronary artery disease with 4 stents placed [**2111-8-1**] at [**Hospital1 2025**]
2. Hypertension
3. Diabetes mellitus type 2
4. CVA [**9-/2111**] (nonverbal at baseline)
5. Macular degeneration, legally blind
6. G-tube placement (all nutrition via G-tube per GI)
7. Hypothyroidism
8. Hyperlipidemia
9. Anemia
10. Depression
Social History:
From [**Hospital1 **] NH. Son is HCP. [**Name (NI) 4084**] smoked, minimal prior alcohol
use, no illicit drugs. Of Latvian descent and has devoted
children. Lives at [**Hospital1 **] senior care. Retired from working at
histology lab at [**Hospital1 2025**]. Was very independent prior to CVA.
Family History:
Noncontributory
Physical Exam:
VITALS: T: 93.2 Ax --> 99.8 Rectally BP: 148/90 HR: 82 RR: 28
O2Sat: 96% 4 L NC
GEN: NAD, unresponsive to voice or sternal rub; when trying to
open eyes, pt does try to shut them.
HEENT: unable to assess EOMI, but pupils reactive to light. R
pupil deviated inward while L pupil in center. unable to assess
OP, no LAD
CHEST: rhonchi in middle-lower lung fields with scattered exp
wheezes and soft inspiratory crackles at bases
CV: RRR, no m/r/g appreciated
ABD: NDNT, soft, NABS
EXT: no c/c/e
NEURO: unknown baseline, but noncommunicative to voice or
sternal rub
SKIN: no rashes noted
Pertinent Results:
[**2113-9-29**] 08:45PM WBC-9.2 RBC-4.26 HGB-12.6 HCT-39.0 MCV-92
MCH-29.5 MCHC-32.3 RDW-20.5*
[**2113-9-29**] 08:45PM cTropnT-0.04*
[**2113-9-29**] 08:45PM GLUCOSE-249* UREA N-49* CREAT-1.2* SODIUM-143
POTASSIUM-6.2* CHLORIDE-110* TOTAL CO2-15* ANION GAP-24*
[**2113-9-29**] 10:10PM URINE RBC-0 WBC-[**12-21**]* BACTERIA-FEW YEAST-FEW
EPI-[**4-5**]
[**2113-9-29**] 10:10PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM
HEAD CT WITHOUT IV CONTRAST [**2113-9-29**]: There is again demonstrated
a large chronic infarction of the left temporoparietal region.
There is no hemorrhage, evidence of acute edema, mass effect, or
shift of normally midline structures.
The ventricles and sulci are prominent and consistent with
age-related
parenchymal atrophy. There is periventricular hyperdensity in a
pattern
consistent with chronic small vessel ischemic disease. Numerous
carotid
calcifications are identified. The visualized paranasal sinuses
are clear.
Soft tissues are remarkable only for evidence of prior cataract
surgery.
IMPRESSION: No evidence of fracture, hemorrhage, or edema.
CXR [**2113-9-29**]
IMPRESSION: Left basilar opacification may represent atelectasis
or
aspiration pneumonia. A left sided effusion is not excluded.
Hazy left upper
lobe opacification could represent superimposed asymmetric
pulmonary edema.
CXR: [**2113-9-30**]
IMPRESSION: Interval improvement in pulmonary vascular
congestion.
Persistent left pleural effusion. The retrocardiac area is not
well
penetrated and atelectasis or consolidation in the left lower
lobe cannot be excluded.
[**2113-10-2**] 06:50AM BLOOD WBC-10.3 Hgb-10.6* Hct-36.0 MCHC-31.8
Plt Ct-257
[**2113-10-2**] 06:50AM BLOOD Glucose-171* UreaN-52* Creat-1.2* Na-144
K-4.0 Cl-110* HCO3-22 AnGap-16
Brief Hospital Course:
# SOB: Resolved by time of arrival in ICU. BNP>[**Numeric Identifier **]. SOB
responded to IV lasix. Given nebulizers, CE x3 negative. BUN
and Creat slightly higher than baseline at 52/1.2. Currently
receiving lasix 40 mg daily and received an extra dose of 20 mg
today for episode of congestion and SOB with O2sat of 82%. With
02 via NC replaced she returned to 02 sat of 94%. Pt.
frequently removes the oxygen. Her pattern of breathing
(intermittent tachypnea) has been noted in the past and may be
due to intermittent discomfort (e.g., from constipation). She
may receive supplemental oxygen prn at her nursing home.
# CHF, acute on chronic, diastolic and systolic: EF 20-25% on
[**12/2112**] echo.
- continued ACE-I, lasix and spironolactone
- received IV diuresis in the ICU and BP remained stable. SOB
and 02 sat improved and she was restarted on usual dose of lasix
per peg tube.
# Diabetes, type 2
- has been covered with regular insulin sliding scale. Tube
feedings have been gradually titrated to 60 cc/hr with rising
blood sugar today to 300. She does not show any signs of active
infection. She has remained afebrile and her WBC is normal at
10.3.
# UTI: When admitted she was already on cephalexin and the urine
culture done here grew yeast with UA positive for bacteria and
WBCs. UCx grew 10,000 - 100,000 yeast. She was treated with
Ceftriaxone on admission. She continued on cephalexin throughout
her hospital stay and the 7th and final day is today, [**2113-10-2**].
# Herpes zoster, left T7-8 dermatome: Last day of Valtrex is
today. Lesions have scabbed over, she does not require
precautions.
# Diarrhea: C diff x1 negative. Diarrhea was resolved by [**10-1**].
# Depression: She is on effexor, but her MS at this time is
impossible to evaluate. She is non verbal and does not interact
in any meaningful fashion. Consideration should be given to
discontinuing antidepressant medication if it is not known to be
beneficial for her.
# stage II decubitus pressure ulcers: sacrum and mid-back, local
wound care continued.
# Advanced Care Planning: She and her son may benefit from a
palliative care consultation to clarify the goals of care.
# Code status: DNR, may be intubated.
Medications on Admission:
Timolol 0.25% eye drops 1 drop in each eye [**Hospital1 **]
Venlafaxine 37.5 mg via GTube
Vit D 50,000 unit capsule 1 capsule via G-tube once a month (due
on [**2113-10-9**])
Metoclopramide 5 mg [**Hospital1 **]
KCl 20 meq/15 ml concentration; 7.5 ml daily
Spironolactone 25 mg daily
Protonix 40 mg daily
Acetaminophen 650 mg po q4 hours prn
Milk of Magnesia 30 ml daily prn constipation
Dulcolax 10 mg prn
Fleet Enema prn
Albuterol sulfate neb q6 hour prn
Ipratropium neb q6 hour prn
ASA 81 mg daily
Carvedilol 12.5 mg [**Hospital1 **]
Ferrous sulfate 7.5 ml daily
Furosemide 40 mg dialy
Keppra 250 mg oral solution daily
Levothryroxine 125 mcg daily
Lisinopril 20 mg daily
Vicodin 5/500 mg 1 tablet q4 hours prn pain
Valtrex 1 gm TID x 1 week (uncertain when doses started/ended)
Keflex 500 mg TID x 1 week (uncertain when doses started/ended)
.
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY as needed.
2. Senna 8.6 mg Tablet Sig: One Tablet PO BID (2 times a day) as
needed.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One Injection
TID (3 times a day).
4. Timolol Maleate 0.25 % Drops Sig: One Drop Ophthalmic [**Hospital1 **] (2
times a day).
5. Venlafaxine 37.5 mg Tablet Sig: One Tablet PO BID (2 times a
day).
6. Metoclopramide 10 mg Tablet Sig: One Tablet PO BID (2 times a
day).
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One Tablet,
PO DAILY.
8. Docusate Sodium 50 mg/5 mL Liquid Sig: One PO BID (2 times a
day).
9. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: One PO
DAILY
10. Levetiracetam 100 mg/mL Solution Sig: One PO DAILY
11. Levothyroxine 125 mcg Tablet Sig: One Tablet PO DAILY
12. Insulin Regular Human 100 unit/mL Solution Sig: One
Injection AS DIRECTED.
13. Carvedilol 12.5 mg Tablet Sig: One Tablet PO BID (2 times a
day).
14. Furosemide 40 mg/5 mL Solution Sig: One PO DAILY
15. Lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY
16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One Inhalation PRN for wheezing.
17. Ipratropium Bromide 0.02 % Solution Sig: One Inhalation Q6H
(as needed for wheezing.
18. Valacyclovir 500 mg Tablet Sig: One Tablet PO TID (3 times a
day): last dose [**2113-10-2**] pm.
19. Cephalexin 500 mg Capsule Sig: One Capsule PO Q8H (every 8
hours): last dose [**2113-10-2**] pm.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Primary Diagnoses:
Acute on Chronic Diastolic and Systolic Congestive Heart
Failure
Secondary Diagnosis:
Urinary Tract Infection
Herpes zoster Left T7-8 dermatome
Coronary artery disease with 4 stents placed [**2111-8-1**] at [**Hospital1 2025**]
Hypertension
Diabetes mellitus type 2
CVA [**9-/2111**] (nonverbal at baseline)
Macular degeneration, legally blind
G-tube placement (all nutrition via G-tube per GI)
Hypothyroidism
Hyperlipidemia
Anemia
Depression
Discharge Condition:
Removes O2 and becomes SOB at times. Desats to low 80's,
returns to normal with O2 in place. Tolerating tube feeds well.
Episodic hyperglycemia treated with sliding scale regular
insulin.
Discharge Instructions:
Monitor for weight gain, edema, cough, congestion.
Followup Instructions:
To be seen by nursing home MD
ICD9 Codes: 5990, 2762, 4280, 412, 2449, 2724, 2859, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1320
} | Medical Text: Admission Date: [**2187-7-4**] Discharge Date: [**2187-7-13**]
Date of Birth: [**2107-4-14**] Sex: F
Service: MEDICINE
Allergies:
Prochlorperazine
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
chest pressure
Major Surgical or Invasive Procedure:
cardiac catheterization with placement of RCA bare metal stent
History of Present Illness:
Ms. [**Known lastname 10407**] is an 80yo woman with h/o HTN and dyslipidemia who
presents with chest pain. She was in her usual state of health
today and spent the day working around the house. She had
returned from picking up her sister from chemotherapy when she
walked into the house, feeling very hot and dizzy. She headed
for the bathroom but did not make it and had diarrhea while on
her way. She fell to her knees and her husband and neighbor came
to help her clean up. +Sweaty, +nauseated, though cannot say
when the nausea began. EMS was called; of note, she developed
substernal chest pressure while en route to the hospital. She is
not sure when the chest pressure went away.
In the ED, initial VS were: 95.3 54 125/59 18 98% RA. She was
noted to have inferior ST elevations and code STEMI was called.
Guaiac was noted to be negative. She was chest pain free. She
was given ASA 324mg, metoprolol 5mg IV x 3, plavix 600mg, and
started on IV heparin (after bolus) and IV eptifibatide gtt.
In the cath lab, she had 100% proximal lesion of her RCA.
Thrombectomy was done and she received bare metal stent to RCA.
Hemodynamics revealed RV EDP of [**12-9**] with wedge of 24. She
received 150ml of contrast. She was sent out of the cath lab on
integrillin gtt.
At the time of presentation to the CCU, she was oozing from her
groin site. She had no chest pressure but was complaining of
some nausea.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, cough, hemoptysis, black stools or red stools.
He 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.
Past Medical History:
CAD with single vessel disease in RCA per cath at [**Location (un) 511**]
[**Hospital1 **] [**6-/2172**]
HTN
Dyslipidemia
h/o partial colectomy for GI/GU fistula at [**Hospital1 2025**]
ALLERGIES: compazine--shaking
OUTPATIENT CARDIOLOGIST: none
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4469**] at [**Hospital3 **]--has not seen him in [**6-2**]
years but gets Rx through his office. Dr. [**Last Name (STitle) **] is her new
cardiologist. Dr. [**Last Name (STitle) 3315**] is her new PCP.
Social History:
Social history is significant for the absence of current tobacco
use: she smoked for one year at the age of 18. There is no
history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T no temp yet, BP 114/72, HR 93, RR 18, O2 96% on 4L
Gen: Elderly woman, lying calmly in bet but quite anxious about
having received a stent, tearful. Oriented. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of 6 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
Irreg irreg with normal rate and normal S1, S2. No S4, no S3. No
murmur.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi as heard anteriorly.
Abd: Soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: No c/c/e.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+; 2+ DP
Pertinent Results:
EKGs from [**7-4**] demonstrated:
18:50 AFib at 63, normal axis, QTc of 481, isolated Q wave in
III, STE in II, III, and aVF (III>II), inverted T waves in
V2-V6, ST depressions in I and aVL.
20:23 AFib at 79, normal axis, QTc of 453, atill with Q wave in
III and STE in III and aVF as well as I and aVL.
There was no prior EKG for comparison.
.
TELEMETRY demonstrated: AFib with rate in 90s. Pt initially had
bradycardia in the setting of her inferior STEMI. Pt has had
several conversion pauses (up to 5) when converting from A fib
to sinus rhythm and then would later convert back to A fib. Pt
converted back to sinus rhythm the morning of discharge.
.
CARDIAC CATH performed on [**2187-7-4**] demonstrated (prelim):
LAD: 30% proximal
LCx: 30% ramus
RCA: 100% proximal
.
HEMODYNAMICS [**2187-7-4**]:
RA 14
RV 50/2
PA 36/26 mean 30
Wedge 24
Ao 127/65
.
ECHOCARDIOGRAM [**2187-7-5**]:
The atria are moderately dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with basal
inferior/inferolateral and inferoseptal akinesis. The remaining
segments contract normally (LVEF = 45%). Right ventricular
chamber size and free wall motion are normal. The aortic arch is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The pulmonary artery systolic
pressure could not be determined. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w CAD. Mild aortic regurgitation.
.
[**2187-7-4**] 07:00PM BLOOD WBC-8.2 RBC-4.59 Hgb-13.1 Hct-40.1 MCV-87
MCH-28.6 MCHC-32.8 RDW-13.7 Plt Ct-450*
[**2187-7-4**] 07:00PM BLOOD Glucose-205* UreaN-28* Creat-1.3* Na-142
K-4.4 Cl-106 HCO3-21* AnGap-19
[**2187-7-4**] 07:00PM BLOOD PT-13.1 PTT-20.8* INR(PT)-1.1
.
[**2187-7-4**] 07:00PM BLOOD CK(CPK)-77
[**2187-7-4**] 10:25PM BLOOD CK(CPK)-908*
[**2187-7-5**] 05:08AM BLOOD CK(CPK)-1354*
[**2187-7-5**] 11:09AM BLOOD CK(CPK)-1103*
.
[**2187-7-4**] 07:00PM BLOOD cTropnT-0.02*
[**2187-7-4**] 10:25PM BLOOD CK-MB-59* MB Indx-6.5 cTropnT-3.69*
[**2187-7-5**] 05:08AM BLOOD CK-MB-121* MB Indx-8.9* cTropnT-6.59*
[**2187-7-5**] 11:09AM BLOOD CK-MB-93* MB Indx-8.4*
.
[**2187-7-5**] 09:50AM BLOOD %HbA1c-6.3*
.
[**2187-7-13**] 06:10AM BLOOD Glucose-97 UreaN-17 Creat-1.0 Na-141
K-4.5 Cl-106 HCO3-27 AnGap-13
[**2187-7-12**] 06:30AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.3
[**2187-7-13**] 06:10AM BLOOD WBC-7.6 RBC-4.31 Hgb-12.0 Hct-38.4 MCV-89
MCH-27.9 MCHC-31.2 RDW-14.2 Plt Ct-465*
[**2187-7-13**] 06:10AM BLOOD PT-17.2* PTT-64.2* INR(PT)-1.6*
[**2187-7-13**] 06:10AM BLOOD ALT-25 AST-26
Brief Hospital Course:
Ms. [**Known lastname 10407**] is an 80yo woman with h/o HTN and dyslipidemia
admitted with inferior STEMI and presumed new onset A fib.
.
# Inferior STEMI:
Patient is s/p BMS to RCA. Given that she has an RCA lesion and
RCA infarct with persistent ST elevations after her cath, she
was monitored for complications of bradyarrhythmias. She was on
integrillin for 18 hours and bolused with heparin at the time of
cath. She was maintained on a heparin drip for both her A fib
and a remaining clot in the distal branched of the RCA. She was
started on medical management with ASA 325mg (increased from
81mg), plavix 75mg, lisinopril 5mg, metoprolol 37.5mg PO BID,
and simvastatin of 80mg.
.
# Pump:
She has no known h/o heart failure and was not clinically in
heart failure during her hospital course. Her echo on [**2187-7-5**]
showed moderately dilated atria. There is mild symmetric left
ventricular hypertrophy and mild regional left ventricular
systolic dysfunction with basal inferior/inferolateral and
inferoseptal akinesis. Her LVEF is 45%. She has mild aortic and
mitral regurgitation. She was started on an increased beta
blocker dose (metoprolol 37.5mg [**Hospital1 **]) and ACE inhibitor
(lisinopril 5mg QD).
.
# Atrial fibrillation:
She was noted to be in atrial fibrillation, presumed to be new
onset AFib in setting of inferior STEMI. It is unclear how long
she has had A fib especially given that she has not been to a
physician [**Name Initial (PRE) **] 7 years. She had a number of conversion pauses,
each lasting for typically three seconds (but lasting up to six
seconds), followed by some number of beats of normal sinus
rhythm. Some of these episodes were symptomatic, resulting in
lightheadedness and presyncope. For her A fib, she was
originally on amiodarone [**Hospital1 **], then it was decreased to daily,
and then it was discontinued as we thought the amiodarone could
be worsening her pauses. She had fewer pauses after
discontinuing the amiodarone. The frequency of these episodes
decreased during her hospitalization and it was ultimately
decided that she did not need a pacemaker. For her A fib she was
started on a heparin drip and transitioned to coumadin. However,
we were originally considering a pacemaker for her pauses thus
coumadin was held and her INR was not therapeutic at the time of
discharge. She as placed on lovenox 65 [**Hospital1 **] the day of discharge
and will stay on lovenox for 2 days after her INR is therapeutic
(goal [**1-28**]). She is also on ASA 325mg.
.
# HTN:
Mrs.[**Known lastname 10408**] metoprolol dosage was increased from 25mg [**Hospital1 **] to
37.5 mg [**Hospital1 **] because of episodes of HTN. She was also started on
an ACE inhibitor, Lisinopril at 5mg QD.
.
# Nausea:
The patient had repeated nausea early on in her hospitalization
which is most likely vagally mediated in the setting of an
inferior MI. Her episodes of nausea did not correlate with any
ECG changes.
.
# Mood
The patient was very tearful throughout her hospital visit. I
spoke with her about how common depression is after an MI and
what she should look out for. She talked with social work while
in the hospital, and I will follow her as an outpatient and look
for signs of depression.
Medications on Admission:
(fills Rx at [**Last Name (un) 10409**] pharmacy in [**Location (un) 1411**]: ([**Telephone/Fax (1) 10410**]:
Metoprolol 25mg [**Hospital1 **]
ASA 81mg daily
Zocor 40mg QHS
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Outpatient Lab Work
Please have the following blood tests done 3 days ([**7-16**]) after
leaving the hospital: PT, INR, BUN, Creatinine, potassium.
Please forward all results to Dr. [**Last Name (STitle) 3315**]
4. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
5. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Lovenox 65 mg Subcutaneous twice a day: Please stop after INR
therapeutic (goal [**1-28**]) for 2 days.
8. Warfarin 2 mg Tablet Sig: Three (3) mg PO at bedtime: Goal
INR [**1-28**], please adjust dose per PCP.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
ST elevation myocardial infarction s/p bare metal stent to Right
Coronary Artery
New onset Atrial Fibrillation
.
Secondary:
Hypertension
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with a heart attack and you have been treated
with stenting of the affected artery. You were noted to develop
atrial fibrillation, a condition where a chamber of your heart
does not contract in a coordinated fashion. You had a number of
symptomatic pauses, where your heart stopped beating for up to
six seconds, you became lightheaded. However, since the pauses
decreased after we stopped one of your new medications, you do
not need a pacemaker at this time. You were started on a blood
thinner for your atrial fibrillation. You will need to follow
up with your PCP and cardiologist.
.
It is very important that you continue taking Aspirin and Plavix
every day until you are otherwise instructed by Dr.
[**Last Name (STitle) 10411**]/[**Doctor Last Name 171**].
.
You have been started on some new medications:
Plavix (clopidogrel) 75mg PO daily
Coumadin (warfarin) 3mg daily - You will need to have your
warfarin level checked and dose adjusted by your PCP as needed
Lovenox 60 mg twice daily - You will take this until your
warfarin level is stable.
Lisinopril 5mg daily
The following medication have been increased:
Aspirin increased from 81mg to 325mg PO daily
Zocor increased from 40mg to 80 mg daily
Metoprolol increased 25mg twice daily to 37.5mg twice daily
Please take all medications as prescribed.
.
If you develop any recurrent chest pain, shortness of breath,
recurrent nausea/vomiting or any other general worsening of
condition, please call your PCP or come directly to the ED.
Followup Instructions:
[**Hospital3 **]: You have a follow up appointment at the
[**Hospital3 **] to monitor your Coumadin levels, at [**Hospital1 **] [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] on Monday, [**7-16**] at 2pm. Please
go to [**Apartment Address(1) 10412**]. Please call [**Telephone/Fax (1) 10413**] with any questions.
Please forward INR results to Dr. [**Last Name (STitle) 3315**].
.
Pt will need to have BUN, Cr, and potassium checked on Monday.
Please forward results to Dr. [**Last Name (STitle) 3315**].
.
PCP: [**Name10 (NameIs) **] have a follow up with Dr. [**Last Name (STitle) 3315**] on [**8-1**] at
10:00 am on the [**Hospital Ward Name 516**] at [**Hospital1 18**].
.
Cardiac Electrophysiology: You have a follow up appointment with
Dr. [**Last Name (STitle) **] on Tuesday, [**8-14**] at 1pm.
Completed by:[**2187-7-13**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1321
} | Medical Text: Admission Date: [**2100-8-31**] Discharge Date: [**2100-9-3**]
Date of Birth: [**2080-8-6**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Transferred to MICU for altered mental status
Major Surgical or Invasive Procedure:
Intracranial Pressure Monitor placement
Central Venous Line placement
History of Present Illness:
20 y/o F w/no past med hx who originally presented to [**Hospital 39437**] Hospital on [**2100-8-29**] complaining of one week of nausea,
headache, ear pain, neck pain, and suprapubic pain. Reportedly
the day before she had slept all day and c/o a generalized
headache. She went to the ED, where she it was felt she had a
UTI (WBCs/bacturia) and otitis media ("bloody ear"). She was
treated with amoxicillin. Her symptoms became progressively
worse, and she had fevers and chills. She returned to the
emergency room the next day c/o suprapubic discomfort, fever,
n/v, headache, and back pain. She had CVA tenderness and was
febrile to 101.1. At that time she had no meningismus and a
normal mental status, nonfocal neuro exam. Her WBC at that time
was 20, which was elevated from 9 the day prior. She was
admitted with a diagnosis of pyelo and treated with ceftriaxone
and/or ciprofloxacin (unclr from notes which she received). She
was given lorazepam 1 mg for anxiety.
Approximately 8 am on [**2100-8-31**], she was found by her nurse to be
unresponsive. She was incontinent of stool and urine. Her eyes
were open and deviated to the left. She was responsive to pain.
Hemodynamically, she was tachycardic in the 140s (sinus) and
febrile to 103. BP 110/70. Exam was otherwise unremarkable.
They felt she was postictal and she was given Ativan and loaded
with dilantin (1000 mg). A noncontrast CT scan was negative.
She was given vancomycin, continued on ceftriaxone (2 g iv q12h)
and acyclovir. An LP revealed an opening pressure of 380 (?mm).
WBC 988, RBC 45. Differential on WBC was 58 PMNs, 25 lymphs,
17 monos. Gram stain negative for bacteria. Glucose 80,
protein 167. She also received Dexamethasone 10 mg IV given the
meningitis. She continued to have deviation of her eyes as well
as lip smacking, and was transferred to [**Hospital1 18**] on the
Neurology/SICU service on [**2100-8-31**] for further management.
She was evaluated by Neurology on arrival who felt she had
encephalomeningitis and recommended an MRI. She was intubated
for her mental status. At that time, she was on dilantin,
propofol, and ativan gtt. She continued to seize (w/occasional
decerebrate posturing, downward eye deviation) and was loaded
with depakote. The MRI demonstrated enhancement of medial
temporal lobes, caudate, and thalamus bilaterally and
symmetrically. MRV was negative for thrombosis. She had a CT
scan of her sinuses (given hx of otitis) which revealed mucosal
thickening but no evidence of sinusitis, as well as a 5 mm dense
soft tissue mass which appeared to be adherent to her left
tympanic membrane, of unclear significance. She was continued
on the aforementioned antibiotics and ampicillin was added. ENT
evaluated her and felt that it was either a foreign body vs.
osteoma, and that it was not related to her meningoencephalitis.
She was then transferred to the Medical ICU.
Past Medical History:
None
Social History:
Lives with her parents in [**Location (un) 745**], [**Location (un) 3844**]. Occasionally
uses her boyfriend's klonepin, also + ecstasy. Tobacco unknown,
etoh unknown. Works as a cashier at an auto dealer.
Family History:
Noncontributory
Physical Exam:
T: 100.8 BP: 119/58 P: 105
Vent: AC 500x16 PEEP 5 FiO2 40%, SaO2 99%
Gen: intubated, sedated
HEENT: EEG leads in place, tongue protruding, pupils deviated
inferiorly, sclerae anicteric, MMM
Neck: no lymphadenopathy, or thyromegaly
Chest: lungs clear to auscultation bilaterally
CV: tachycardic, regular, no m/r/g
Abd: soft, nontender, nondistended. hypoactive bowel sounds.
no hepatosplenomegaly.
Ext: warm, no edema.
Skin: diaphoretic, no rash
Pertinent Results:
[**2100-8-31**] 06:37PM BLOOD WBC-25.8* RBC-4.13* Hgb-13.1 Hct-38.1
MCV-92 MCH-31.8 MCHC-34.5 RDW-11.9 Plt Ct-139*
[**2100-9-1**] 03:38AM BLOOD WBC-22.8* RBC-3.70* Hgb-11.6* Hct-33.5*
MCV-91 MCH-31.4 MCHC-34.7 RDW-12.0 Plt Ct-147*
[**2100-8-31**] 06:37PM BLOOD Neuts-88* Bands-4 Lymphs-1* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2100-8-31**] 06:37PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-2+ Polychr-OCCASIONAL
[**2100-9-1**] 03:38AM BLOOD Plt Ct-147*
[**2100-8-31**] 06:37PM BLOOD PT-12.8 PTT-26.3 INR(PT)-1.1
[**2100-8-31**] 06:37PM BLOOD Fibrino-527* D-Dimer-695*
[**2100-9-1**] 04:24PM BLOOD Glucose-92 UreaN-5* Creat-0.5 Na-145
K-3.4 Cl-112* HCO3-25 AnGap-11
[**2100-8-31**] 06:37PM BLOOD ALT-28 AST-30 LD(LDH)-194 AlkPhos-69
TotBili-0.2
[**2100-9-1**] 04:24PM BLOOD Calcium-7.9* Phos-1.4* Mg-1.8
[**2100-9-1**] 04:24PM BLOOD Phenyto-8.7* Valproa-71
[**2100-9-1**] 04:38PM BLOOD Type-ART pO2-196* pCO2-33* pH-7.48*
calHCO3-25 Base XS-2 Intubat-INTUBATED
[**2100-9-1**] 04:38PM BLOOD Lactate-2.0
MRI: MR [**First Name (Titles) **] [**Last Name (Titles) **]: There is abnormal, elevated T2/FLAIR
signal involving the medial temporal lobes, and continuing into
the tails and thr bodies of the caudate nuclei, and portions of
the thalamus bilaterally and symmetrically. There is
corresponding abnormal signal on the diffusion- weighted
sequences in these regions. An accompanying ADC map is not
available to distinguish true slowed diffusion from T2 shine-
through effect. There is no susceptibility artifact or abnormal
bright T1 signal to suggest hemorrhage. The brain parenchyma
demonstrates otherwise unremarkable signal intensity. The
ventricles, cisterns, and sulci are unremarkable. No definite
enhancement is noted in the areas of signal abnormality on the
post gadolinium-enhanced sequences.
MR [**First Name (Titles) **] [**Last Name (Titles) **]: The venous sinuses demonstrate no evidence
of thrombosis. There is mild asymmetry of the transverse and the
sigmoid sinuses which is likely developmental. Expected areas of
artifact on the 3D images without corresponding evidence of flow
abnormality/thrombus on the axial source data.
IMPRESSION:
1) Constellation of [**Last Name (Titles) 4493**] concerning for limbic encephalitis
involving the medial temporal lobes, basal ganglia, caudate, and
portions of the thalamus. Possible etiologies include viral,
Herpes, and Listeria encephalitis; less likely a paraneoplastic
syndrome. Correlate with clinical symptoms and lumbar puncture
results.
2) No evidence of venous sinus thrombosis.
CT: [**Last Name (Titles) **]: There is mild mucosal thickening of the maxillary,
ethmoid, and sphenoid sinuses. There are no air-fluid levels or
area of osseous destruction. There is more polypoid focal
thickening in the right maxillary sinus likely representing a
retention cyst. The mastoid processes and air cells are clear.
There is a small amount of cerumen in the right external
auditory canal but no evidence of an infectious process.
Centered on the left tympanic membrane is a focal, circular,
hyperdense soft tissue mass. It is difficult to definitively
localize this soft tissue mass; however, it appears adherent to
the tympanic membrane within the middle ear rather than within
the external auditory canal. There is a trace amount of
fluid/soft tissue adjacent to it. There is no associated osseous
destruction. The dentition and remaining osseous structures are
unremarkable. The orbits appear normal. The visualized brain
parenchyma is unremarkable.
IMPRESSION:
1) No evidence of mastoiditis.
2) Sinus polypoid and mucosal thickening without evidence to
suggest acute sinusitis.
3) 5mm focal, dense soft tissue mass, which is difficult to
definitively localize but appears adherent to the tympanic
membrane within the middle ear. This finding is of unclear
etiology and significance, and does not appear likely to
represent the source of the patient's clinically suspected
encephalomeningitis. There is no associated osseous destruction.
After treated for the acute process, an ENT consult may be
helpful.
CXR: no acute cardiopulmonary process. ETT at thoracic inlet.
Brief Hospital Course:
The pt was admitted to MICU on [**2100-9-1**] from the SICU service.
The following summarizes her MICU course (for SICU course, see
HPI). She was admitted on an Ativan gtt, as well as depakote
and dilantin. She continued to seize through this regimen,
despite reloading with both the dilantin and depakote. She was
then placed on phenobarbitol (loading dose and daily dosing).
She was continued on the same antibiotic regimen (ceftriaxone,
vancomycin, ampicillin, acyclovir). ID felt that the most
likely diagnosis was EEE given the clinical scenario and MRI
[**Date Range 4493**]. Unfortunately, the only treatment for this is
supportive care. She continued to spike temperatures. On
[**2100-9-2**], she began to have worsening hypernatremia. She became
progressively hypotensive requiring pressors, including
norepinephrine and phenylephrine. Her head CT revealed cerebral
edema. She was given mannitol and an intracranial pressure
monitor was placed. Her sodium continued to rise, to >180. A
family meeting was held and the goals of care were changed to
comfort measures only, given the poor prognosis of her
encephalitis. She was extubated, placed on a morphine drip, and
died peacefully with her family by her side.
Medications on Admission:
Medications on transfer:
Ativan gtt at 4 mg/hr
Phenytoin 100 q8h
Depakote 250 q8h
Ceftriaxone 2 g IV q12h
Ampicillin 2 g IV q6h
Vancomycin 1 g IV bid
Acyclovir 500 IV q8h
Protonix
SQ heparin
Insulin SS
Cipro ear gtt
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Encephalitis (likely Eastern Equine)
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
ICD9 Codes: 2760 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1322
} | Medical Text: Admission Date: [**2130-7-8**] Discharge Date: [**2130-7-15**]
Date of Birth: [**2072-8-23**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
C6 corpectomy and C5-7 fusion
History of Present Illness:
57 yo female with fall from bike. + LOC 5 min. Wearing helmet.
c/o back pain, bilateral hand numbness/tingling.
Past Medical History:
- HTN
- Depression
Pertinent Results:
IMAGING:
CT Head: no fracture or hemorrhage
CT C-Spine: Anterior splaying of the intervertebral disc space
at C6-7 with minimal anterolisthesis of C6 on C7 and apex
anterior angulation of the spine at this level are concerning
for ligamentous injury. Prominent posterior osteophyte at C5-6
causes severe narrowing of the canal at this level with
indentation of the cord. No definite paraspinal hematoma seen.
CT Chest: Burst-type compression fracture of the T7 vertebra,
with 2 mm of retropulsion. Left second rib nondisplaced
fracture.
CT Torso: No evidence of traumatic injury seen in the abdomen
and pelvis. Bibasilar posterior consolidation likely atelectasis
and/or aspiration.
MRI C-Spine: Cord hyperintensity at C5 and C6 with an associated
disc osteophyte complex and a large central disc protrusion at
C5-C6 with cord compression. Whether this represents acute
injury to the cord or chronic myelomalacia from prior
preexisting DJD or acute superimposed on chronic changes is
unclear.
Brief Hospital Course:
She was admitted to the trauma service. Orthopedic Spine surgery
was consulted for her spine fracture; she was taken to the
operating room on [**2130-7-10**] for:
1. C6 corpectomy through an anterior approach.
2. C5-C7 anterior arthrodesis.
3. Application of structural allograft C5-C7.
4. Application of anterior cervical plate C5-C7.
5. Application of local autograft.
6. Application and removal of [**Location (un) 976**]-[**Doctor Last Name 3012**] tongs with traction.
Postoperatively she was fitted for a TLSO brace which is to be
worn when she is not lying flat and supine in bed. The cervical
collar is to be worn at all times.
She was seen by Orthopedics for her radius fracture and placed
in an ulna gutter splint. She will follow up with Dr. [**Last Name (STitle) **]
[**Telephone/Fax (1) 1228**] in a week after discharge.
Ophthalmology was consulted for complaints of diplopia in her
left eye; it was recommended that she have an MR of her head to
rule out any intracranial processes, which was negative.
She complained of abdominal cramping without nausea or vomiting
on HD #7; an NG tube was placed with little to no output. She
was placed on IVF's and made NPO. She had not moved her bowels
and it was suspected that her abdominal symptoms was from
constipation. she was ordered for suppository and Fleet's enema.
After having a bowel movement, the tube was removed and her
diet was advanced.
She had sutures placed in her face at the OSH, which were
removed during this admission. She will follow up as needed
with the plastic surgery cosmetic clinic.
Medications on Admission:
fluoxetine, amitryptiline, statin
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
4. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5,000 units
Injection TID (3 times a day).
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 3 hours as
needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
s/p Fall
C6 fracture
T7 compression fracture
Left ulnar fracture
Left second rb fracture
Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.
Discharge Instructions:
The TLSO brace to be worn at all times [**Last Name (un) 4050**] out of bed; the
cervical collar needs to be worn when in bed.
Followup Instructions:
Follow up next week in [**Hospital **] clinic, call [**Telephone/Fax (1) 253**]
for an appointment.
Follow up next week with Dr. [**Last Name (STitle) **], Orthopedic Hand Surgery,
call [**Telephone/Fax (1) 1228**] for an appointment.
Follow up in 2 weeks with Dr. [**Last Name (STitle) 1352**] Orthopedic Spine Surgery,
call [**Telephone/Fax (1) 1228**] for an appopintment.
ICD9 Codes: 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1323
} | Medical Text: Admission Date: [**2182-5-1**] Discharge Date: [**2182-5-8**]
Date of Birth: [**2125-4-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Codeine / Toprol Xl / Contraceptives, Oral Classifier
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2182-5-2**]
1. Aortic valve replacement with a 23-mm On-X mechanical
valve.
2. Full biatrial Maze procedure using a combination of the
[**Company 1543**] Gemini irrigated bipolar RF device as well as
the Cryocath.
History of Present Illness:
This 56 year old woman with a known bicuspid aortic valve and
aortic insufficiency is followed by echocardiograms. She
developed atrial fibrillation in the fall of [**2179**] and started on
Coumadin. During recent retinal surgery she developedpulmonary
edema, and was admitted and treated with diuretics. A
follow-up echocardiogram in [**2182-2-18**] revealed a significant
drop in her ejection fraction from 55% to 25% with at least
moderate aortic insufficiency. She is now admitted for cardiac
catheterization to assess for coronary disease
and Heparin in preparation for valve surgery.
Past Medical History:
Hypertension
Hyperlipidemia
Atrial fibrillation
Congestive heart failure
Cardiomyopathy
[**Doctor Last Name 933**] disease -s/p Radioactive iodine [**2172**]
hypothyroidism secondary to ablation therapy
Obesity
Sick sinus syndrome
s/p permanent pacemaker ([**First Name8 (NamePattern2) **] [**Male First Name (un) 923**])- [**2167**]
Osteopenia
Aortic valve insufficiency
Depression
Retinal detachment left eye
non insulin dependent diabetes mellitus
Social History:
Lives with: Daughter (will assist post op)
Occupation: Food services at B&W hospital
Tobacco: [**12-22**] ppd x 6 years. Quit [**2160-12-21**]
ETOH: 1 drink every three months
Family History:
non-contributory
Physical Exam:
admission:
Pulse: 89 Resp: 16 O2 sat: 98
B/P Right: 122/85 Left: 135/55
Height: 5'5" Weight: 88 kg
General: No acute distress
Skin: Dry [X] intact [X] on bedrest unable to assess back
HEENT: EOMI [X] right eye with contact unable to assess respon
se
to light, left eye with retinal detachment - no pupil
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X] anterior
Heart: RRR [] Irregular [X] Murmur [**2-23**] diastolic
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X] no palpable masses
Extremities: Warm [X], well-perfused [X] Edema none
Varicosities:
None [X]
Neuro: Grossly intact
Pulses:
Femoral Right: cath site sm hematoma Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Pertinent Results:
Intra-op Echo [**2182-5-2**]
PRE BYPASS The left atrium is moderately dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left
atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No 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. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. There is severe global left
ventricular hypokinesis (LVEF = 25-30%). The righjt ventricle
displays severe global free wall hypokinesis. The descending
thoracic aorta is mildly dilated. There are simple atheroma in
the descending thoracic aorta. The aortic valve is functionally
bicuspid. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (valve area 1.5 cm2).
Moderate (2+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen. The
tricuspid regurgitation jet is eccentric and may be
underestimated. Dr. [**Last Name (STitle) 914**] was notified in person of the
results in the operating room at the time of the study.
POST BYPASS The patient is atrially paced and is receiving
epinephrine by infusion. Right ventricular free wall systolic
function is improved - now with mild to moderate global
hypokinesis. The left ventricle also displays improved global
function - now also with mild to moderate global hypokinesis an
an EF of about 40%. There is a bioprosthesis in the aortic
position. It appears well seated. There are only limited views
of the leaflets and they do appear to display normal mobility.
There is trace valvular aortic regurgitation which is normal for
this prosthesis. The peak gradient across the aortic valve is
31mm Hg with a mean gradient of 133 mmHg at a cardiac output of
7 liters/minute. The effective orifice area of the valve is
approximately 1.9 cm2. There is trace mitral regurgitation. The
tricuspid regurgitation appears improved - now likeky mild to
moderate.
[**2182-5-8**] 04:25AM BLOOD WBC-11.6* RBC-3.15* Hgb-9.0* Hct-26.8*
MCV-85 MCH-28.7 MCHC-33.7 RDW-14.5 Plt Ct-353#
[**2182-5-1**] 10:55AM BLOOD WBC-5.8 RBC-3.81* Hgb-10.7* Hct-32.6*
MCV-86 MCH-28.0 MCHC-32.7 RDW-14.1 Plt Ct-288
[**2182-5-8**] 04:25AM BLOOD PT-27.5* PTT-49.0* INR(PT)-2.7*
[**2182-5-7**] 04:40AM BLOOD PT-25.5* PTT-93.6* INR(PT)-2.5*
[**2182-5-6**] 06:10PM BLOOD PT-23.5* PTT-74.7* INR(PT)-2.2*
[**2182-5-6**] 06:05AM BLOOD PT-19.6* INR(PT)-1.8*
[**2182-5-5**] 04:30AM BLOOD PT-13.5* INR(PT)-1.2*
[**2182-5-8**] 04:25AM BLOOD Glucose-90 UreaN-10 Creat-0.7 Na-134
K-4.3 Cl-98 HCO3-28 AnGap-12
[**Known lastname **],[**Known firstname **] [**Medical Record Number 86797**] F 57 [**2125-4-18**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2182-5-5**] 4:01
AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2182-5-5**] 4:01 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 86798**]
Reason: hypotension,low u/o eval fld status
Final Report
PORTABLE CHEST, [**2182-5-5**], 05:04.
INDICATION: Hypotension.
COMPARISON: [**2182-5-3**].
FINDINGS:
Again seen is multi-chamber cardiomegaly, unchanged from prior.
Left
retrocardiac opacity stable in appearance. No new areas of
consolidation. No
evidence for progressive distension of the pulmonary
vasculature. Pacemaker
with dual chamber leads, stable in appearance.
IMPRESSION: No significant interval change versus prior.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4347**]
Approved: SUN [**2182-5-5**] 5:09 PM
Brief Hospital Course:
The patient was admitted to the hospital after catheterization
and started on Heparin. The patient noted some vaginal bleeding
following administration of Heparin. She is 4 years
post-menopausal. An Ob/Gyn consult was called. Bleeding
ceased, and after evaluation, no further intervention was
indicated.
She was brought to the Operating Room on [**2182-5-2**] where she
underwent aortic valve replacement (23mm On-X valve), MAZE and
left atrial appendage ligation. Overall the patient tolerated
the procedure well and post-operatively was transferred to the
CVICU in stable condition for recovery and invasive monitoring
on Epinephrine and Propofol infusions. Vancomycin &
Ciprofloxacin was used for surgical antibiotic prophylaxis,
given the patient's pre-operative stay. Of note, the patient's
left antecubital IV infiltrated and she extravasated
approximately 300cc of cell-[**Doctor Last Name 10105**] blood into the right upper
extremity. Hand surgery was consulted. She did not have
compartment syndrome, and no further intervention was warranted.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable on no inotropic or vasopressor
support. She remained in atrial fibrillation, and an EP consult
was obtained. Amiodarone was continued. Beta blocker was
initiated and the patient was gently diuresed toward her
preoperative weight. The patient was transferred to the
telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the Physical Therapy
Service for assistance with strength and mobility. Coumadin was
begun for her mechanical aortic valve.
Atrial fibrillation (ventricular rate in the 80s) persisted and
the patient underwent a TEE in preparation for cardioversion.
There was a question of atrial thrombus and cardioversion was
postponed. Amiodarone was discontinued per EP recommendations
with plans for TEE and possible cardioversion in 1 month.
Verapamil was not restarted for rate control due to a systolic
blood pressure in the 90's. She was loaded with Digoxin for
rate control and Diltiazem was begun for rate control. She was
continued with Coumadin for anticoagulation for an INR goal of
[**1-23**]. She will return for Electrophysiology follwo up and
cardioversion at a later date.
By the time of discharge on POD 6 she was ambulating, the wound
was healing and pain was controlled with oral analgesics. The
patient was discharged to [**Hospital3 2558**] in good condition with
appropriate follow up instructions.
Medications on Admission:
ALBUTEROL SULFATE - (Prescribed by Other Provider) - 90 mcg HFA
Aerosol Inhaler - 2 puffs inh prn
ATROPINE - (Prescribed by Other Provider) - 1 % Drops - 1 gtt
left twice a day
BRIMONIDINE - (Prescribed by Other Provider) - 0.15 % Drops - 1
gtt in the left eye twice a day
DIGOXIN - (Prescribed by Other Provider) - 125 mcg Tablet - 1
Tablet(s) by mouth once a day
FUROSEMIDE - (Prescribed by Other Provider) - 80 mg Tablet - 1
Tablet(s) by mouth twice a day
LEVOTHYROXINE [SYNTHROID] - (Prescribed by Other Provider) -
150
mcg Tablet - 1 Tablet(s) by mouth once a day
LISINOPRIL - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth once a day
MECLIZINE - (Prescribed by Other Provider) - 25 mg Tablet - 0.5
(One half) Tablet(s) by mouth once a day as needed for prn
PREDNISOLONE ACETATE - (Prescribed by Other Provider) - 1 %
Drops, Suspension - 1 gtt in the left eye once a day
SERTRALINE - (Prescribed by Other Provider) - 25 mg Tablet - 1
Tablet(s) by mouth once a day
SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
TOLTERODINE [DETROL LA] - (Prescribed by Other Provider) - 4 mg
Capsule, Sust. Release 24 hr - 1 Capsule(s) by mouth once a day
VERAPAMIL - (Prescribed by Other Provider) - 240 mg Cap,24 hr
Sust Release Pellets - 1 Cap(s) by mouth once a day
WARFARIN - (Prescribed by Other Provider) - 2.5 mg Tablet - 1
Tablet(s) by mouth once a day LD prior to cath was [**2182-4-27**]
WARFARIN - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth once a day total dose is 12.5mg daily. Last
dose prior to cath was [**2182-4-27**]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
4. Atropine 1 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times
a day).
5. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Sertraline 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic DAILY (Daily).
11. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**3-26**]
hours as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
14. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
16. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO TID (3 times a day).
17. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
18. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime.
19. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) ml Inhalation Q6H (every 6 hours) as
needed for dyspnea.
20. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
21. Coumadin 10 mg Tablet Sig: One (1) Tablet PO at bedtime:
Titrate dose for INR of [**1-22**].5.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 86**] Center for Rehab & Sub-Acute Care - [**Location (un) 2312**]
Discharge Diagnosis:
aortic stenosis
aortic insufficiency
chronic atrial fibrillation
s/p aortic valve replacement, MAZE [**2182-5-2**]
Hypertension
Hyperlipidemia
h/o Congestive heart failure
Cardiomyopathy
[**Doctor Last Name 933**] disease- s/p Radioactive iodine [**2172**]
hypothyroidism secondary to ablative therapy
Obesity
Sick sinus syndrome
s/p permanent pacemaker (St. [**Male First Name (un) 923**]) [**2167**]
Osteopenia
Depression
Retinal detachment left eye
noninsulin dependent diabetes
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Surgeon: Dr. [**Last Name (STitle) 914**] on [**2182-6-11**] at 1pm ([**Telephone/Fax (1) 170**])
Please call to schedule appointments with:
HVA Device Clinic, Dr. [**First Name (STitle) **] on [**2182-5-15**] at 10:50am
([**Telephone/Fax (1) 86799**])
Primary Care: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 3530**]) in [**12-22**] weeks
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6512**] ([**Telephone/Fax (1) 2258**]) in [**12-22**] 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:[**2182-5-8**]
ICD9 Codes: 5849, 4254, 4241, 4280, 4019, 2724, 4589, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1324
} | Medical Text: Admission Date: [**2144-5-26**] Discharge Date: [**2144-6-5**]
Date of Birth: [**2144-5-26**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: This preterm infant was admitted
to the NICU for management of prematurity. This infant was
born at 34 and 5/7 weeks to a 33-year-old G2 para 0 B
positive mother. Remainder of prenatal labs were not
available at the time of admission. Patient reportedly has
had an unremarkable antepartum history. She was admitted in
labor after spontaneous rupture of membranes 3 hours prior to
delivery. Received 1 dose of Penicillin 1 hour prior to
delivery. No evidence of maternal fever. Infant was delivered
via normal spontaneous vaginal delivery with Apgars of 8 and
8 at 2:16 a.m. in the morning.
PHYSICAL EXAMINATION: At the time of admission was
remarkable for a pink infant with minimal respiratory signs
and head circumference of 29 cm 10th percent, length 43.5 cm
25th percentile and weight of 1820 grams 25th percentile.
Vital signs at the time of temp 98, heart rate 160,
respiratory rate 60, BP 72/33 with a mean of 45. The
remainder of the physical examination showed no rash. HEENT
soft anterior fontanel, marked molding, normal feces, intact
[**Last Name (un) **]. Respiratory mild retractions, clear breath sounds.
Cardiovascularly no murmur, present femoral pulses. Abdomen
flat, soft, nontender without hepatosplenomegaly. Extremity
exam stable hips. GU normal female external genitalia. Neuro,
normal tone and activity with normal perfusion.
This preterm infant with sepsis risk factors of prematurity,
pre prom, partially attenuated by incomplete antepartum
antibiotic prophylaxis. She initially had a CBC and blood
culture performed on admission and no further evaluation or
treatment was deemed necessary unless the CBC was abnormal or
there was evidence of a positive blood culture or clinical
sign of infection.
HOSPITAL COURSE: Respiratory, this patient has been in room
air since birth and shows no signs of spells and is stable in
room air.
Cardiovascular, the patient has been stable with stable blood
pressures and heart rate. No evidence of a murmur has been
detected.
Fluids, electrolytes and nutrition, infant was initially
started on gavage feeds, then advanced to full po feeds of
breast milk 24 now with a minimum of 130 cc per kg per day. Here
electrolytes on [**5-27**] were Na 145 K 4.6 Cl 112 CO2 21.
Birth weight was 1828 grams. Discharge weight is now 1845
grams.
GI, patient was noted with hyperbilirubinemia with a max
bilirubin of 10.6/0.3 for which she was under phototherapy
x2, rebound bilirubin was 7.5/0.2. Hyperbilirubinemia now
resolved.
Hematology, her hematocrit on admission was 51.4 with a platelet
count of 301.
ID, baby [**Name (NI) **] is status post a 48 hour rule out with Amp
and Gent with all blood cultures negative to date.
Neurology, no head ultrasound indicated for this patient.
Sensory, audiology hearing screen was performed with
automated auditory brain stem responses. Patient passed her
hearing exam on [**2144-6-2**]. Ophthalmology, patient was not
indicated for this. Patient was delivered at 34 and 5/7 weeks
and had no oxygen requirement. Received an ophthalmological
exam in the unit.
Psycho/social, the [**Hospital1 18**] social work is involved with this
family. The contact social worker can be reached at [**Telephone/Fax (1) **].
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 7035**] in [**Hospital1 8**], Ma ([**Telephone/Fax (1) 67916**]. Appointment is scheduled for [**2144-6-8**] at 3 pm.
VNA: VNA will visit over the weekend (1-2 days after discharge).
CARE AND RECOMMENDATIONS: Feeding at discharge, the patient
is to continue on her breast milk 24 alternating with breast
feeding. Mom has been informed that the patient is to continue
with equal feeds of breast mild 24 made with neosure powder via
bottle and breast feeding to maintain adequate weight gain.
Medications, the patient will continue on her ferrous sulfate
and multivitamin.
She passed her car seat exam on [**2144-6-4**]. State newborn
screen has been sent [**2144-5-29**].
Immunizations:
she received her first hepatitis B vaccine on [**2144-5-26**].
Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following 3
criteria; 1) born at less then 32 weeks. 2) born between 32 and
35 weeks with 2 of the following, daycare during RSV season, a
smoker in the household, neuromuscular disease, airway
abnormalities or school age siblings or three, with chronic lung
disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age (and for the first 24 months of the child's life)
immunization against influenza is recommended for household
contacts and out of home caregivers.
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Sepsis evaluation.
3. Hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) 62855**]
MEDQUIST36
D: [**2144-6-4**] 11:22:25
T: [**2144-6-4**] 12:02:16
Job#: [**Job Number 67917**]
ICD9 Codes: 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1325
} | Medical Text: Admission Date: [**2109-8-15**] Discharge Date: [**2109-9-17**]
Service: [**Doctor First Name 147**]
Allergies:
Sulfa (Sulfonamides) / Sulfamethoxazole
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
occult gastrointestinal bleeding and duodenal adenoma
Major Surgical or Invasive Procedure:
[**2109-8-15**] Pylorus preserving pancreaticoduodenectomy and open
cholecystectomy
[**2109-8-16**] 1. Reopening of recent laparotomy.
2. Evacuation of intraperitoneal blood and hematoma.
3. Reappraisal of hepaticojejunostomy with afferent external
biliary drainage catheter placement.
4. Combined feeding jejunostomy and draining gastrostomy tube
placement.
History of Present Illness:
Mrs. [**Known lastname 58620**] is an 85 year old woman with a history of chronic
blood loss anemia who endoscopically has been found to have a
circumferential duodenal adenoma that is friable and bleeding.
She is also on coumadin for atrial fibrillation.
Past Medical History:
Her surgical history is significant for an appendectomy,
tonsillitis, a bladder operation, and a uterine cancer in the
past. Her medical history is significant for arthritis, anemia,
atrial fibrillation, and subacute bacterial endocarditis many
many years ago. She has had no sequelae to that long-term. She
also has congestive heart failure.
Social History:
1 alcoholic drink per day, she stopped smoking in [**2092**].
Physical Exam:
On discharge patient is afebrile with stable vital signs. Her
abdomen is soft, nontender and nondistended. Her surgical
incision is healing well with pink granulation tissue. The small
incisions where 2 [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] drains had been placed are
closed and healing well. She has a T-tube which is capped and a
j-feeding tube which is in place. Her heart remains in sinus
rythym. Her lungs are clear except for crackles that improve
with cough bilaterally.
Brief Hospital Course:
1. GI- Patient went to the operating room for a whipple
procedure on [**2109-8-15**]. During the first 24 hours
postoperatively, she had clinical indications of slow, sustained
bleeding in the abdomen necessatated transfusion. She was taken
back to the operating room for revision and removal of blood
clots on [**8-16**]. She was transferred to the intensive care
unit postoperatively and remained intubated. 2 jp drains were
placed near the anastomoses, a drain was placed in the common
hepatic duct across the anastomosis and a combined MIC draining
gastrostomy and feeding jejunostomy tube were also placed.
2. Cardiovascular- rapid atrial fibrillation: treated with IV
lopressor and diltiazem drip intially and eventally
electrocardioverted late in her hospital course. Patient was
also initially on digoxin early in her hospital course, but
showed signs of digoxin toxicity per ECG and was discontined
soon after being transferred to the floor. Patient was started
back on coumadin the last few days of hospitalization and was
not therapeutic the day of discharge.
2. Pulmonary- While the intensive care unit, patient was
intubated and treated with gentamycyin and zosyn for
pseudomaonas found in her sputum. Patient was difficult to wean
of the ventalator and a pleural effusion was drained
percutaneously with ultrasound guidance. She was successfully
extubated on post operative day 16. Patient also had an episode
of shortness of breath early in the morning of the last day of
hospitalization. The symptoms responded to diuresis with lasix
and patient was started back on her home dose of lasix.
3. endocrine- Patient was covered on a insulin sliding scale
throughout her hospital course. While in the intensive care
unit, one of the jp drains had an amylase of over 3000.
Approximately 2 weeks later, the output decreased and amylase
was retested and was low.
4. heme- transfusion of 1 unit while in intensive care unit for
a hct of 27, in addition to the transfusion between the two
operations.
5. nutrition- Patient began tube feedings soon after 2nd
procedure through j tube. Late in her hospital course she was
transitioned to regular diet and tube feeds were decreased.
6. GU- Patient spike a fever late in her hospital course and a
UTI was diagnosed. Patient was started on cipro and transition
to ampilcillian based on culture data.
7. Physical therapy was consulted while patient was being weaned
from the vent and continued to see throughout rest of hospital
course.
Medications on Admission:
coumadin- 20mg weekly
cozaar 50mg qd
lasix 80mg qd
digoxin 125mcg qd
? 2nd heart medication
premarin 0.3mg qd
fergon 2 qd
prilosec
vit. C
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Cape & Islands
Discharge Diagnosis:
Circumferential duodenal adenoma with bleeding
Right apical lung nodule
urinary tract infection
atrial fibrillation
congestive heart failure
anemia
arthritis
Discharge Condition:
good
Discharge Instructions:
Continue tube feedings until patient is able to take in adequate
nutrition.
Keep t-tube in until patient follows up with Dr. [**Last Name (STitle) 468**] in
clinic.
Followup Instructions:
Patient is to follow up with primary care provider.
[**Name10 (NameIs) **] up CT for right apical lung nodule.
Patient with follow up with Dr. [**Last Name (STitle) 468**] by phone.
ICD9 Codes: 5789, 2851, 4280, 5119, 5990 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1326
} | Medical Text: Admission Date: [**2116-10-2**] Discharge Date: [**2116-10-12**]
Date of Birth: [**2037-8-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10842**]
Chief Complaint:
ICD Firing x4 times
Major Surgical or Invasive Procedure:
VT ablation
ICD interrogation
History of Present Illness:
HPI: 79M with CAD, ischemic cardiomyopathy EF = 20%, VT--s/p
ablation, BiV/ICD placement, CRI, hypertension and
hyperlipidemia p/w ICD firing. Pt admitted in [**2-1**] for ICD
firing, interrogation found to be ATP of SVT; ICD reset to avoid
ATP. Over past month, has felt weak, fatigued, and with
decreased PO intake. Today, felt slight fever, and vomited x 2
(watery, non-bloody) when attempted PO intake. No abd pain,
Nausea, LH, CP, or diarrhea. Pt has chronic SOB, and chronic
cough [**1-1**] COPD, unchanged. Last night, while laying in bed, ICD
fired at 10PM 1 time lightly, then 15 min later fired 3 more
times that were "sharp." Pt denied any symptoms following.
*
In ED, found to have Cr elevated at 5.2, with K 6.2, and Dig
3.9. Given CaGluc, Kayexelate 30mg, and D50/Insulin.
Past Medical History:
PMH:
-- CAD s/p CABG [**2109**]
-- CHF (Class II-III)
-- h/o VT s/p ablation AICD placement
-- HTN
-- hyperlipidemia
-- pAF (DCCV [**1-31**])
-- COPD(180 py tobacco)
-- GOUT
-- 3+ MR
-- CRI (bl cr 1.5-2.0)
Social History:
SOCHx:
180py tobacco, EtOH 1-2drinks/day, primary caretaker for
demented wife,
Family History:
NC
Physical Exam:
VS: Tm98.4 BP90-116/56-70 HR69-72 RR18-20 o2sat: 94-98%RA
Is/Os [**Telephone/Fax (1) 107065**]
GEN: NAD
HEENT: PERRL. EOMI.
NECK: O/P clear. No erythema/exudate
CV: Regular, nml s1,s2. +systolic murmur at RUSB.
RESP: CTAB. Moving air well.
ABD: Soft. NTND. +BS. No TTP
EXT: No edema bilat. +Chronic skin changes
SKIN: Resolving bruise on lower lip. Scattered healing bruises
on legs bilat.
Pertinent Results:
[**2116-10-7**] 06:35AM BLOOD WBC-8.3 RBC-3.57* Hgb-10.9* Hct-33.8*
MCV-95 MCH-30.6 MCHC-32.3 RDW-16.4* Plt Ct-163
[**2116-10-7**] 06:35AM BLOOD Plt Ct-163
[**2116-10-5**] 07:30PM BLOOD PT-13.3 PTT-44.8* INR(PT)-1.2
[**2116-10-7**] 06:35AM BLOOD Glucose-138* UreaN-55* Creat-2.0* Na-147*
K-4.8 Cl-112* HCO3-25 AnGap-15
[**2116-10-2**] 06:00AM BLOOD CK-MB-NotDone cTropnT-0.12*
[**2116-10-1**] 11:30PM BLOOD cTropnT-0.08*
[**2116-10-4**] 06:55AM BLOOD calTIBC-182* VitB12-256 Folate-5.8
Ferritn-67 TRF-140*
[**2116-10-7**] 06:35AM BLOOD Digoxin-1.3
.
Shoulder Xray [**10-2**]
RIGHT SHOULDER, THREE VIEWS: No fracture or dislocation is
identified. There is mild degenerative change of the
glenohumeral joint. Local evidence for several loose bodies in
the glenohumeral joint. There is mild calcific tendonitis of the
supraspinatus tendon. The visualized lung is clear.
.
IMPRESSION: No evidence of fracture.
.
CT Head [**10-2**]
IMPRESSION: No acute intracranial hemorrhage.
.
Renal U/S [**10-3**]
IMPRESSION: Multiple bilateral renal cysts. No hydronephrosis or
stones.
.
CXR [**10-3**]
Moderate cardiomegaly has progressed and maybe a slight increase
in atelectasis or new dependent left pleural effusion, but there
is not a substantial change in the radiographic appearance in
that area. Borderline interstitial edema is seen in the right
lower lung. The upper lungs are clear. Hyperinflation indicates
COPD. There is a calcified apical ventricular aneurysm. The
courses of the intended right atrial and left ventricular pacers
and right ventricular pacer defibrillator leads are unchanged.
There is no obvious discontinuity in any of the electrodes. No
pneumothorax or mediastinal widening.
Brief Hospital Course:
A/P: 79M PMH BiV/ICD, CHF--EF 20%, CAD--s/p CABG, CRI (BL Cr 1.5
- 2), p/w ICD firing in the setting of acute renal failure.
*
CARDIAC:
A. Cor: No chest pain throughout this admission.
--Continued ASA, Bblocker, statin, ACE
*
B. Pump: EF 20%, likely [**1-1**] CAD.
Pt with a h/o CHF with an EF of 20%. Pt on ASA/Bblocker,
statin, ACE, Aldactone, Digoxin, Lasix prior to admission. On
admission, digoxin level supratherapeutic and patient found to
be in ARF with a Cr of 5.2 likely due to dehydration/prerenal
azotemia. Held diuretics and Digoxin on admission. Bblocker
was initially held due to ? decompensated CHF but was quickly
restarted and titrated up to pre-admission levels.
IVFs were started for his prerenal ARF and patient's Cr rapidly
decreased over 3 days back to his baseline Cr of [**1-1**].2. Pt's
diuretics were restarted on HD#3, and patient continued to be
euvolemic until day of discharge.
Pt discharged on home dose of ASA, Bblocker, statin, Aldactone,
Lasix. Digoxin continued to be held on discharge.
*
C. Rhythm: Paced rhythm, with widened QRS likely due to
hyperkalemia/acidosis on admission. Pt felt ICD firing 4 times
at home, and called EMS to bring him to [**Hospital1 18**]. On interrogation
of his pacer by the EP team, pt was found to have been in Vfib
arrest s/p ICD firing x10 times, with the pacer timing out afte
10 shocks. Pt had been in vfib arrest after the 10th shock, but
spontaneously returned to NSR.
- Pt was continued on telemetry during admission. Pt had an
episode of asymptomatic 10 beat run of NSVT on HD#2. Pt was
counseled on his options and chose to go for VT Ablation as he
had had this procedure previously. On HD#6, pt was taken for VT
ablation which was unsuccessful, as in the [**Name (NI) 13042**] pt had 3 runs of
NSVT that were shocked back into NSR by the patient's ICD. Pt
at the time was on a low dose dopamine drip, and it was thought
the catecholamine action was causing the NSVT. The drip was
d/c'ed and a lidocaine drip was started, and patient was
transferred to the CCU to be observed overnight. There were no
issues overnight, and patient was weaned off the lidocaine drip
and transferred to the floor. On the floor over the weekend
prior to discharge, pt had an asymptomatic 40 beat of NSVT while
ambulating with PT. Pt was asymptomatical without any other
c/o's. EP evaluated the patient and it was decided to add
mexiletine 150mg po bid to his current regimen of amiodarone
400mg po qD and Toprol XL 50mg qD.
- EP did not think pt needed DFT evaluation as his ICD fired
successfully 3 times in the [**Name (NI) 13042**]. On discharge, pt was sent out
on Amiodarone 400mg po qD x2 weeks --> amiodarone 200mg qday
standing dose, mexiletine 150mg po qd, and Toprol XL 50mg qD.
*
RENAL FAILURE: No apparent etiology, but likely pre-renal due to
poor PO hydration and increased BUN/Cr ratio.
- Urine lytes c/w prerenal state. IVFs were started on
admission, and Cr decreased quickly back to baseline with his
hydration. On HD#3, pt's Cr back to 2.1 his baseline.
- Diuretics were restarted gingerly, and titrated up to
pre-admission levels. Creatinine increased s/p diuretic
addition to 2.7 on discharge. Pt will follow creatinine levels
as outpatient with PCP.
[**Name Initial (NameIs) **] [**Name11 (NameIs) **] sign of volume overload during this admission - euvolemic
on discharge.
*
ANEMIA:
- Pt's hct on admission 35, decreased to 30 on HD#2 thought
likely to hydration from a hemoconcentrated state. However on
HD#4, pt's hct decreased to 26 and with his CAD h/o, was
transfused 1u pRBC which increased his hct to 35 post
transfusion. Hct 28 on discharge.
- Pt had iron studies, vit b12, folate studies which showed MCV
97, Ferritin 67, on feso4 325 qd, nml vit b12, folate levels.
Iron was continued during this admission. It was thought that
likely CRI contributing to chronic anemia.
- Pt with hct of 28 on discharge, stable x3 days.
*
COPD: PRN albuterol, o2 as needed. No intervention needed this
admission.
*
DISPO: Full Code. Pt was evaluated by PT/OT who thought due to
his unsteadiness as well as his primary responsibility of caring
for his wife, who is currently in rehab herself, pt would
benefit from rehab stay. Pt was sent to rehab s/p EPS/VT
ablation.
Medications on Admission:
Amiodarone 200mg daily
Allopurinol 150mg daily
ASA 81mg daily
Aldactone 25mg daily
Coumadin 5mg daily
Digoxin .25mg daily
Flomax .4mg daily
Lasix 40mg daily
Lipitor 40mg daily
Toprol XL 50mg daily
Ferrous Sulfate 5gr tablets tid
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
7. Flomax 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO once a day.
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
8. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*2*
9. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day
for 12 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Please start on [**10-23**] after completed course of amiodarone 400mg
qday x12days.
Disp:*30 Tablet(s)* Refills:*2*
11. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO twice a
day.
Disp:*60 Capsule(s)* Refills:*2*
12. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) inhalation Inhalation twice a day.
Disp:*1 diskus* Refills:*2*
13. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation every 6-8 hours as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*2*
14. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
Governor [**Location (un) 4628**] Nursing Center - [**Location (un) 4628**]
Discharge Diagnosis:
ICD firing due to V.fib
NSVT s/p VT ablation
ARF
.
CAD
CHF EF 20%
VT s/p ablation/ICD s/p re-VT ablation this admission
CRI
HTN
Hyperchol
Discharge Condition:
Afebrile, chest pain free, stable to be discharged to rehab.
Discharge Instructions:
1. Please follow up with Dr. [**Last Name (STitle) 1147**] in 1 month after
discharge. Call ([**2116**] to scheduled that appointment.
Follow up with your device clinic appointment as below.
.
2. Please take your medications as below.
.
3. Monitor INR levels 2x/week until therapeutic on coumadin -
goal INR [**1-2**].
.
4. If develop chest pain, shortness of breath, fainting,
defibrillator firing, or any other sx's, please call your doctor
or report to the nearest ER.
.
5. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet. Fluid Restriction: <2L per day
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2117-1-18**]
1:00
Completed by:[**2116-10-12**]
ICD9 Codes: 4271, 5849, 496, 5859, 4240, 4280, 2762, 2767, 2749, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1327
} | Medical Text: Admission Date: [**2127-7-1**] Discharge Date: [**2127-7-14**]
Date of Birth: [**2054-3-5**] Sex: F
Service: MEDICINE
Allergies:
Levaquin / Neurontin / Neomycin / Ciprofloxacin / Percocet /
Perfume Ht52 / Shellfish Derived / Statins-Hmg-Coa Reductase
Inhibitors
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
abdominal pain, diarrhea, nausea
Major Surgical or Invasive Procedure:
ICU stay with central venous line placement [**7-1**]
Cardiac catheterization [**7-10**]
History of Present Illness:
73 year-old female with CAD, hypertension, CRI (baseline
1.3-1.4), SMA partial stenosis, chronic diarrhea admitted with
weakness x2-3 days in context of abdominal pain, diarrhea,
nausea. Cramping began three days prior to admission.
Periumbilical, without radiation, and not associated with PO
intake. Also with diarrhea, similar to baseline chronic
diarrhea; no noticeable blood in stools. Nausea without
vomiting. Decreased PO intake, although reports drinking plenty
of water. Denies fevers; reports chills at night for which she
used a heating pad on her abdomen. Denies sick contacts. Denies
dysuria. Reports decreased urine production. She feels her
symptoms are secondary to stress; her sister recently had a
stroke. Reports taking Tylenol 1 tablet approximately 4-5 days
ago for low back pain, and Vicodin x1 tablet today and
yesterday. Reports spending time in garden in heat recently.
.
In the ED, 112/41 80% RA. Physical examination notable for
abdominal distension, guaiac positive stool. Laboratory
evaluation significant for leukocytosis with bandemia,
thrombocytopenia (65), transaminitis, elevated lipase,
creatinine 8.1 with anion gap 39, normal coag panel, serum osm
341, lactate 3.8. Opiate positive; Tylenol 16.8. VBG prior to
transfer with 7.15 26 61. Blood cultures sent. EKG reportedly
unremarkable. CXR 2V reportedly unremarkable. CT abdomen/pelvis
without contrast with "diffuse distension of stomach and small
bowel and large bowel loops extending into rectum is mostly
suggestive of gastroenteritis." Surgery consulted; feel
consistent with severe gastroenteritis; no acute surgical issue,
but will continue to follow. Case discussed with renal; no acute
indication for dialysis, will continue to follow. Received
vancomycin, Zosyn, Flagyl; received 150mEq HCO3 in D5W, 2L total
@ 150cc/hr.
On transfer to MICU, 98.9 71 113/45 26 98% NRB.
.
On the floor, she reports discomfort with Foley catheter. Also
with persistent abdominal cramping, need to take BM. Also
reports feeling very thirsty.
.
Review of systems:
(+) Per HPI. Reports weight loss over past 1 week, unable to
quantify amount. Reports chronic low back pain.
(-) Denies fever, night sweats. Denies headache, rhinorrhea.
Denies cough, shortness of breath, or wheezing. Denies chest
pain, chest pressure, palpitations, or weakness. Denies rashes.
Past Medical History:
CAD 1VD s/p BMS to D1 ([**2124**])
CRI
Hypertension
Hyperlipidemia
SMA stenosis with chronic abdominal pain with eating
Chronic intermittent diarrhea
Stable, bilateral 60-69% ICA stenosis
Severe scoliosis
Lumbar spondylosis
Postherpetic neuralgia
Nocturnal leg cramps
Chronic anemia
Osteoporosis
Arthritis
s/p left rotator cuff repair
s/p bilateral cataract surgery
s/p right breast lumpectomy
Social History:
Lives with husband in [**Name (NI) 745**]. Reports 1 alcohol drink per
evening, none recently. Stopped tobacco use 45 years ago. Denies
illicit drug use.
Family History:
non-contributory
Physical Exam:
96.4, 61, 93/57, 14, 100% 2L NC
General: In mild distress
HEENT: Sclera anicteric; dry mucous membranes; OP clear
Neck: JVP to angle of mandible at 30 degreess
Lungs: Clear to auscultation bilaterally; no wheezes, rales,
rhonchi
CV: Decreased heart sounds; regular rate and rhythm; normal
S1/S2; no murmurs appreciated
Abdomen: Hypoactive bowel sounds; mildly distended; diffusely
tender to palpation; no rebound or guarding; no appreciable
hepatomegaly.
GU: Foley
Ext: Cool upper extremities; radial pulses 1+ and symmetric;
warm lower extremities, DP pulses 1+ and equal bilaterally; no
edema
Skin: Tanned; no jaundice
Pertinent Results:
Labs at admission:
[**2127-7-1**] 01:00PM BLOOD WBC-16.2*# RBC-4.22 Hgb-13.5 Hct-40.3
MCV-95 MCH-31.9 MCHC-33.4 RDW-13.7 Plt Ct-65*#
[**2127-7-1**] 01:00PM BLOOD Neuts-63 Bands-12* Lymphs-16* Monos-7
Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0
[**2127-7-1**] 01:00PM BLOOD PT-10.9 PTT-28.7 INR(PT)-0.9
[**2127-7-2**] 02:56PM BLOOD Fibrino-388
[**2127-7-6**] 09:50AM BLOOD Parst S-NEG
[**2127-7-3**] 05:51AM BLOOD Ret Aut-0.4*
[**2127-7-1**] 01:00PM BLOOD Glucose-200* UreaN-137* Creat-8.1*#
Na-135 K-5.3* Cl-87* HCO3-9* AnGap-44*
[**2127-7-1**] 01:00PM BLOOD ALT-227* AST-642* AlkPhos-166*
TotBili-0.5
[**2127-7-1**] 08:27PM BLOOD ALT-169* AST-502* LD(LDH)-950*
CK(CPK)-[**Numeric Identifier 98991**]* TotBili-0.4
[**2127-7-1**] 01:00PM BLOOD Lipase-525*
[**2127-7-1**] 01:00PM BLOOD cTropnT-<0.01
[**2127-7-1**] 08:27PM BLOOD Calcium-5.0* Phos-9.6*# Mg-2.0
[**2127-7-1**] 08:27PM BLOOD Hapto-57
[**2127-7-5**] 07:15PM BLOOD calTIBC-126* Folate-17.7 Ferritn-1608*
TRF-97*
[**2127-7-3**] 05:51AM BLOOD VitB12-GREATER TH
[**2127-7-1**] 08:27PM BLOOD TSH-1.8
[**2127-7-6**] 07:15AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2127-7-1**] 01:00PM BLOOD [**Month/Day/Year **]-NEG Ethanol-NEG Acetmnp-16.8
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2127-7-1**] 08:27PM BLOOD Acetmnp-11.4
[**2127-7-2**] 04:15AM BLOOD Acetmnp-NEG
[**2127-7-6**] 09:50AM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN
GRANULOCYTIC EHRLICHIA [**Doctor Last Name **]) IGG/IGM-PND
)
Test Result Reference
Range/Units
PARVOVIRUS B-19 ANTIBODY 5.43 H
(IGG)
Reference Range
<0.9 Negative
0.9-1.1 Equivocal
>1.1 Positive
IgG persists for years and provides life-long immunity.
To diagnose current infection, consider a Parvovirus
B19 DNA, PCR test.
Test Result Reference
Range/Units
PARVOVIRUS B-19 ANTIBODY <0.9
(IGM)
Reference Range
<0.9 Negative
0.9-1.1 Equivocal
>1.1 Positive
Liver/GB U/S [**7-7**]
FINDINGS: The gallbladder is normal with no gallstones, no wall
thickening, and no pericholecystic fluid identified. There is no
biliary dilatation and the common duct measures 0.2 cm. No focal
liver lesion is identified. The pancreas is unremarkable, but is
only partially visualized due to overlying bowel. The spleen is
unremarkable and measures 7.7 cm. A scant trace of ascites is
seen in the perihepatic space. Small bilateral pleural effusions
are noted.
DOPPLER EXAMINATION: Color Doppler and pulse-wave Doppler images
were
obtained. The main, right and left portal veins are patent with
hepatopetal flow. Appropriate arterial waveforms are seen in the
main, right and left hepatic arteries. Appropriate flow is seen
in the IVC, the hepatic veins, the SMV, and the splenic vein.
IMPRESSION:
1. No gallstones and no evidence of cholecystitis.
2. Patent hepatic vasculature.
3. Scant trace of ascites in the perihepatic space. Bilateral
pleural
effusions.
LUE U/S [**7-7**]
FINDINGS: Grayscale, color and Doppler images were obtained of
the left IJ, subclavian, axillary, brachial, basilic, and
cephalic veins. There is normal flow, compression and
augmentation seen in all of the vessels.
IMPRESSION: No evidence of deep vein thrombosis in the left arm.
CXR [**7-3**]
REASON FOR EXAM: CAD, hypertension, abdominal complaint, and
chronic renal
failure.
Comparison is made with prior study performed a day earlier.
Small-to-moderate bilateral pleural effusions are new. Cardiac
size is
normal. There are bibasilar atelectases. There is mild pulmonary
edema.
Biapical pleural thickening is unchanged. There is no
pneumothorax.
[**7-3**] TTE
The left atrium is normal in size. The estimated right atrial
pressure is 0-5 mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). Right ventricular chamber size and free wall motion are
normal. The aortic 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
tricuspid valve leaflets are mildly thickened. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Normal biventricular systolic function. Large
pleural effusion.
[**7-1**] CT abd/pelvis
FINDINGS: The study is moderately limited as no IV or oral
contrast has been administered, however no definite bowel wall
thickening is noted. Moderate fluid-filled distention of the
stomach, small bowel, large bowel loops and rectum are noted. No
free fluid is noted. No pathologically enlarged nodes are
visualized. Small hiatal hernia is noted. The liver, spleen,
adrenal glands, kidneys appear unremarkable. Tiny punctate foci
of calcification noted within the right renal pelvis may be
vascular or within the collecting system. The urinary bladder
contains a Foley catheter. The uterus and adnexa appear
unremarkable.
BONE WINDOWS: Severe levoconvex scoliosis of the lumbar spine
with associated degenerative changes are noted.
IMPRESSION: Moderate fluid-filled distention of the stomach,
small bowel and large bowel loops to the level of the rectum are
most likely suggestive of infectious enteritis. As no IV and
oral contrast was administered, evaluation for ischemic bowel is
limited, however no signs of bowel ischemia such as wall
thickening was noted.
[**7-1**]/ CXR
FINDINGS: Hyperexpansion is again evident, similar to prior
exam. Stable
calcified pleural plaques predominantly over the lung apices are
again noted. The mediastinum is grossly stable but difficult to
assess due to the profound dextroconcave scoliosis involving the
lower thoracic spine. No large effusion or pneumothorax is seen.
IMPRESSION: Severe but stable scoliosis as detailed above. No
definite
superimposed acute process. Relatively stable chest x-ray
examination.
TTE [**7-9**]
Left ventricular wall thicknesses and cavity size are normal.
There is moderate regional left ventricular systolic dysfunction
with akinesis of the distal LV and apex. No masses or thrombi
are seen in the left ventricle. There is no ventricular septal
defect. 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. Mild to moderate ([**2-1**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2127-7-3**],
regioanl LV systolic dysfunction is new.
ANAPLASMA PHAGOCYTOPHILUM (HUMAN GRANULOCYTIC EHRLICHIA [**Doctor Last Name **])
IGG/IGM
Test Result Reference
Range/Units
A. PHAGOCYTOPHILUM IGG 1:1024 <1:64
A. PHAGOCYTOPHILUM IGM 1:80 <1:20
Anaplasma phagocytophilum is the tick-borne [**Doctor Last Name 360**]
causing Human Granulocytic Ehrlichiosis (HGE).
HGE is distinct and separate from Human Moncytic
Ehrlichiosis (HME), caused by Ehrlichia chaffeensis.
Serologic crossreactivity between A. phagocyto-
philum and E. Chaffeensis is minimal (5-15%).
This test was developed and its performance
characteristics have been determined by [**Company 30232**] [**Doctor Last Name **] Institute, Chantilly, VA.
It has not been cleared or approved by the U.S.
Food and Drug Administration. The FDA has determined
that such clearance or approval is not necessary.
Performance characteristics refer to the analytical
performance of the test.
Test Result Reference
Range/Units
INTERPRETATION see note
Recent/Current Infection
Labs at discharge:
Brief Hospital Course:
Ms. [**Known lastname 17437**] is a 73 year old female with a history of CAD,
hypertension, CRI, SMA partial stenosis, chronic diarrhea and
abdominal pain admitted with abdominal cramping, nausea, and
diarrhea and found to have acute on chronic renal failure,
transaminitis, and thrombocytopenia.
.
# Acute systolic heart failure: EF 35%. Akinesis at the distal
LV and apex on ECHO; catheterization [**7-10**] showed dilation at the
apex, no flow limitations requiring intervention. Differential
includes ischemia (less likely given cath results), infectious
myocarditis (more likely given positive Anaplasma titers,
below), or Takotsubo's. Is currently tachycardic, thought to be
compensatory for systolic dysfunction. She was continued on
aspirin and atenolol, with diuresis with lasix. She will need a
repeat TTE in 3 weeks in Dr.[**Name (NI) 5452**] office.
.
# Human granulocytic ehrlichiosis (aka anaplasmosis): Positive
IgG and IgM serologies for anaplasma phagocytophilum returned
from [**2127-7-6**]; may have been the inciting cause of her
hypotensive shock and presenting symptoms, though her
presentation was atypical in being afebrile. Though ID
unimpressed, as you cannot always seen organsims on smear, given
+IgM and unknown cause of illness, elected to treat with
Doxycycline 100mg [**Hospital1 **] X 10 days. She should have repeat titers
in one month by PCP.
.
# Anemia: Continued slow decline. Tbili and haptoglobin were
normal, so concern for occult bleeding (vs. hemolysis). Rectal
guiaic [**7-9**] positive. Trended Hcts. Follow up with GI as
outpatient unless has transfusion needs then will contact here.
.
# Abdominal pain/diarrhea: Chronic abdominal cramping and loose
stools; thought to have exacerbation on admission. Symptoms
improved with codeine. RUQ ultrasound was normal. Outpatient
workup recommended by GI. Appointment scheduled with Dr.
[**Last Name (STitle) 1940**].
.
# Transaminitis: Enzymes are continuing to trend down.
Elevations on admission thought to be due to shock liver from
hypotension, possibly from infection, though she was only
documented to be severely hypotensive after admission. Has been
noted to have partial SMA stenosis, so may have had transient
ischemia at some point. RUQ ultrasound did not show signs of
infiltrative or cholestatic processes.
.
# Thrombocytopenia: Baseline platelet count 200+, was 63 on
admission; now above baseline in 300s. Possible etiologies are
anaplasmosis or other infection, ITP (less likely because of
resolution without steroids), or toxic insult/drug reaction.
.
# Acute on chronic renal failure: Resolved. Thought to be due to
ATN from rhabdomyolysis given CK and UA on admission.
.
# CAD: 2 bare metal stents placed [**2123**] and [**2124**]. Aspirin 81 mg
started and atenolol restarted. Held [**Year (4 digits) **] due to
thrombocytopenia and risk of bleeding and no absolute indication
for [**Year (4 digits) **] given remote history of bare metal stents.
# Hypertension: SBP has been 100s-120s. Increased atenolol to 50
mg as patient was tachycardic, decreased lisinopril to 5 mg and
stopped HCTZ, nifedipine.
.
# Hypercholesterolemia: Discontinued statin due to elevated
CK/suspected rhabdomyolysis. Held Zetia. Consider alternate
anti-cholesterol [**Doctor Last Name 360**], such as niacin as an outpatient.
.
# Osteoporosis: Held Actonel.
.
# Communication: [**Name (NI) **] (husband), ([**Telephone/Fax (1) 98992**]
# Code status: FULL CODE, confirmed with patient in ICU
Medications on Admission:
Medications: (Per PCP [**Name Initial (PRE) 626**], [**2127-6-18**])
ATARAX - 25MG Tablet - ONE TID, AS NEEDED
ATENOLOL - 25MG Tablet - ONE EVERY DAY
ATORVASTATIN [LIPITOR] - (Dose adjustment - no new Rx) - 80 mg
Tablet - 1 Tablet(s) by mouth
CELEBREX - 200MG Capsule - ONE EVERY DAY
CLOPIDOGREL [[**Month/Day/Year **]] - (Prescribed by Other Provider) - 75 mg
Tablet - 1 Tablet(s) by mouth once a day pt to stop 7 days prior
to procedures
FLUOROURACIL [EFUDEX] - (Prescribed by Other Provider) - 5 %
Cream - take as directed as needed
HCTZ - 25 MG - ONE EVERY MORNING
LISINOPRIL - 10MG Tablet - ONE EVERY DAY
NITROQUICK - 0.4MG Tablet, Sublingual - AS DIRECTED
OMEPRAZOLE - (Prescribed by Other Provider) - Dosage uncertain
PROCARDIA XL - 60MG Tablet Extended Rel 24 hr - ONE EVERY DAY
RISEDRONATE [ACTONEL] - (Dose adjustment - no new Rx) - 35 mg
Tablet - 1 Tablet(s) by mouth weekly
TYLENOL/CODEINE NO.3 - 30-300MG Tablet - ONE TABLET BY MOUTH Q 6
HOURS AS NEEDED FOR PAIN
ZETIA - 10MG Tablet - TAKE ONE TABLET DAILY.
COMPRESSION STOCKINGS - Misc - WEAR AS DIRECTED
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. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Codeine Sulfate 30 mg Tablet Sig: One (1) Tablet PO Q4H
(every 4 hours) as needed for pain.
5. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 6 days.
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
7. Lorazepam 0.5 mg Tablet Sig: 0.25-0.5 mg PO Q8H (every 8
hours) as needed for anxiety .
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day): to be given until patient
ambulates.
9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
12. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
13. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
Primary:
-acute renal failure
-thrombocytopenia
-viral gastroenteritis
-acute MI
Secondary
-CAD
Discharge Condition:
alert, oriented X3
ambulating with assistance
Discharge Instructions:
You were admitted to [**Hospital1 69**]
because of abdominal pain, nausea and diarrhea. While you were
here you were found to have severe kidney injury. This greatly
improved and was normal at discharge. You also had low
platelets, which also improved and were normal at discharge.
You had liver injury and muscle breakdown which may have been
due to your Lipitor. You should not take statins, which lower
cholesterol, in the future.
Your liver injury also improved.
While you were here you were found to have had mild damage to
your heart muscle. You were restarted on some of your
medications.
You were seen by the hematology, gastroenterology, and kidney
doctors.
You required a stay in the intensive care unit.
Be sure to follow-up with your primary care doctor within [**2-1**]
weeks after discharge.
While you were here, some of your medications were changed.
You should STOP taking:
ATARAX
ATORVASTATIN [LIPITOR]
CELEBREX
CLOPIDOGREL [[**Month/Day (2) **]]
FLUOROURACIL [EFUDEX]
HYDROCHLORTHIAZIDE
NITROQUICK
PROCARDIA XL
RISEDRONATE [ACTONEL]
ZETIA
You should CONTINUE:
COMPRESSION STOCKINGS "
ATENOLOL
You should CHANGE:
INSTEAD of TYLENOL/CODEINE NO.3, take CODEINE alone
DECREASE LISINOPRIL to 5mg daily
INSTEAD of OMEPRAZOLE, take PANTOPRAZOLE
You should START:
ASPIRIN
You will need to have your hematocrit (blood level) checked
every 3 days to determine if it is decreasing.
Followup Instructions:
Department: [**State **] SQ
When: [**Last Name (LF) 766**], [**7-21**] at 3:40 pm
With: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 6564**], MD [**Telephone/Fax (1) 2205**]
Building: [**State **] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: On Street Parking
Department: PAIN MANAGEMENT CENTER
When: [**Location (un) **] [**2127-7-21**] at 7:50 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: PAIN MANAGEMENT CENTER
When: FRIDAY [**2127-7-25**] at 7:50 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 1652**]
Building: One [**Location (un) **] Place ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: GASTROENTEROLOGY
When: THURSDAY [**2127-7-24**] at 12:30 PM
With: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 463**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: Cardiology
When: Wednesday, [**7-30**] at 4:00 (you will also have an echo
the same day)
With: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
[**Apartment Address(1) 98993**]
[**Location (un) 86**], [**Numeric Identifier 8542**]
Phone: [**Telephone/Fax (1) 7960**]
ICD9 Codes: 5849, 4280, 2875, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1328
} | Medical Text: Admission Date: [**2111-8-21**] Discharge Date: [**2111-9-8**]
Date of Birth: [**2068-11-7**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
hematopoeitic stem cell transplant
History of Present Illness:
Ms. [**Known lastname **] is a 42 year old woman with M5 acute myeloid leukemia
with complex cytogenetics and refractory to multiple
chemotherapeutic regimens. She presents for matched unrelated
donor
allogeneic stem cell transplantation with cytoxan and total body
irradiation conditioning. She was given Dacogen for 10 days.
Persistently chemoablated bone marrow since that time. She has
developed likely leukemia cutis over last couple of weeks.
Continued on cipro and flagyl given her previous S. viridans
bacteremia and C. diff. Also on voriconazole.
.
Had an episode of emesis following line insertion today, but is
otherwise doing well. Has a chronic, dry cough. Able to tolerate
PO's. Denies fever, chills, SOB, bleeding, headaches, dysuria,
chest pain.
Past Medical History:
ONCOLOGIC HISTORY:
Presented initially with several weeks of bone pain. This
progressed to include pleuritic chest pain and she was seen in
an OSH. Her WBC was 10.1 with 15% others. She was diagnosed
with acute monocytic leukemia, M5, and had complex cytogenetics.
She underwent remission induction therapy with 7+3 (daunorubicin
90mg/m2 days [**12-1**] and cytarabine 100 mg/m2 days [**12-5**]). Her course
was complicated by pulmonary infiltrates which were likely
leukemia, fever/neutropenia with negative evaluation and thought
to be possible drug fever and pericardial effusion/tamponade
requiring pericardiocentesis. The etiology of her pericardial
tamponadewas not determined, though there were atypical cells in
the fluid (thought to be reactive lymphocytes). Her counts
recovered with blasts and she had several indeterminate bone
marrow examinations. Her day +27 marrow was consistent with
regenerating marrow without clear evidence of leukemia. Her
cytogenetics on serial bone marrows did normalize after her
complex cytogenetics on her initial specimen. Her peripheral
blasts did resolve with further recovery.
.
She received post-remission therapy with high dose cytarabine
from [**Date range (3) 78038**]. On [**2111-6-8**], she was noted to have a new
rash on her torso and biopsy demonstrated leukemia cutis. Bone
marrow examination on [**2111-6-10**] demonstrated generalized dysplasia
with 5% blasts. She began re-induction therapy with
clofarabine/cytarabine on [**2111-6-16**]
.
Other past medical history
Hypertension (not on meds)
Gestational diabetes
Hypercholesterolemia (not on meds)
.
Past surgical history
Casearian section
Gastric bypass [**2107**]
[**Last Name (un) 8509**]
Social History:
Married with 2 children, age 13 and 15. Currently on leave from
her position as an ophthalmic technician. Denies ETOH, She is a
never smoker and denies illicit drugs.
Family History:
Mother: ALL, Breast Cancer, Lung Cancer.
Father: Fatal myocardial infarction 50's.
Physical Exam:
ADMISSION PHYSICAL EXAM:
T 98 BP 140/76 HR 72 RR 16 O2 sat 100 RA 142 lbs. H 64.75 inches
Gen: well appearing, no distress
HEENT: Oropharynx is clear without any erythema, lesions, or
thrush.
NECK: Supple, without adenopathy. Right and left lines placed
without hematoma.
LYMPHATICS: No infraclavicular, supraclavicular,lymphadenopathy
noted.
CHEST: Clear to auscultation.
HEART: Regular rate and rhythm, S1, S2, no clicks, murmurs or
rubs, question slightly tachycardic.
ABDOMEN: Normal bowel sounds, soft, nontender, nondistended,
without any palpable hepatosplenomegaly.
EXTREMITIES: Without edema.
SKIN: 1 cm RLQ lesion consistent with leukemia cutis.
.
Pertinent Results:
ADMISSION LABS:
[**2111-8-21**] 09:10AM BLOOD WBC-0.1* RBC-3.12* Hgb-9.1* Hct-23.5*
MCV-75* MCH-29.1 MCHC-38.7* RDW-12.6 Plt Ct-37*
[**2111-8-21**] 09:10AM BLOOD PT-13.7* PTT-21.7* INR(PT)-1.2*
[**2111-9-4**] 12:00AM BLOOD Fibrino-853*#
[**2111-8-22**] 12:25AM BLOOD Glucose-99 UreaN-15 Creat-1.0 Na-140
K-2.8* Cl-101 HCO3-29 AnGap-13
[**2111-8-22**] 12:25AM BLOOD ALT-8 AST-13 LD(LDH)-262* AlkPhos-86
TotBili-0.7
[**2111-8-21**] 09:10AM BLOOD Calcium-9.5 Phos-4.1 Mg-1.6
[**2111-8-25**] 12:00AM BLOOD calTIBC-204 Ferritn-3915* TRF-157*
[**2111-9-5**] 10:07AM BLOOD Hapto-98
[**2111-8-30**] 12:01AM BLOOD Triglyc-229*
[**2111-9-7**] 01:10PM BLOOD Osmolal-310
[**2111-9-7**] 01:10PM BLOOD HCG-<5
.
DISCHARGE LABS:
[**2111-9-8**] 07:40AM BLOOD WBC-.0*# RBC-2.52* Hgb-7.9* Hct-22.6*
MCV-90 MCH-31.5 MCHC-35.2* RDW-16.3* Plt Ct-66*#
[**2111-9-8**] 07:40AM BLOOD PT-35.7* PTT-52.8* INR(PT)-3.6*
[**2111-9-8**] 03:13AM BLOOD Fibrino-638*
[**2111-9-7**] 05:56PM BLOOD PT-44.5* PTT-39.6* INR(PT)-4.6*
[**2111-9-8**] 07:40AM BLOOD Glucose-31* UreaN-71* Creat-2.4* Na-146*
K-5.6* Cl-108 HCO3-12* AnGap-32*
[**2111-9-8**] 07:40AM BLOOD CK(CPK)-446*
[**2111-9-8**] 03:13AM BLOOD ALT-42* AST-55* LD(LDH)-392* AlkPhos-67
TotBili-7.7*
[**2111-9-6**] 10:26AM BLOOD Lipase-11
[**2111-9-8**] 07:40AM BLOOD CK-MB-45* MB Indx-10.1* cTropnT-2.88*
[**2111-9-8**] 07:40AM BLOOD Calcium-9.4 Phos-8.5*# Mg-2.0
[**2111-9-8**] 03:13AM BLOOD TotProt-4.2* Albumin-2.7* Globuln-1.5*
UricAcd-1.5*
[**2111-9-8**] 07:52AM BLOOD Type-ART pO2-139* pCO2-43 pH-7.07*
calTCO2-13* Base XS--17
[**2111-9-8**] 07:52AM BLOOD Lactate-13.6* K-5.5*
.
MICRO:
BETA-GLUCAN AND GALACTOMANNAN PENDING
[**8-31**] URINE CULTURE
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 16 S
CEFEPIME-------------- 16 I
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- =>16 R
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ =>16 R
.
[**2111-8-31**] BLOOD CULTURES NO GROWTH TO DATE
.
IMAGING:
[**9-4**] RUQ DOPPLER; FINDINGS: The liver demonstrates no focal or
textural abnormality. There is no biliary dilatation. The common
duct measures 4 mm. The partially visualized pancreas appears
unremarkable. The gallbladder is within normal limits. The
spleen measures 9 cm, appearance within normal limits.
Color Doppler son[**Name (NI) **] was performed, demonstrating patent left
portal, right anterior and right posterior portal veins, SMV,
IVC, and hepatic veins, with direction appropriate flow. The
hepatic arteries are also patent, with expected sharp systolic
upstroke.
IMPRESSION: No evidence of [**Last Name (un) **]-occlusive disease.
.
[**9-7**] RUQ ULTRASOUND: RIGHT UPPER QUADRANT ULTRASOUND:
The liver is normal in echogenicity, without focal lesions. The
gallbladder is partially distended without wall edema,
gallstones, biliary sludge, or pericholecystic fluid.
Ultrasonographic [**Doctor Last Name 515**] sign was negative. There is no
abdominal ascites.
Evaluation of hepatic vasculature was suboptimal, due to
patient's inability to breath-hold. There is normal flow in the
portal vein, hepatic veins, and IVC. However, Doppler waveforms
demonstrate slightly increased phasicity.
IMPRESSION:
1. Normal liver, without evidence of ascites.
2. Partially distended gallbladder, without acute cholecystitis.
3. Patent portal and hepatic veins. Slightly increased
pulsatility could be compatible with hepatic [**Last Name (un) **]-occlusive
disease in the correct clinical
setting.
.
[**9-7**] CT CHEST/ABD/PELVIS: CHEST: Left internal jugular line
terminates in the distal SVC, and a right large-bore catheter
extends from the internal jugular vein into the deep right
atrium.
Lung volumes are low. There is mild interstitial and alveolar
pulmonary
edema, with smooth interlobular septal thickening and perihilar
ground-glass opacities. Moderate left and small right simple
pleural effusions have developed. There are few hazy peripheral
opacities in both lungs, most compatible with subsegmental
atelectasis, although aspiration or early multifocal infection
cannot be excluded.
Heart is normal in size. Relative hypoattenuation of the blood
pool is
compatible with anemia. There is a trace pericardial effusion.
Scattered prominent mediastinal, axillary, and hilar lymph nodes
are present, likely reactive.
Note is made of a small sliding hiatal hernia.
ABDOMEN: There is mild simple ascites throughout the abdomen and
pelvis.
Laparoscopic gastric band surrounds the gastric fundus, without
evidence of obstruction or leak. The port is well seated in the
subcutaneous tissues of the left upper quadrant. Small bowel is
within normal limits. There are no air-fluid levels or
transition points to indicate obstruction. No appreciable wall
thickening to suggest inflammation.
There is mild fatty infiltration of the liver. Gallbladder
appears slightly prominent, but was normal by ultrasound.
Pancreas is normal. There is no intra- or extra-hepatic biliary
ductal dilation. Spleen is normal in size.
The adrenals are slightly full, without discrete nodularity.
Kidneys are
normal in size, without stones or hydronephrosis. Mild bilateral
perirenal
edema is noted.
PELVIS: The colon is diffusely fluid-filled, compatible with
low-residue
diet. Foley catheter is present in a partially collapsed
bladder. Uterus and adnexa are within normal limits.
Mesenteric and retroperitoneal lymph nodes are not
pathologically enlarged.
No suspicious lytic or sclerotic osseous lesions are identified.
There is
diffuse body wall edema.
IMPRESSION:
1. Limited non-contrast examination reveals no clear source of
infection.
2. Volume overload with pulmonary edema, pleural effusions,
ascites, and
anasarca.
.
[**9-8**] CXR: FINDINGS: In comparison with the earlier study, the
endotracheal tube has been re-positioned so that the tip lies
approximately 2 cm above the carina. It still could be pulled
back about 2 cm. Dialysis catheter extends to the region of the
right atrium and the left subclavian catheter extends to the
region of the cavoatrial junction. Opacification in the
retrocardiac region persists, consistent with substantial volume
loss in the left lower lobe. Hazy opacification bilaterally is
consistent with substantial elevation of pulmonary venous
pressure. There probably is a left and possibly right
effusion.
More coalescent opacification at the right base could represent
a developing consolidation.
Brief Hospital Course:
Ms. [**Known lastname **] was a 42 year old female with a history of acute
myelogenous leukemia with complex cytogenetics and failed
remission efforts who was admitted to the hospital to undergo an
allogeneic stem cell transplant. She was conditioned with total
body radiation and cytarabine. She received the transplant on
the floor, but a few days later she had worsening liver and
renal function with rising bilirubin, INR, and creatinine.
.
Patient was transferred to the ICU following an episode of
hypotension during which she was unresponsive. Her BP was
70s/40s when a Code Blue was called. Following initial fluid
resuscitation, her SBP increased transiently to the 120s and she
became responsive. Her SBP again feel to the 70s and pressors
were initiated. She did not loose her pulse during this episode
and she was transferred to the ICU.
.
Upon arrival to the ICU, crystalloid and colloid fluid
resuscitation and pressors were continued. Her antibiotic
coverage was broaded and her BP improved to the point where she
was no longer pressor dependent.
.
She remained stable throughout the day, however it was noted
that she was having increased work of breathing. In the early
evening, her respiratoy rate began to slow down and she was
intubated out of concern that she was developing an acidosis. A
post-intubation CXR revealed that the ET tube was in the right
mainstem bronchus, the location of which was adjusted and
confirmed on repeat CXR. Her acidosis did not improve. Bone
marrow transplant service was notified and her steroids were
increased to try to treat a possible engraftment
syndrome/cytokine storm. Also, vancomycin was added for
additional gram positive coverage.
.
Patient also demonstrated rising bilirubin, INR, and creatinine.
There was concern for [**Last Name (un) **]-occulsive disease due to her
transplant. A RUQ ultrasound did not show ascites, venous
occlusion, or hepatomegaly. However, she did have new
right-sided abdominal pain for the first time during the
admission. Because of this, she was treated empirically for
possible [**Last Name (un) **]-occulsive disease with defibrotide.
.
She developed profound acidosis and was again required
vasopressors for blood pressure support. Eventually, patient's
clinical course continued to deteriorate, and eventually and
another code blue was called for PEA arrest (pulseless
electrical activity). Despite maximum medical support, tgh
resuscitation efforts were unsuccessful and the patient expired.
.
TRANSITIONAL ISSUES
none
Medications on Admission:
ACYCLOVIR - 400 mg Tablet - 1 Tablet(s) by mouth three times a
day
ALPRAZOLAM - 0.25 mg Tablet - [**11-30**] Tablet(s) by mouth every
twelve
(12) hours as needed for anxiety Do not drive while on this
medication. Do not take if have taken lorazepam.
CIPROFLOXACIN - 500 mg Tablet - 1 Tablet(s) by mouth every
twelve
(12) hours
HYDROXYUREA - 500 mg Capsule - 3 Capsule(s) by mouth [**Hospital1 **] or as
directed.
LORAZEPAM - (Dose adjustment - no new Rx) - 0.5 mg Tablet - 1
Tablet(s) by mouth every 6 hours as needed for
nausea/anxiety/insomnia DO NOT TAKE IF TAKING XANAX.
METRONIDAZOLE - (Prescribed by Other Provider) - 500 mg Tablet
-
1 Tablet(s) by mouth every eight (8) hours
ONDANSETRON - 8 mg Tablet, Rapid Dissolve - 1 Tablet(s) by mouth
every 8 hours as needed
OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth every six (6)
hours as needed for pain
POTASSIUM CHLORIDE - 20 mEq Packet - 1 Packet(s) by mouth daily
PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth
every six (6) hours as needed for nausea
VANCOMYCIN IN D5W - (Prescribed by Other Provider) - 1 gram/200
mL Piggyback - 1 Piggyback(s) Q 24h
VORICONAZOLE - (Prescribed by Other Provider) - 200 mg Tablet -
1 Tablet(s) by mouth every twelve (12) hours
ZOLPIDEM - 10 mg Tablet - 1 Tablet(s) by mouth at bedtime as
needed for insomnia "DOSE CHANGE"
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
refractory metabolic acidosis
cardiopulmonary arrest
Acute myelogenous leukemia
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
ICD9 Codes: 5845, 2762, 0389, 4019, 2724, 2875, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1329
} | Medical Text: Admission Date: [**2167-4-21**] Discharge Date: [**2167-4-27**]
Date of Birth: [**2108-4-9**] Sex: M
Service: SURGERY
Allergies:
Iron Dextran Complex
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
ESRD
Major Surgical or Invasive Procedure:
Attempted renal transplant/aborted [**2167-4-21**]
History of Present Illness:
59 year-old male with h/o ESRD secondary to DM. Started
dialysis in [**2165-5-15**] via LUE AV graft. Last dialysis was done
[**2167-4-21**]. He has dialysis Tuesday, Thursday, and Saturday.
Typically urinates 4-5 times a day. He is admitted today,
[**2167-4-21**] for a kidney transplant.
Past Medical History:
1. ESRD on hemodialysis, awaiting placement on transplant list
(HD T,Th, Sat)
2. Renal cell carcinoma of left kidney (s/p partial nephrectomy
[**5-17**]) T1, N0, M0. Surveillance MR [**First Name8 (NamePattern2) **] [**2165-5-15**] was negative
for recurrence.
2. CHF (stage II) - diastolic - followed by Dr. [**First Name (STitle) 437**]. Recently
started on carvedilol (end of [**Month (only) 547**])
3. Hypertension
4. DM2, HbA1C 9
5. Hepatitis C
6. HOH
7. Gout
8. Anemia
9. [**Doctor Last Name 15532**]??????s Esophagus
10. Prostate nodule, PSA 2.8 fall [**2164**]
11. Viral Pericardial effusion - [**1-20**]. [**Month (only) 958**] seen by echo to
have resolved. Not thought to be uremic effusion.
Social History:
Lives with sister, previously worked in a hotel, quit after [**Month (only) **]
admission to hospital.
Previous 80 pack year smoking history, quit in [**2165-5-15**].
Previous ETOH history of 1 pint per week, quit in [**2165-5-15**]
Previous crack cocaine use (1-2 times per month), quite in [**Month (only) **]
[**2164**]
Previous heroin use, quite 5-6 years ago
Family History:
Sister- DM
[**Name (NI) **] reported CAD.
Positive for alcoholism.
Mother died of "liver problems"; father died of stroke at 51. He
is unsure of any other medical problems in his family.
Physical Exam:
ADMISSION EXAM:
100.0 88 147/95 20 96% room air
NAD
A&O x 3
RRR
CTA bilaterally
soft, obese, NT, NABS
no cyanosis, cords, edema
DISCHARGE EXAM:
97.3 61 128/65 16 94% room air
NAD
A&O x 3
RRR
CTA bilaterally
soft, obese, NT, NABS
incision clean, dry, intact
no cyanosis, cords, edema
Pertinent Results:
ADMISSION LABS:
[**2167-4-21**] 06:57PM BLOOD WBC-11.2* RBC-4.55* Hgb-12.3* Hct-39.6*
MCV-87# MCH-27.1 MCHC-31.2 RDW-20.9* Plt Ct-416
[**2167-4-21**] 06:57PM BLOOD PT-12.3 PTT-27.4 INR(PT)-1.1
[**2167-4-21**] 06:57PM BLOOD UreaN-24* Creat-8.2*# Na-141 K-4.0 Cl-98
HCO3-26 AnGap-21*
[**2167-4-21**] 06:57PM BLOOD ALT-40 AST-51*
[**2167-4-21**] 06:57PM BLOOD Albumin-4.3 Calcium-9.9 Phos-4.3# Mg-1.9
.
DISCHARGE LABS:
[**2167-4-27**] 08:08AM BLOOD WBC-12.9* RBC-3.88* Hgb-10.6* Hct-33.6*
MCV-87 MCH-27.3 MCHC-31.6 RDW-20.7* Plt Ct-358
[**2167-4-23**] 03:53AM BLOOD PT-11.9 PTT-25.3 INR(PT)-1.0
[**2167-4-27**] 08:08AM BLOOD Glucose-132* UreaN-62* Creat-10.3*#
Na-136 K-4.2 Cl-92* HCO3-26 AnGap-22*
[**2167-4-23**] 03:53AM BLOOD ALT-25 AST-47* AlkPhos-137* Amylase-107*
TotBili-0.3
[**2167-4-23**] 03:53AM BLOOD Lipase-100*
[**2167-4-27**] 08:08AM BLOOD Calcium-8.5 Phos-7.0* Mg-2.2
.
RADIOLOGY Final Report
-59 DISTINCT PROCEDURAL SERVICE [**2167-4-21**] 10:53 PM
CHEST PORT. LINE PLACEMENT; -59 DISTINCT PROCEDURAL SERVIC
Reason: ptx
[**Hospital 93**] MEDICAL CONDITION:
59 year old man with r IJ
REASON FOR THIS EXAMINATION:
ptx
INDICATIONS: 59-year-old man with right internal jugular
catheter.
COMPARISONS: Earlier in the same day.
CHEST, AP PORTABLE: There is a new endotracheal tube, beyond the
thoracic inlet, terminating 4 cm above the carina. A right
internal jugular central venous catheter terminates in the
distal superior vena cava. A new nasogastric tube terminates in
the stomach but there is a sidehole latter immediately at or
above the gastroesophageal junction.
Cardiac and mediastinal contours are unchanged. There is new
focal opacity in the left upper lobe, consistent with aspiration
or pneumonia.
IMPRESSION:
1. Nasogastric tube with side hole latter above the
gastroesophageal junction. 2. New focal opacity in the left
upper lobe with rapid onset, with the differential diagnosis
including aspiration or pneumonia.
Findings discussed with resident covering the patient.
.
RADIOLOGY Final Report
CHEST (PA & LAT) [**2167-4-21**] 6:59 PM
CHEST (PA & LAT)
Reason: pre op kidney [**Hospital 23678**]
[**Hospital 93**] MEDICAL CONDITION:
59 year old man with for kidney tx
REASON FOR THIS EXAMINATION:
pre op kidney tx
INDICATION: 59-year-old man with kidney transplant. Preop
study..
PA AND LATERAL CHEST RADIOGRAPHS: The heart size is at the upper
limits of normal. Mediastinal and hilar contours are stable and
unremarkable. The ill- defined pulmonary vasculature as well as
basilar interstitial opacities are most consistent with stable
vascular congestion. Overall there has been little interval
change compared to prior study.
IMPRESSION: No evidence of pneumonia. Mild vascular congestion.
.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2167-4-22**] 11:58 AM
CHEST (PORTABLE AP)
Reason: infiltrates
[**Hospital 93**] MEDICAL CONDITION:
59 year old man with r IJ
REASON FOR THIS EXAMINATION:
infiltrates
PORTABLE UPRIGHT CHEST, 12:08 P.M.
INDICATION: Followup infiltrate.
FINDINGS: Compared with 5/8 at 11:38 p.m., no significant change
in tube and line positions. The right lung is grossly clear. No
overt CHF.
There has been partial interval clearing of the streaky
atelectasis/infiltrate in the retrocardiac region. There has
also been partial clearing of what appears to be atelectasis in
the left peri/suprahilar region.
.
Cardiology Report ECHO Study Date of [**2167-4-22**]
Conclusions:
The left atrium is mildly dilated. The right atrium is
moderately dilated.
Left ventricular wall thickness, cavity size, and systolic
function are normal
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion
abnormality cannot be fully excluded. There is no ventricular
septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and
no aortic regurgitation. The mitral valve appears structurally
normal with
trivial mitral regurgitation. The pulmonary artery systolic
pressure could not
be determined. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2166-4-25**], no
change.
.
RADIOLOGY Preliminary Report
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2167-4-23**] 7:46 PM
CTA CHEST W&W/O C&RECONS, NON-
Reason: CTA CHEST ONLY; eval for PE infiltrates and pulmonary
fibros
Field of view: 36 Contrast: [**Hospital 13288**]
[**Hospital 93**] MEDICAL CONDITION:
59M s/p aborted kidney tx for hypoxia in OR
REASON FOR THIS EXAMINATION:
CTA CHEST ONLY; eval for PE infiltrates and pulmonary fibrosis
CONTRAINDICATIONS for IV CONTRAST: None.
STUDY: CTA OF THE CHEST WITHOUT AND WITH CONTRAST.
INDICATION: 59-year-old male status post aborted kidney
transplant, presenting with hypoxia. Assess for pulmonary
embolism.
COMPARISONS: None.
TECHNIQUE: Non-contrast MDCT axial images were acquired of the
chest. Following administration of intravenous contrast, MDCT
axial images were acquired from the thoracic inlet to the upper
abdomen. Coronal, sagittal, and oblique reformatted images were
then obtained.
CTA OF THE CHEST WITHOUT AND WITH IV CONTRAST: There are no
filling defects present within the main pulmonary arteries or
the segmental branches to the upper lobes bilaterally. However,
given technical difficulties of bolus administration, the lower
lobe arteries cannot be evaluated bilaterally. There is biatrial
enlargement. There is no aortic dissection. There is no evidence
of pulmonary fibrosis. There is a bilateral, dependent
atelectasis. There are mild, streaky opacities within the left
lobe. The lungs are otherwise unremarkable. A prominent
prevascular node measures 9 mm (3:18). There are few prominent
mediastinal nodes, particularly posterior to the esophagus. None
meet criteria for pathology. There are no pathologic hilar or
axillary lymph nodes.
Bone windows demonstrate no lytic or blastic lesions. There are
mild degenerative changes of the mid to lower thoracic spine.
Limited views of the upper abdomen are unremarkable.
IMPRESSION:
1. No evidence of pulmonary embolism within the main pulmonary
arteries and segmental branches to the upper lobes of the lungs.
The segmental arteries to the lower lobes of the lungs are
incompletely evaluated on this examination. A repeat evaluation
could be performed if clinically indicated.
2. No pulmonary fibrosis.
3. Mild, streaky opacities present at the left lung base largely
unchanged compared to the CT torso from [**2166-2-21**].
.
RADIOLOGY Preliminary Report
US ABD LIMIT, SINGLE ORGAN [**2167-4-26**] 12:04 PM
US ABD LIMIT, SINGLE ORGAN
Reason: seroma/hematoma
[**Hospital 93**] MEDICAL CONDITION:
59 year old man with aborted RLQ renal transplant now with cont
drainage from wound despite stitches
REASON FOR THIS EXAMINATION:
seroma/hematoma
LIMITED ABDOMINAL ULTRASOUND
INDICATION: 59-year-old man with aborted right lower quadrant
renal transplant, presenting with drainage from the wound. Rule
out seroma, hematoma.
COMPARISON: Not available.
FINDINGS: Limited [**Doctor Last Name 352**]-scale images of the right lower quadrant
area were obtained. No abnormal fluid collection was identified.
IMPRESSION: No evidence of fluid collection.
Brief Hospital Course:
The patient was admitted to Dr.[**Name (NI) 670**] Transplant Service at
the [**Hospital1 69**] on [**2167-4-21**] for a DCD
renal transplant. For details of the operation, please refer to
the operative report. The operation was aborted
intra-operatively due to unknown cause of hypoxia. The patient
was transferred to the SICU for further care immediately
post-operatively and continued to be intubated. A chest xray a
new focal opacity in the left upper lobe with rapid onset. On
POD 1, he remained intubated and sedated with continuing
improvement of his oxygenation status. His sedation was weaned
in the afternoon and he was successfully extubated without
complications. In the SICU, he underwent HD with 1.8
ultrafiltrate. On POD 2, he was deemed stable for transfer to
the floor. He remained afebrile and his oxygenation status
remained good on 3 liters nasal cannula. His diet was advanced
to clear liquid, which he tolerated well. He underwent HD with
an ultrafiltrate of 2.2 liters. A CTA chest demonstrated no
PEs. On POD 3, he continued to remain afebrile and was
tolerating a renal diet. PFTs were performed. On POD 4, he
continued to remain afebrile and toelrating a renal diet. He
remained stable on room air and continued to have bowel
movements. On POD 5, he remained afebrile and toelrating a
renal die. His wound continued to have serous drainage and 3-0
nylon stiches were placed to better approximate the skin edges.
An abdominla ultrasound was performed which did not demonstrate
any fluid collection. On POD 6, he was deemed stbale for
discharge home with VNA services. He was tolerating a renal
diet, afebrile, ambulating well, and continued to have bowel
movements. Further 3-0 nylon sutures were placed to better
approximate the skin edges to stop the serous drainage. He will
follow-up with Dr. [**First Name (STitle) **]. He will resume his previous HD
schedule.
Medications on Admission:
Allopurinal 100', ASA 81', diltiazem 360', diovan 320',
gabapentin 100"', glyburide 2.5', insulin, lantus 10u qHS,
nephrocaps 1', norvasc 10', prilosec 20", toprol 100', zoloft
100'
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
take while taking pain medication.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
esrd
hypoxia
Discharge Condition:
good
Discharge Instructions:
Please call Dr.[**Name (NI) 670**] office if fever, chills, nausea,
vomiting, incision red/bleeding/draining pus or any questions
No heavy lifting
[**Month (only) 116**] shower
resume Tuesday-Thursday-Sat hemodialysis schedule
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2167-5-1**] 8:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK
Date/Time:[**2167-5-4**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2167-5-4**] 2:40
ICD9 Codes: 4280, 2749, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1330
} | Medical Text: Admission Date: [**2128-12-26**] Discharge Date: [**2129-1-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1674**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
EGD
EGD
Colonoscopy
History of Present Illness:
HPI: The patient is a [**Age over 90 **] yo F transferred from an OSH ED for
melena x 24 hours. While at the OSH, the patients initial hct
was 26.2. She was transfused 2 units PRBC without improvement.
She was transfused another 2 units prior to transfer. Per report
was briefly hypotensive at the OSH but has been hemodynamically
stable since arrival.
.
In the ED, initial vitals were HR 51, BP 124/59, RR22, 98%2L.
She remained hemodynamically stable while in the ED. Two 18g
peripheral IV's were placed. She received 2L NS and protonix
40mg IV x 1. Hct drawn here was 38 (s/p a total of 4 units at
OSH). GI was called and will scope in the AM
Past Medical History:
CHF
COPD
Hyperlipidemia
Hypothyroid
Diverticulosis
Osteoporosis
Osteoarthritis
Social History:
Lives in nursing home. Denies smoking. ETOH 2oz daily. No drugs.
Family History:
Non-contributory
Physical Exam:
Physical Exam:
Vitals - HR 57 BP 127/62 RR 15 O2 96%
General - elderly female, no acute distress
HEENT - PERRL, EOMI
Neck - supple
Heart - bradycardic, no murmur appreciated
Lungs - CTA B/L
Abdomen - soft, NT/ND, + BS
Ext - trace edema
Rectal - g+ black stool (per ED report)
Pertinent Results:
Hct stable -
[**2128-12-26**] Hct-38.9
[**2128-12-27**] Hct-36.4
[**2128-12-29**] Hct-33.8
nl INR, platelets
[**2128-12-29**] 05:08AM BLOOD WBC-8.1 RBC-3.74* Hgb-11.1* Hct-33.8*
MCV-90 MCH-29.8 MCHC-33.0 RDW-14.0 Plt Ct-271
[**2128-12-29**] 05:08AM BLOOD Glucose-90 UreaN-17 Creat-0.5 Na-132*
K-4.1 Cl-98 HCO3-23 AnGap-15
.
EGD:
Findings: Esophagus:
Lumen: A large size hiatal hernia was seen with mild
esophagitis.
Mucosa: Normal mucosa was noted.
Stomach:
Mucosa: Normal mucosa was noted.
Duodenum:
Mucosa: Normal mucosa was noted.
Impression: Normal mucosa in the esophagus
Normal mucosa in the stomach
Normal mucosa in the duodenum
Large hiatal hernia
Recommendations: serial hematocrits
Discuss with family need for colonoscopy. If family/HCP wants to
procede with further workup, prep for colonoscopy.
consult IR for angio if acutely bleeds.
Additional notes: The attending was present for the entire
procedure. Routine post-procedure orders No source of bleeding
seen on this exam. The patient??????s reconciled home medication list
is appended to this report.
.
[**2128-12-31**]
.
COLONOSCOPY.
Showed severe diverticulosis and internal and external
hemorrhoids
Brief Hospital Course:
[**Age over 90 **] yo F presented with melena, but no evidence of UGIB found on
EGD, with stable Hct after 5 unit of PRBCs, only hypotensive at
OSH.
# GI Bleed - Patient with melena x 24 hours. She was briefly
hypotensive. She subsequently received 4 units PRBCS at OSH
with hct 29 --> 38. She was transfered to [**Hospital1 18**]. GI consulted
in the ED. EGD was performed that showed no evidence of current
or recent bleeding. Patient's Hct remained stable at 33-36.
She was continued on IV protonix up until EGD was performed.
She was subsequently transferred to the floor. After adequate
prep, she underwent colonoscopy on [**12-31**] which revealed severe
diverticulosis and internal as well as external hemorrhoids. She
had no further episodes of melena and her blood pressure
remained stable.
.
# CHF/CAD - Patient on toprol/zocor/asa at home. Her BB was
held. Her lasix was held and restarted prior to discharge. Her
statin was continued. Her aspirin was held while in hospital,
she will discuss with her doctor when to restart this as well as
her toprol. She did a prn dose of lasix after her transfusions
with good urinary output.
.
# Hypothyroid - her synthroid dose was kept at 75 micrograms.
.
# COPD - She received nebulizers atrovent and albuterol prn.
.
Code - DNR/DNI
Communication - Son [**Name (NI) **] is HCP - [**Telephone/Fax (1) 76488**]
Medications on Admission:
Toprol XL 50mg daily
Zocor 20mg daily
Prozac 10mg daily
Aspirin 325mg daily
Synthroid 75mg daily
Folic Acid 1mg daily
Nitro Patch 0.2mg/hr daily
Lasix 20mg daily
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
5. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
Our Island Home
Discharge Diagnosis:
Diverticulosis
Internal and External Hemorrhoids
Blood Loss anemia, acute on chronic
Secondary:
Heart Failure, Systolic, Chronic.
COPD
Discharge Condition:
Good. Hematocrit stable.
Discharge Instructions:
Admitted with blood in stool. You had an EGD (camera in your
mouth) which revealed no problems in your stomach. You had a
colonoscopy that revealed diverticulosis and hemorrhoids. Take a
diet with plenty of fiber. For the hemorrhoids, [**First Name8 (NamePattern2) **] [**Last Name (un) **] baths as
often as possible, such as 4 times a day. Do not strain at the
toilet. Drink enough water. Sit on an inflatable doughnut for
relief.
.
Two of your medications, toprol and lasix, were stopped because
of low blood pressure. Now you can [**Last Name (un) 14670**] resume them.
.
Your blood volume remains stable. Please follow up with the
doctor at the nursing home to make sure you do not lose too much
blood. Return to the Emergency Room if you have any concerns.
Followup Instructions:
With the doctor at the nursing home within 3 days of discharge
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**]
ICD9 Codes: 2851, 496, 2724, 4280, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1331
} | Medical Text: Admission Date: [**2184-8-2**] Discharge Date: [**2184-8-13**]
Date of Birth: [**2130-1-22**] Sex: F
Service: MEDICINE
Allergies:
Morphine And Related / Levaquin
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
fevers
Major Surgical or Invasive Procedure:
Thoracocentesis
History of Present Illness:
Patient is a 54 year-old female with a history of pulmonary
embolism, chronic left-sided pleural effusion, and Non-small
cell lung CA on seliciclib chemotherapy who presents with
fevers. Patient is s/p several regimens of chemotherapy and XRT,
as well as rigid bronchoscopy and laser treatment for
obstructive bronchial lesion, currently on seliciclib received
3rd cycle on [**2184-7-29**]. She was recently discharged from the
hospital on [**2184-7-15**] with a newly diagnosed right-sided
pulmonary embolism, as well as a post-obstructive pneumonia, for
which she received azithromycin x 5 days and cefpodoxime x 14
days. The patient's fevers have not improved on either regimen.
Past Medical History:
Past Medical History:
#. Non-small cell lung CA diagnosed [**10/2183**] from bronchoscopic
biopsy of left-upper lobe mass at [**Hospital3 417**] Hospital with
PET CT showing uptake in mediastinal lymph nodes and left
adrenal, S/P rigid bronchoscopy and laser treatment and stenting
in [**11/2183**] at [**Hospital1 18**], cisplatin and XRT from [**Month (only) 404**]-[**Month (only) 956**]
[**2183**], XRT to 4th left rib in [**2184-2-28**], pemetrexed therapy in
[**2184-3-30**], Taxotere therapy in [**2184-4-29**], CT in [**2184-5-30**] with
disease progression, enrolled in clinical trial for seliciclib
in [**2184-6-29**]
#. Pulmonary embolism diagnosed in [**2184-6-29**], started on
enoxaparin
#. Left-sided pleural effusions, unsusccessful thoracentesis on
[**2184-7-13**], repeat on [**2184-8-3**].
#. GERD
#. Hypothyroidism
PAST SURGICAL HISTORY:
1. Cholecystectomy [**2169**].
2. Total abdominal hysterectomy for uterine fibroids [**2164**].
3. Partial thyroidectomy in [**2164**] for further evaluation of a
nodule.
.
PAST ONCOLOGIC HISTORY: history of meningioma resected in [**2181**];
developed a chronic cough in the beginning of 11/[**2182**]. On
[**2183-11-16**] she developed hemoptysis which prompted her to
present to [**Hospital 76515**] Hospital in [**Hospital1 1474**]. A mass was seen in her left
upper
lobe on chest x-ray. She underwent bronchoscopy on [**2183-11-19**]
with pathology consistent with nonsmall cell lung cancer, most
likely adenocarcinoma. IH was positive for TTF-1 and CK7,
negative for CK20. A PET-CT on [**2183-11-29**], reportedly showed
uptake in the left lung, mediastinal lymph nodes, and left
adrenal gland. Head MRI was negative. She had a bronchoscopy on
[**2183-12-19**] at which time a stent was placed in the left mainstem
bronchus. She underwent repeat bronchoscopy and endobronchial
ultrasound on [**2184-1-1**]. A level 7 and a level 4 node were
biopsied by FNA. The cytology from these was negative. She
started radiation therapy on [**2184-1-6**].
Social History:
She lives with her partner. She smoked for 30
years x 1.5 packs per day, quit seven years ago. She denies
alcohol use.
Family History:
Father - prostate cancer. No other family
history of cancers
Physical Exam:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: NCAT, EOMI, PERRL, sclera anicteric, MMM, OP with white
plaques at interface of gums and buccal mucosa bilat.
NECK: No JVD, no cervical lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: dullness to percussion and decreased breath sounds on
left, crackles at right base.
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
[**2184-8-1**] 10:00PM WBC-23.4* RBC-3.32* HGB-8.3* HCT-26.2*
MCV-79* MCH-24.9* MCHC-31.5 RDW-19.5*
[**2184-8-1**] 10:00PM NEUTS-93.6* BANDS-0 LYMPHS-2.6* MONOS-3.5
EOS-0.1 BASOS-0.1
[**2184-8-1**] 10:00PM HYPOCHROM-2+ ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-OCCASIONAL
[**2184-8-1**] 10:00PM GLUCOSE-127* UREA N-27* CREAT-1.4*
SODIUM-131* POTASSIUM-4.2 CHLORIDE-89* TOTAL CO2-30 ANION GAP-16
.
.
STUDIES:
[**2184-8-2**] - CT TORSO
FINDINGS:
.
CT OF THE CHEST WITH IV CONTRAST: Hyponehancement of left
lingula and left lower lobe conistent with Pnuemonia is noted.
There is a large plueral effusion filling the whole of the left
hemithorax with complete collapse of the left lung. The large
necrotic tumor in the left lower lung has increased in size
since the last examination
.
Multiple bilateral new axillary lymph nodes are seen with the
biggest
measuring 13 x 4 in the right axillary region (series 3, image
15). A new
prevascular lymph node is seen abutting between the left
subclavian vein and left subclavian artery measuring 25 x 20 mm
(series 3, image 14), which was not seen in the previous
examinations. There aorticopulmonary node seen in the previous
examination appears stable. The local tumor infiltration
involving the mid portion of the left rib has increased in size
with greater associated rib destruction (series 3, image 22). In
addition, the left plueral tumor deep in the posterior sulcus
along the spine has also increased in size. In the right lung,
innumerable new pulmonary metastases along with interval
increase in previous lesions, measuring up to 13 mm and are more
extensive in the right middle lobe.
.
CT OF THE ABDOMEN WITH IV CONTRAST: New hypodense lesions are
noted in the liver, most likely metastases. The patient is
status post cholecystectomy. The intra- and extra-hepatic
biliary duct dilatation is unchanged. Bilateral adrenal masses
seen on the previous examination have increased in size. In
addition, multiple retroperitoneal and mesenteric lymph nodes
are noted which are new, with the left paraaortic lymph node
measuring up to 21 x 35 mm, (series 3, image 75). Enhancing foci
in the left psoas and right paraspinal seen on [**2176-6-15**]
have also increased in size. A new metastatic focus is seen in
the posterior subcutaneous tissue at the level of L3.
.
CT OF THE PELVIS WITH IV CONTRAST: Heterogeneously enhancing
foci in the
right iliacus, right gluteus, and the left quadriceps are
persistent and have increased in size. Increase in interval
pelvic lymphadenopathy is seen with the biggest lymph node
measuring 19 x 24 along the left pelvic wall, series 3, image
104.
.
BONE WINDOWS: Interval increase in the destructive left fourth
rib lesion is noted.In addition, new metastatic bony lesions are
seen in vertebrae T4- T5.
.
Multiplanar reformats were essential in delineating the findings
described above.
.
IMPRESSION:
1. Post-obstructive multilobar left lung pneumonia.
2. Marked progression of metastatic disease with increase in
size of previous metastes, and development of innumerable
multiple new metastases, more prominently in the right lung.
3. Increase in left pleural effusion filling the whole of left
hemithorax
causing collapse of the left lung.
.
.
[**2184-8-3**] - PLEURAL FLUID: Gram stain negative, no growth on
culture.
.
.
[**2184-8-5**] - CXR
IMPRESSION:
1. Worsening confluent opacity in the right mid-lung zone is
concerning for superimposed pneumonia.
2. Probable increasing left pleural effusion and unchanged
collapse of the left lung.
.
.
[**2184-8-5**] - CXR
IMPRESSION:
1. Rapidly progressive airspace process in the right mid-lung
and base,
which, in clinical context, may represent noncardiogenic
pulmonary edema
related to the apparent clinical transfusion reaction.
Progressive pneumonic consolidation (including endobronchial
spread of infection) and alveolar hemorrhage are additional
concerns. Progression of known pulmonary metastases is most
unlikely given the rapidity of change.
2. Complete opacification of the left hemithorax, reflecting a
combination of obstructing [**Location (un) 21851**], lung collapse and
effusion.
.
.
TRANSFUSION REACTION WORKUP
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS:
Ms. [**Known lastname 76514**] experienced a 3 degree F temperature increase,
chills, a
significant drop in her O2 saturation from 90-94% to 81%, and
wheezing
following transfusion of 40 cc's of ABO/Rh compatible
leukoreduced,
irradiated RBC's. Her O2 saturation improved to 97% when
switched from
6L nasal cannula to non-rebreather mask. Response to Lasix per
the
clinical team was minimal (300cc diuresis). Post-transfusion CXR
showed
possible non-cardiogenic edema in right lung (left lung collapse
unchanged).
.
There was no evidence of hemolysis in the post-transfusion
sample (DAT
negative, clear yellow serum). Possible explanations for this
constellation of symptoms include TRALI (Transfusion-Related
Acute Lung
Injury), fluid-overload (TACO), allergy, or symptoms due to her
underlying medical condition (pneumonia, pleural effusion,
metastasis).
The presence of fever, minimal response to diuresis, and
noncardiogenic
pulmonary edema on CXR are suspicious for TRALI. Blood samples
will be
sent to the Red Cross for work-up of this possible TRALI
reaction and
reported in an addendum. TRALI reactions are thought to be
related to
the donor product and would require no change in transfusion
practice
for this patient.
.
Transfusion associated circulatory overload (TACO) is less
likely given
the small volume of RBCs transfused (40cc), and lack of
significant
response to Lasix per the clinical team. The post-transfusion
NTProBNP
did rise in this patient, however the increase is difficult to
interpret
in this setting. An allergic transfusion reaction is also less
likely
in this patient given the absence of additional typical allergic
symptoms. Ms. [**Known lastname 76520**] symptoms could also be due to her
underlying
pulmonary infections, lung collapse, and cancer.
.
No changes in transfusion practices are recommended at this time
in this
patient. Additional American Red Cross test results will be
reported in
an addendum.
Brief Hospital Course:
54 year old female with NSCLC on palliative chemotherapy
admitted [**2184-8-2**] with fevers. She had been treated for post
obstructive pneumonia with 2 courses of antibiotics as an
outpatient with no relief of her fevers. She continued to have
fever to 102. After admission, a CT scan was preformed which
showed worsening left sided pleural effusion. She underwent
thoracentesis, without positive cultures, and was cultured many
times for recurrent/daily fevers. The pleural fluid and blood
cultures remain negative. It was thought that her fevers were
likely related to her tumor/possible necrotic tissue in the
lung. Her antibiotic coverage was switched to Augmentin and
with the plan of being discharged on a ten day course. On
[**2184-8-5**], Ms. [**Known lastname 76514**] was receiving a blood transfusion for
anemia, and had an acute hypoxic reaction with heart rates to
the 150s. She was transferred to the [**Hospital Unit Name 153**] and her oxygen
requirement was weaned down to 4-5L at transfer. Her antibiotic
coverage was broadened to Zosyn on the day of [**Hospital Unit Name 153**] transfer, and
the patient has continued on Zosyn since this time.
In the ICU, the patient's decompensation was though to be
associated with TRALI, although other possibilities such as
volume overload, were considered. The patient was diuresed with
Furosemide. PE was unlikely given that the patient was on
therapeutic enoxaparin. Exacerbation of post-osbtructive
pneuomonia was also considered and the patient was continued on
Zosyn. Vancomycin was added to her regimen. The patient's
condition improved in the ICU and he was transfered back to the
floor.
Upon return to the floor the patient remained stable. She
complained of chest pressure and an subsequent ECG was noted to
show ST elevations in V1 and V2. Cardiac enzymes were negative.
The patient was started on ASA and her enoxoparin was continued.
The patient's pain was controlled on oxycodone. The did not have
any more chest pain following this episode.
The patient continued to have intermittent febrile episodes.
This was thought to be realted to her tumor or secondary to lung
infection. Given persistence of symptoms despite several courses
of antibiotics, it was less likely that this represents an
infectious source. Zosyn was continued. Fevers were controlled
with ibuprofen as needed.
The patient's hematocrit continued to decrease during her stay
with a nadir of 20.7. ASA and lovenox were held and the HCT
improved.
During the duration of admission the patinent and her partner,
who is her health care proxy, were [**Name2 (NI) 76521**] what the
appropriate goals of care would be. They decided that a
outpatient hospice program would be the best way to proceed at
this time.
Medications on Admission:
#. Benzonatate
#. Albuterol q6H PRN
#. Enoxaparin 80mg q12H
#. Lacutlose 30mL q8H:PRN
#. Levothyroxine 150mcg daily
#. Lorazepam 0.5mg q4H PRN
#. Ondansetron 8mg PO or IV q8H PRN
#. Oxycodone SR 60mg QAM, 80mg qPM
#. Ranitidine 150mg daily
#. Tiotropium 18mcg daily
#. docusate 100mg [**Hospital1 **]
#. MVI daily
#. Senna
#. Hydromorphone 2-4mg PO q3-4H PRN
#. Fluticasone-salmeterol 250/50 [**Hospital1 **]
#. Glyburide 2.5mg daily
Discharge Disposition:
Home With Service
Facility:
Old [**Hospital **] Hospice
Discharge Diagnosis:
Fever
Post-obstructive PNA
Transfusion reaction
NSCLC
Discharge Condition:
Comfortable
Discharge Instructions:
You were admitted with fever which was atributed to a
multifactorial process including a pneumonia and tumor related
changes in your lungs. With these in mind you were started on
antibiotic therapy. Also, during your stay you were noted to
have a worsening anemia which necessitated transfusion of blood
cells. During this process, you had a rare reaction that
resulted in problems with your blood oxygenation. We imediately
stopped the transfusion and trasnfered you to the intensive care
unit for observation. There you remained stable and then
transfered back to the oncology [**Hospital1 **]. You remained stable for
the remainder of your hispitalization.
Followup Instructions:
Home with hospice
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
Completed by:[**2184-8-13**]
ICD9 Codes: 486, 5180, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1332
} | Medical Text: Admission Date: [**2131-2-8**] Discharge Date: [**2131-2-15**]
Date of Birth: [**2077-10-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Amitriptyline / Latex / adhesive tape / adhesive bandage
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of breath and fatigue
Major Surgical or Invasive Procedure:
[**2131-2-8**] Redo mitral valve replacement with a size 27-mm St. [**Male First Name (un) 923**]
mechanical valve
History of Present Illness:
Ms. [**Known lastname **] is a 53 year old female with a history of mitral
valve disease and heart failure 2 years and 3 months after
resection of a large left atrial myxoma and mitral valve repair
with annuloplasty ring. Since the time of her surgery, she has
continued to have very limited exercise tolerance and gets short
of breath with routine activities such as climbing stairs,
grocery shopping etc. She has not had orthopnea or PND and has
not had any acute episodes of severe dyspnea since beginning
medical therapy with furosemide and lisinopril. Her last echo in
[**Month (only) 596**] showed moderate to severe mitral regurgitation. She is very
dissatisfied with her current quality of life and is depressed.
She has thus been referred for evaluation for a redo mitral
valve replacement.
Past Medical History:
Mitral regurgitation s/p Mitral valve repair/Resection of atrial
myxoma.rep. ASD [**9-10**]
Hidranitis suppurativa (feet/left inframammary/bil. groins)
Prediabetes
Benign pelvic mass (removed)
Glaucoma
Hypertension
Hyperlipidemia
Palpitations
Depression/Anxiety
Osteoarthritis neck
Remote B foot fractures
Past Surgical History:
s/p Laproscopic BSO [**5-13**]
s/p Vaginal delivery x 2, one complicated by stillbirth
s/p Right Shoulder arthroscopy
s/p Lumpectomy for benign breast mass
s/p L thigh mass removal
Social History:
Race: Caucasian
Last Dental Exam:one yr ago
Lives with: Husband
Occupation:
[**Name2 (NI) 1139**]: Smokes [**1-18**] cigarettes per day since age 18, denies
drug use.
ETOH: 2 drinks per week
Family History:
No cardiac relevant history
Physical Exam:
Pulse:67 Resp:18 O2 sat: 100%
B/P Right 136/69: Left:
Height:5' 3 [**2-4**] " Weight: 154#
General:NAD; well-appearing
Skin: Warm[] Dry [x] intact [x]right instep/bil. groins/left
inframammary fold with small ingrown areas and tiny red spots;
no
obvious infection present
HEENT: NCAT[x] PERRLA [x] EOMI [x]anicteric sclera;OP
unremarkable
Neck: Supple [x] Full ROM []no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur- 2/6 SEM heard loudest at
apex
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
no HSM/CVA tenderness; healed scars
Extremities: Warm [x], well-perfused [x] Edema -none
Varicosities: None [x]
Neuro: Grossly intact; MAE [**6-7**] strengths; nonfocal exam
Pulses:
Femoral Right: 1+ Left:2+
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2+ Left:2+
Radial Right: 2+ Left:2+
Pertinent Results:
[**2131-2-8**] Intraop Echo: Left ventricular wall thicknesses and
cavity size are normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. There are simple atheroma in
the ascending aorta. There are simple atheroma in the aortic
arch. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic regurgitation. A
mitral valve annuloplasty ring is present. Moderate to severe
(3+) mitral regurgitation is seen.The jet is
transvalvular,etiology from a coaptation defect bettween the
anterior and residual remnant of the posterior mitral valve
replacement.
Post Bypass: Patient is now s/p 27 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Mechanical Mitral
valve replacement on a Norepinephrine drip at 0.06 mcg/kg/min.
The cardiac output is 5.2lpm. The mechanical mitral valve is
well seated with appropriate washing jets observed.There are no
paravalvular leaks observed. The mean gradient across the Mitral
valve is 4mmHg. The ventricular function is preserved with an
EF>55%. There are no visible aortic dissection flaps observed.
.
[**2131-2-14**] Discharge Chest x-ray: The tiny right apical
pneumothorax is decreased and the miniscule left apical
pneumothorax is unchanged. Small bilateral pleural effusions are
unchanged. Opacification of the right middle lobe has increased.
Linear left basilar atelectasis is unchanged. Moderate
cardiomegaly is unchanged and has a normal post-operative
appearance. A prosthetic mitral valve is seen.
.
[**2131-2-14**] WBC-6.0 RBC-3.48* Hgb-10.8* Hct-30.9* MCV-89 MCH-31.1
MCHC-35.0 RDW-16.0* Plt Ct-331
[**2131-2-13**] WBC-5.6 RBC-3.21*# Hgb-9.8*# Hct-28.3*# MCV-88 MCH-30.5
MCHC-34.5 RDW-16.7* Plt Ct-273
[**2131-2-12**] WBC-6.0 RBC-2.35* Hgb-7.6* Hct-21.5* MCV-91 MCH-32.2*
MCHC-35.2* RDW-14.4 Plt Ct-221
[**2131-2-11**] WBC-8.6 RBC-2.54* Hgb-8.1* Hct-23.0* MCV-91 MCH-31.7
MCHC-35.1* RDW-14.6 Plt Ct-203
[**2131-2-10**] WBC-10.9 RBC-2.78* Hgb-8.8* Hct-25.5* MCV-92 MCH-31.5
MCHC-34.4 RDW-15.2 Plt Ct-191
[**2131-2-15**] PT-27.5* INR(PT)-2.7*
[**2131-2-14**] PT-24.8* PTT-37.0* INR(PT)-2.4*
[**2131-2-13**] PT-23.1* INR(PT)-2.2*
[**2131-2-12**] PT-33.6* PTT-41.4* INR(PT)-3.4*
[**2131-2-11**] PT-17.5* INR(PT)-1.6*
[**2131-2-14**] Glucose-133* UreaN-8 Creat-0.5 Na-138 K-4.0 Cl-103
HCO3-28
[**2131-2-13**] Glucose-101* UreaN-11 Creat-0.5 Na-139 K-3.9 Cl-103
HCO3-29
[**2131-2-12**] Glucose-131* UreaN-11 Creat-0.6 Na-137 K-3.7 Cl-100
HCO3-32
[**2131-2-11**] Glucose-103* UreaN-7 Creat-0.4 Na-134 K-4.0 Cl-99
HCO3-30
[**2131-2-10**] Glucose-105* UreaN-6 Creat-0.5 Na-135 K-4.2 Cl-103
HCO3-29
Brief Hospital Course:
Mrs. [**Known lastname **] was a same day admit and on [**2131-2-8**] was brought
directly to the operating room where she [**Date Range 1834**] a
redo-sternotomy, and mitral valve replacement. Please see
operative report for surgical details. Following surgery she was
transferred to the CVICU for invasive monitoring. Within 24
hours she was weaned from sedation, awoke neurologically intact
and was extubated without incident. On post-op day one,
beta-blockers and diuretics were started. On post-op day two she
was transferred to the step-down floor for further care and
recovery. Chest tubes and epicardial pacing wires were removed
without complication. Coumadin was started with a Heparin bridge
until patient's INR was therapeutic. Given the mechanical mitral
valve, Coumadin was dosed daily and titrated for a goal INR
between 3.0 - 3.5. She experienced a postoperative delirium
which improved with several days of Haldol. By discharge, her
mental status improved significantly. Over several days, she
otherwise continued to make clinical improvements with diuresis.
She remained in a normal sinus rhythm as beta blockade was
advanced as tolerated. She was cleared for discharge to home on
postoperative day seven. Prior to discharge, outpatient Coumadin
followup was arranged with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] [**Hospital6 733**].
Medications on Admission:
AMOXICILLIN - 500 mg Tablet - 4 Tablet(s) by mouth 1 hour before
dental procedure
FUROSEMIDE [LASIX] - 20 mg Tablet - 1 Tablet(s) by mouth once a
day
LISINOPRIL - 5 mg Tablet - 1 Tablet(s) by mouth daily
LORAZEPAM - 1 mg Tablet - 1 (one) Tablet(s) by mouth at bedtime
[**Month (only) 116**] take additional [**2-4**] tablet twice during the day prn anxiety
METOPROLOL TARTRATE - (Dose adjustment - no new Rx) - 50 mg
Tablet - 0.5 (One half) Tablet(s) by mouth twice a day
PAROXETINE HCL - 20 mg Tablet - 1 Tablet(s) by mouth once a day
TRAVOPROST (BENZALKONIUM) [TRAVATAN] - (Prescribed by Other
Provider: [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **]) - 0.004 % Drops - 1 gtts bilateral eyes as
directed by optho
TRAZODONE - 50 mg Tablet - 1 [**2-4**] Tablet(s) by mouth at bedtime
call with any worsening of symptoms.
ACETAMINOPHEN - (OTC) - 500 mg Tablet - [**2-4**] Tablet(s) by mouth
once a day as needed for pain
ASPIRIN - (OTC) - 81 mg Tablet - 1 Tablet(s) by mouth DAILY
(Daily)
MULTIVITAMIN [ONE DAILY MULTIVITAMIN
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 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:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*70 Tablet(s)* Refills:*0*
5. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily).
Disp:*qs qs* Refills:*0*
7. Travatan Z 0.004 % Drops Sig: One (1) gtt Ophthalmic at
bedtime: 1 gtt in each eye .
Disp:*qs qs* Refills:*0*
8. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
twice a day.
Disp:*180 Tablet(s)* Refills:*2*
9. lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
10. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Take
for INR between 3.0 and 3.5.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] homecare
Discharge Diagnosis:
Mitral regurgitation s/p Redo-sternotomy Mitral valve
replacement
Hypertension
Hyperlipidemia
Depression/Anxiety
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tylenol and Dilaudid
Incisions:
Sternal - 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**]
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:
You are scheduled for the following appointments
Surgeon: Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**] at [**2131-3-5**] 1:30
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 62**] Date/Time:[**2131-3-12**]
3:40
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 410**] [**Telephone/Fax (1) 1144**] Date/Time:[**2131-4-13**]
2:00
**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 Mechanical mitral valve
Goal INR 3.0 - 3.5
First draw [**2131-2-16**]
Results to [**Company 191**] Anticoagulation phone [**Telephone/Fax (1) 2173**] fax
[**Telephone/Fax (1) 3534**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2131-2-15**]
ICD9 Codes: 2930, 4240, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1333
} | Medical Text: Admission Date: [**2121-8-13**] Discharge Date: [**2121-8-27**]
Date of Birth: [**2053-10-25**] Sex: F
Service: Cardiac Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 67-year-old
woman with a known history of three vessel coronary artery
disease dating back to [**2117**], a remote history of a silent
myocardial infarction and a known history of renal artery
disease. She originally underwent cardiac catheterization in
[**2117**] at which time no intervention was performed.
More recently, the patient underwent an EGG/Thallium stress
test. She had no anginal symptoms during exercise. Nuclear
imaging revealed distal anterior and apical ischemia with
ejection fraction of approximately 42% with akinesis of the
apex.
The patient's main complaint has been low extremity edema
which has been controlled with Lasix. Prior to admission,
she denied any chest pain or shortness of breath, although
according to patient's relatives she does become short of
breath after ambulating one and a half blocks. The patient
was consequently referred for a cardiac catheterization on
[**2121-8-14**]. Cardiac catheterization revealed a severe three
vessel coronary artery disease. Please see the full report
for detail.
The patient presented to [**Hospital6 256**]
for a possible surgical intervention for her coronary artery
disease.
PAST MEDICAL HISTORY:
1. Coronary artery disease x3
2. History of a silent myocardial infarction
3. Right renal artery stenosis, status post stenting in [**2117**]
4. Hypertension
5. Low extremity edema
SOCIAL HISTORY: History of smoking x40 years
PAST SURGICAL HISTORY: Cesarean section in [**2089**]
ALLERGIES: PENICILLIN
ADMISSION MEDICATIONS:
1. Aspirin 325 mg po q day
2. Atenolol 50 mg q day
3. Lasix 20 mg q day
4. Zestril 50 mg q day
5. Plavix 75 mg q day
6. Vioxx 25 mg q day
7. Isordil 10 mg tid
8. Serax 10 mg q day
ADMISSION LABORATORIES: Hematocrit 41, white blood cell
count 10, platelets 281. Sodium 140, potassium 4.5, BUN 27,
creatinine 1.6, INR 1.2, glucose 90.
PHYSICAL EXAMINATION:
GENERAL: Alert and oriented, afebrile.
VITAL SIGNS: Heart rate 60.
HEAD, EARS, EYES, NOSE AND THROAT: Within normal limits.
NECK: No bruits and no jugular venous distention.
CHEST: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm, no murmurs.
ABDOMEN: Soft, obese with a scar from previous cesarean
section.
EXTREMITIES: Trace ankle edema with normal pulses.
SUMMARY OF HOSPITAL COURSE: Given results of the cardiac
catheterization and patient's symptoms, it was decided that a
surgical approach would be the best option for her coronary
artery disease. On [**2121-8-15**], the patient underwent coronary
artery bypass grafting x3 with left internal mammary artery
to the ramus intermedius, coronary artery and reverse
saphenous vein graft from the aorta to the left anterior
descending coronary artery; reverse saphenous vein graft from
the aorta to the third obtuse marginal coronary artery. The
patient tolerated the procedure well. Pacing leads were
placed. There were no complications. The patient was
transferred to the Intensive Care Unit in stable condition.
The patient continued to do well in the Intensive Care Unit.
She was extubated on postoperative day 1. Postoperative
ejection fraction was 42%. The patient was without any
pressors postoperative day 1. She was started on Lasix,
Lopressor and aspirin. The patient exhibited 90% oxygen
saturation on 4 liters. She had a temperature of 100.7??????
which was thought to be due atelectasis. Physical therapy
was consulted which was following the patient throughout her
hospitalization. The patient was transferred to the floor on
postoperative day 2. Her pacing wires were removed. Her
chest tube was removed as well. Hematocrit remained stable.
The patient remained in sinus rhythm during her stay on the
floor. There was some difficulty in the beginning to wean
the patient off of supplemental oxygen. The chest x-ray
showed persistent left lower lobe atelectasis and left
pleural effusion.
On postoperative day 7, an attempt was made to tap pleural
fluid on the left side. That side tap was unsuccessful. The
patient was sent to radiology for ultrasound guided tap
effusion. However, that effort was unsuccessful as well
since there was little fluid to drain. At the same time, a
decubitus left lateral chest x-ray showed loculated fluid
question of a small pocket of consolidation. The patient was
diuresed aggressively. She continued to require less
supplemental oxygen. The patient was discharged on
postoperative day 7.
DISCHARGE CONDITION: Stable
DISPOSITION: Rehabilitation facility
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass graft x3
2. History of silent myocardial infarction
3. Renal artery stenosis status post stenting
4. Hypertension
DISCHARGE MEDICATIONS:
1. Lopressor 50 mg po bid
2. Plavix 75 mg po q day
3. Lasix 40 mg po bid x14 days, followed by outpatient dose
of 20 mg po q day
4. Potassium chloride 20 milliequivalents po bid x14 days
5. Ranitidine 150 mg [**Hospital1 **]
6. Percocet 1 to 2 tablets po q 4 to 6 hours prn pain
7. Milk of Magnesia 30 ml po hs prn constipation
8. Tylenol 650 mg po q4h prn
9. Colace 100 mg po bid prn
DISCHARGE INSTRUCTIONS:
1. The patient is to follow up with her surgeon, Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 70**], in approximately six weeks.
2. The patient is to follow up with her primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], in approximately one to two
weeks.
3. The patient is to follow up with cardiologist in
approximately three to four weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2121-8-26**] 09:34
T: [**2121-8-26**] 09:43
JOB#: [**Job Number **]
ICD9 Codes: 5180, 5990, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1334
} | Medical Text: Admission Date: [**2165-4-24**] Discharge Date: [**2165-7-19**]
Date of Birth: [**2101-6-19**] Sex: M
Service: SURGERY
Allergies:
Benadryl / Morphine
Attending:[**First Name3 (LF) 1781**]
Chief Complaint:
right lower extremity ischemia
Major Surgical or Invasive Procedure:
- s/p fem-fem bipass
Status post right groin exploration, evacuation
of hematoma, VAC dressing placement.
History of Present Illness:
63M s/p fem-fem bypass [**4-25**] c/b R groin hematoma.
Past Medical History:
1. Coronary artery disease: Myocardial infarction in [**2155**],
MQWMI in [**2160**]. Most recent cath, [**2163-10-18**]: LCx stenting; previous
RCA stent patent at that time.
2. Nonischemic dilated cardiomyopathy; EF [**12-6**] 33%. EF [**2164-1-11**]
to 25%
3. Diabetes greater than 20 years; with triopathy.
4. Hypertension.
5. End stage renal disease on hemodialysis, q. Monday,
Wednesday and Friday via right arteriovenous fistula.
6. Hypothyroidism.
7. Chronic obstructive pulmonary disease.
8. Hepatitis C.
9. Chronic pancreatitis.
10. Peptic ulcer disease.
11. Right perinephric hematoma; status post embolization.
12. Obstructive sleep apnea on CPAP.
13. Ruptured right groin abscess; recurrent right groin
abscess in [**2162-12-4**].
14. Peripheral vascular disease.
15. Status post R PFA to BK [**Doctor Last Name **] bypasss graft with vein
16. Status post 2nd and 3rd toe amps
17. Status post left CFA to AK [**Doctor Last Name **] with PTFE
18. Status post L inguinal hernia repair
19. Status post umbilical hernia repair
20. Ischemic left foot
21. A - Fib
Social History:
Social: [**Location (un) 686**], lives with wife, has older children, tob: 1
ppd x 60 yrs. quit 3 months ago, no EtOH
Family History:
Non contributary
Physical Exam:
On discharge
vital: 97.9 88 116/69 16 99%ra FS 113-161
WD, WN, NAD
CTAB no w/c/r
RRR, no m/r/g
soft, nt, nd, nabs
Groin: Right - VAC dressing in place / wound C/D / exposed graft
L foot w/well granulated wound on W->D dressing changes; right
foot warm
Pulses: R DP.PT dop, L DP/PT dop, graft palp
Pertinent Results:
[**2165-7-19**] 08:00AM BLOOD
WBC-8.7 RBC-3.51* Hgb-12.3* Hct-38.6* MCV-110* MCH-35.2*
MCHC-31.9 RDW-26.8* Plt Ct-336
[**2165-7-15**] 07:25AM BLOOD
Neuts-75* Bands-0 Lymphs-10* Monos-6 Eos-7* Baso-0 Atyps-2*
Metas-0 Myelos-0 NRBC-1*
[**2165-7-4**] 05:08AM BLOOD
PT-15.0* PTT-36.5* INR(PT)-1.4*
[**2165-7-17**] 07:30AM BLOOD
Glucose-120* UreaN-58* Creat-6.9* Na-135 K-5.7* Cl-96 HCO3-20*
AnGap-25*
[**2165-6-18**] 01:23PM BLOOD
ALT-34 AST-30 LD(LDH)-149 AlkPhos-177* Amylase-182* TotBili-0.2
[**2165-7-12**] 07:55AM BLOOD
Albumin-3.9 Calcium-8.7 Phos-5.5* Mg-2.2 UricAcd-5.0
[**2165-6-10**] 01:09AM BLOOD
calTIBC-213* Ferritn-678* TRF-164*
[**2165-6-18**] 09:18AM BLOOD
PTH-609*
[**2165-6-28**] 8:30 am
BLOOD CULTURE
**FINAL REPORT [**2165-7-4**]**
AEROBIC BOTTLE (Final [**2165-7-4**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2165-7-4**]): NO GROWTH
[**2165-7-11**] 1:19:38 PM
Sinus rhythm.
Left anterior fascicular block
QT interval prolonged for rate
Lateral ST-T changes may be due to myocardial ischemia
Since previous tracing of earlier [**2165-7-11**], no significant change
Intervals Axes
Rate PR QRS QT/QTc P QRS T
83 170 100 416/455.71 -4 -48 128
[**2165-7-3**] 2:09 PM
FINDINGS: Subcutaneous edema was present in the left lower
extremity. The left greater saphenous vein has been previously
harvested. The left lesser saphenous vein is patent with
diameters varying between 0.16 and 0.23 cm. The vein measures
0.18 cm superiorly, 0.23 cm in its mid portion, and 0.16 cm
inferiorly.
The right greater saphenous vein has been previously harvested.
The right lesser saphenous vein contains mural calcifications
but is patent. The diameters of the right lesser saphenous vein
vary between 0.14 and 0.18 cm.
A PICC line is present in the left cephalic vein, which is
otherwise patent. The left basilic vein is patent with diameters
of 0.25 cm superiorly, 0.14 cm in the mid arm, 0.39 cm at the
antecubital fossa, and 0.14 cm in the forearm.
The right forearm has an arteriovenous fistula. The right
cephalic vein has diameters varying between 0.35 and 0.52 cm and
is patent. There is pulsatility of the flow in the right
cephalic vein and this possibly represents an outflow vein from
the arteriovenous fistula. The right basilic vein is patent in
the arm with diameters varying between 0.29 and 0.51 cm.
IMPRESSION: Prior harvesting of the greater saphenous veins
bilaterally.
Small caliber lesser saphenous veins bilaterally with
calcifications in the right lesser saphenous vein murally.
Patent left cephalic vein containing a PICC.
The left basilic vein is patent with some diameters less than
0.20 cm.
There is an AV fistula on the right forearm. The cephalic and
basilic veins on the right are patent.
[**2165-6-18**] 10:58 AM
CT HEAD W/O CONTRAST
TECHNIQUE: Noncontrast head CT scan.
COMPARISON STUDIES: [**2164-10-28**]. Noncontrast head CT
scan, also performed for mental status changes and interpreted
by Dr. [**Last Name (STitle) **] as showing "small area of low attenuation
involving the right occipital lobe, suggestive of a small
infarct of uncertain age."
FINDINGS: The present study has a few images which are degraded
by streak artifacts. Allowing for this deficiency, no overt
interval change is noted. Once again, a small area of low
density is noted within the right occipital lobe region, which
likely represents an area of chronic infarction. Also, both
studies disclose a small linear area of low density within the
left parietal white matter, again probably representing an area
of chronic infarction within border zone distribution. Upon
referral to the prior MR report of [**2164-10-31**] (the
images not being available on PACS at this time), apparently
areas of T2 hyperintensity within the white matter were detected
by Dr. [**Last Name (STitle) **], and may well conform to the CT abnormalities
noted above. There is no hydrocephalus or shift of normally
midline structures. The surrounding osseous and extracranial
soft tissues are otherwise unremarkable.
IMPRESSION: Stable, abnormal study as noted above.
[**2165-6-20**] 7:26 PM
MRA NECK W/O CONTRAST; MRA BRAIN W/O CONTRAST
MRA OF THE NECK:
The neck MRA demonstrates normal flow signal within the carotid
and vertebral arteries. No evidence of vascular occlusion or
stenosis is identified. The left vertebral origin is not well
visualized. If further evaluation is clinically indicated
consider gadolinium-enhanced MRA.
IMPRESSION: No evidence of stenosis or occlusion in the arteries
of neck. The left vertebral origin is not well visualized and if
clinically indicated, gadolinium-enhanced MRA would help for
further assessment.
MRA OF THE HEAD:
The head MRA demonstrates normal flow signal within the arteries
of anterior and posterior circulation. The distal left vertebral
artery is small in size secondary to the left cervical vertebral
artery ending in posterior inferior cerebellar artery, a normal
variation.
IMPRESSION: Normal MRA of the head.
[**2165-6-12**]
ECHO
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.2 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *6.7 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.7 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.4 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: *7.1 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 6.3 cm
Left Ventricle - Fractional Shortening: *0.11 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 20% (nl >=55%)
Aorta - Valve Level: *3.8 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.6 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.9 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A Ratio: 0.90
Mitral Valve - E Wave Deceleration Time: 228 msec
TR Gradient (+ RA = PASP): *35 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Moderate LA enlargement. Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Mild symmetric LVH. Severely dilated LV cavity.
Severe global LV hypokinesis. Severely depressed LVEF. TVI E/e'
>15, suggesting PCWP>18mmHg.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal
inferoseptal - hypo; mid inferoseptal - hypo; basal inferior -
akinetic; mid inferior - akinetic; basal inferolateral -
akinetic; mid inferolateral - akinetic; septal apex - hypo;
inferior apex - hypo; lateral apex - hypo;
RIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber
size. RV function depressed.
AORTA: Mildly dilated aortic root. Mildly dilated ascending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets. Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Mild [1+] TR. Mild PA systolic hypertension.
PERICARDIUM: No pericardial effusion.
Conclusions:
1The left atrium is moderately dilated. The left atrium is
elongated.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity is severely dilated. There is severe
global left ventricular hypokinesis. Overall left ventricular
systolic function is severely depressed.
Tissue velocity imaging E/e' is elevated (>15) suggesting
increased left
ventricular filling pressure (PCWP>18mmHg). Resting regional
wall motion
abnormalities include basal and mid inferior and inferolateral
akinesis..
3. Right ventricular chamber size is normal. Right ventricular
systolic
function appears depressed.
4.The aortic root is mildly dilated. The ascending aorta is
mildly dilated.
5.The aortic valve leaflets are mildly thickened. Trace aortic
regurgitation is seen.
6.The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
7.There is mild pulmonary artery systolic hypertension.
8.There is no pericardial effusion.
Compared to the previous report of [**2164-4-30**], there has been a
decrease in the severtiy of the MR while the EF has unchanged.
The PA pressure has decreased from 44 mmHg.
[**2165-6-11**]
PERSANTINE MIBI
Left ventricular cavity size is markedly enlarged during rest
and stress. The EDV=331 cc.
Resting and stress perfusion images reveal a mild reversible
lateral wall
perfusion defect. The inferior wall perfusion defect seen in the
prior study is not apparent in this study.
Gated images reveal severe global systolic dysfunction.
The calculated left ventricular ejection fraction is 18%.
IMPRESSION: 1. Mild reversible lateral wall perfusion defect.
The inferior wall perfusion defect seen in the prior study is
not apparent in this study. 2.Dilated LV with severe global
systolic dysfunction. EDV=331 cc and EF=18%. The findings are
consistent with dilated ischemic cardiomyopathy.
[**2165-6-11**]
Stress
TOTAL EXERCISE TIME: 4 % MAX HRT RATE ACHIEVED: 45
SYMPTOMS: NONE
ST DEPRESSION: NONE
INTERPRETATION: This 63 year old type 2 IDDM man with a history
of
CAD and PVD was referred to the lab for evaluation. The patient
was
infused with 0.142 mg/kg/min of dipyridamole over 4 minutes. No
arm,
neck, back or chest discomfort was reported by the patient
throughout
the study. There were no significant ST segment changed during
the
infusion or in recovery. The rhythm was sinus with frequent
isolated
apbs and several isolated vpbs. Appropriate hemodynamic response
to the
infusion. The dipyridamole was reversed with 125 mg of
aminophylline IV.
IMPRESSION: No anginal type symptoms or significant EKG changes.
Brief Hospital Course:
Pt had a very long hospital course.
The hospital course was uneventful for the patient. He did have
the below procedures done.
[**2165-4-25**]
Fem-fem bypass using the pre-existing axillary
femoral bypass as our inflow on the left and our outflow was
the pre-existing profunda to popliteal bypass on the right
with PTFE 8 mm ringed graft.
[**2165-5-23**]
Status post right groin exploration, evacuation of hematoma, VAC
dressing placement.
The patient was kept in the hospital for an exposed graft / IV
Antibiotics / VAC dressing changes.
Pt recieved HD on his scheduled days. M/W/F
PT worked with the patient
On DC pt is taking PO / ambulating with asst. / pos BM / he does
make urine, but is on HD
Most importantly the patient is groin is closing in considerably
around the graft site.
Medications on Admission:
heparin 5000""
lasix 80"
sevelamer 1600"
protonix 40'
metoprolol 25"
epoetin 4000""
lisinopril 5'
amiodarone 200'
atorvastatin 10'
lactulose 30'
[**Month/Day/Year 4532**] 75'
[**Month/Day/Year **] 81'
tylenol 650 prn
albuterol mdi prn
regular isulin sliding scale
ipratropium mdi prn
Discharge Medications:
1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
5. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
7. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
9. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
10. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
13. Ceftazidime-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) Intravenous Q48H (every 48 hours).
14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
15. Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
16. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
17. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
19. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
20. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily).
21. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
22. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
23. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
24. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
ASDIR (AS DIRECTED).
25. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
26. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
27. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed.
28. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
29. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
30. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
31. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
32. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
33. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
34. PICC Care
Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
35. Heparin
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular
Glucose Insulin Dose
0-50 mg/dL 4 oz.
51-150 mg/dL 0 Units 0 Units 0 Units 0 Units
151-200 mg/dL 2 Units 2 Units 2 Units 2 Units
201-250 mg/dL 4 Units 4 Units 4 Units 4 Units
251-300 mg/dL 6 Units 6 Units 6 Units 6 Units
301-350 mg/dL 8 Units 8 Units 8 Units 8 Units
351-400 mg/dL 10 Units 10 Units 10 Units 10 Units
36. Imipenem-Cilastatin 500 mg Recon Soln Sig: One (1)
Intravenous once a day: On Hemodilaysis days give after
hemodilaysis.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
s/p fem-fem bipass
CRI
Mental status changes / hypotension
Discharge Condition:
- good
Discharge Instructions:
- you may shower; no bath or swimming pool for several weeks
- you should take all medications as instructed to in the
hospital
- you should take pain medication as needed
- do not drive while taking pain medicaiton
- every day you take pain medication you should also take stool
softeners: colace, senna, or dulcolax are all good options
- [**Name8 (MD) 138**] MD or return to ED if T>101.5, chills, nausea, vomiting,
chest pain, shortness of breath, severe pain in leg or at
incision site, redness or smelly drainage from incision site, or
any other concern
Followup Instructions:
- You will need to follow-up with Dr. [**Last Name (STitle) **] in 1 week for
follow-up and staple removal. Please call her office at ([**Telephone/Fax (1) 1804**] to schedule an appointment.
Completed by:[**2165-7-19**]
ICD9 Codes: 4254, 5856, 496, 4589, 3572, 2449, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1335
} | Medical Text: Unit No: [**Numeric Identifier 63484**]
Admission Date: [**2119-7-28**]
Discharge Date: [**2119-10-12**]
Date of Birth: [**2119-7-28**]
Sex: M
Service: Neonatology
HISTORY OF PRESENT ILLNESS: The patient is a 28 and [**1-13**] week
gestational age infant admitted with respiratory distress and
an antenatal diagnosis of fetal hydrops.
MATERNAL HISTORY: Significant for a 29-year-old, gravida 1,
para 0-1 woman with an unremarkable past medical history
including no recent acute viral illness for flu-like
symptoms.
Prenatal screens were as follows: Blood type B+, antibody
negative, hepatitis B negative, RPR nonreactive, rubella
immune, GBS unknown.
ANTENATAL HISTORY: Last menstrual period was on [**2119-1-12**], for an estimated date of delivery of [**2119-10-19**],
and estimated gestational age of 28 and 1/7 weeks. A
quadruple screen was normal, and fetal survey was normal at
18 weeks with the exception of mild size discrepancy of
approximately one week. There were no subsequent ultrasounds.
Pregnancy was complicated by gestational hypertension treated
with bed rest for the past two weeks. In the past 24 hours,
mother noted decreased fetal movement. Assessment at [**Hospital6 33180**] showed IUGR with an estimated fetal
weight of 681 g, with oligohydramnios, cardiomegaly,
echogenic bowel, mild ascites, mild pericardial
effusion, and an elevated MCA Doppler flow, all consistent
with anemia and non-immune hydrops.
Mother received one dose of betamethasone and was transferred
to [**Hospital6 256**].
A biophysical profile was done at [**Hospital1 18**], which was 4 out of 8
with an AFI of 1.7 and breech presentation noted. She proceeded
to cesarean section under spinal anesthesia. Membranes were
ruptured at delivery yielding meconium-stained amniotic
fluid. There was a single nuchal cord.
NEONATAL COURSE: The infant was hypotonic, bradycardiac, and
apneic at delivery. He was orally bulb suctioned, dried and
received bag mask ventilation for less than one minute with
subsequent increase in heart rate to greater than 100. He was
intubated uneventfully with a 2.5 endotracheal tube on the
second attempt with endotracheal tube position confirmed
through auscultation. Clear secretions were noted.
Following intubation, he had irregular respirations, tone
consistent with gestational age, and spontaneous eye opening.
Apgar scores were 4 at one minute, 6 at five minutes, and 7
at ten minutes. Moderate bruising was noted on the right
anterior chest wall. There was no evidence of hydrops on
initial physical exam. He was transferred uneventfully to the
NICU.
PHYSICAL EXAMINATION: Vital signs: On admission heart rate
was 160, respiratory rate 60-80, blood pressure 52/25,
temperature 94.8 up to 98.7 on the warmer, O2 saturation 89%,
100% FIO2 on SIMV. Birth weight 645 g, less than the 10th
percentile, head circumference of 21 cm, less than the 10th
percentile, length 31 cm, less than the 10th percentile. In
general the infant had an examination consistent with a 28-
week gestational age. HEENT: Anterior fontanel was soft and
full. The infant was nondysmorphic with an intact palate.
Neck, mouth and ears normal. Red reflex was deferred. Chest:
Moderate intercostal and subcostal retractions with
spontaneous breaths. Fair exclusion with mechanical
ventilation. Good bilateral breath sounds and scattered
coarse crackles. Cardiovascular: Exam revealed a fairly well
perfused infant with capillary refill 3-4 seconds. No
significant pallor. No edema. Regular rate and rhythm. Normal
femoral pulses. Normal S1 and S2. No murmur. Abdomen: Mildly
distended. Liver was palpated 2 cm below the right costal
margin. There was no splenomegaly. No masses. Bowel sounds
active. Anus was patent. GU: Normal penis with testes
undescended bilaterally. CNS: Exam revealed an active infant
responsive to stimulation. Tone was appropriate for
gestational age. Moving all extremities symmetrically with
spontaneous eye opening. Intact gag. Symmetric grasp. Skin:
Exam showed ecchymosis on the right anterior chest, otherwise
normal. Musculoskeletal: Exam was normal including spine,
limbs, hips, clavicles.
HOSPITAL COURSE:
1. Respiratory: As stated above, the patient was intubated
in the delivery room and was begun on SIMV shortly after
delivery. On day of life #1, due to difficulty with
ventilation, the patient was transitioned to high-flow
oscillating ventilator. O2 remained on until day of life
#7 at which time he was transitioned to conventional
mechanical ventilation.
The patient remained on conventional mechanical ventilation
until day of life #13 when he was transitioned to CPAP. The
patient remained on CPAP until day of life #34 when he was
placed on nasal cannula. The patient is currently on room air
since [**10-7**] and has been successfully weaned from nasal
cannula for greater than four days. On the evening of [**10-12**] he
did require some oxygen immediately post-op from his hernia
repair. This was discontinued by the morning of [**10-13**].
The patient had developed apnea of prematurity and was begun
on caffeine on day of life #8. He remained on caffeine until
day of life #50, at which time the caffeine was discontinued.
The patient has had no apneic or bradycardiac spells in
greater than five days.
Due to concerns of chronic lung disease, the patient received
a three-day course of Lasix beginning on day of life #60 with
good response. He was begun on Diuril on day of life #65,
which he currently remains on at a dose of 40mg/kg/d or 40 mg po
BIO with normal electrolytes on last check
(Na=136/K=4.8/CL=99/HCO3=27. He is also receiving potassium
chloride 1 mEq po BID.
2. Cardiovascular: The patient had an echocardiogram done
shortly after delivery on day of life #1 which showed a
structurally normal heart with normal anatomy and good
biventricular function. There was a large PDA noted with
bidirectional flow. There was no effusion noted on this
initial echocardiogram.
The patient did begin a course of indomethacin and required
two course of indomethacin in order to close the patent
ductus arteriosus. Follow-up echocardiogram on day of life #5
did show that the PDA was closed and continued to show no
pericardial effusion.
Most recent echocardiogram was on day of life #32 which
showed a PFO with some left-to-right shunting, no duct noted,
good biventricular function and continued no effusion. The
patient does continue to have an intermittent murmur but has
been hemodynamically stable with no differences in blood
pressures. The patient never required blood pressure
medications to maintain normal blood pressures.
3. Fluid, electrolytes and nutrition: The patient was
initially NPO on parenteral nutrition and intralipids.
Feedings were initiated on day of life #10 and were
slowly advanced. The patient is currently on ad lib
feedings with a minimum of 140 cc/kg/day of breast milk,
28 cal/oz. Most recent weight on [**10-18**] was 2345g. WEIGHT ON
[**10-17**]=2435g. On [**10-16**], his HC=33cm, L=43.5cm
The infant did have elevated alkaline phosphatase levels,
which improved when feeds were supplemented with HMF only or
concentrate. His max AlkP was 715 on 9/23The most recent
AlkP on [**10-15**] was 520. . FOllow- up recommendations are to
check the AlkP with next set of lytes and if continues to be
decreasing, don't need to further check unless change the way
the milk is being made.
Recent electrolytes on [**10-15**] was 136.4,8.99.27.
4. GI: The patient developed hyperbilirubinemia on day of
life #1 and was begun on phototherapy. The patient
remained on phototherapy through day of life #11 when the
phototherapy was discontinued. The patient has remained
without any further issues of hyperbilirubinemia.
5. Hematology: The patient has received a total of four
packed red blood cell transfusions and three platelet
transfusions throughout his course. The patient is
currently on iron and Vi-Daylin. Most recent hematocrit was
36.3%
6. Infectious disease: The patient was initially started on
ampicillin and gentamicin. At the time of delivery due to
concerns of sepsis, CBC and blood culture was obtained.
CBC was reassuring, and blood culture was negative at 48
hours, and antibiotics were discontinued.
Given the baby's small size, an infectious disease consult
was obtained, and the baby had a viral studies obtained
including a CMV, which was negative, parvovirus which was
negative, toxoplasma was negative.
On day of life #3, due to concerns of sepsis, once again the
baby was started on antibiotics, and blood culture was
obtained. Due to nonreassuring CBC and continued septic-like
picture, the baby was continued on ampicillin and gentamicin
for a total of seven days at that point. The patient had no
further infectious disease concerns at that point.
7. GU: The patient did have a hypospadias noted shortly
after birth for which he will need follow up with the
urology clinic. The patient also had a left-sided
inguinal hernia and had surgical repair by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 37080**]
at [**Hospital3 1810**] on [**10-12**] with bilateral hydrocele
repair as well.
8. Neurology: The infant had a first ultrasound on day of
life #10 which showed a left-sided grade II
intraventricular hemorrhage. He has had many subsequent
head ultrasound; On [**9-22**] which was day of life #56.
Head ultrasound showed continued bilateral cystic changes
c/w periventricular leukomalacia, also with hemorrhage noted
in the left lateral ventricle and left white matter. A repeat
ultrasound on [**10-13**] did not show any change. The
plan is for follow up with neurology as an outpatient.
9. Sensory: Hearing screen passed.
10. Eye examination: Most recent eye examination was done on
day of life #71 which showed stage I zone II retinopathy
of prematurity, five clock-hours bilaterally, with a plan
for a repeat eye exam in two weeks.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1) DIURI 40 mg po q 12 hours.
2) KCL 1 mEq po q 12 hours.
3) [**First Name9 (NamePattern2) **] [**Male First Name (un) **] 0.2 cc po q day
4) Vidaylin 1 cc po q day.
FOLLOWUP APPOINTMENTS:
1) VNA-tomorrow
2) EIP,. referral made
3) Pulmonary with Dr. [**Last Name (STitle) 37305**] [**11-10**] at 1100
4) Urology at ~6 months of age.
5) Neurology
6) Infant [**Hospital **] Clinic at [**Hospital3 1810**]
7) Surgery with Dr. [**Last Name (STitle) 37080**] on 19/25.
8) Ophtho Dr. [**Last Name (STitle) **] on [**10-19**].
DISPOSITION: To home.
PRIMARY CARE PEDIATRICIAN: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D., in [**Hospital1 6930**], [**Telephone/Fax (1) 63485**].
CARE RECOMMENDATIONS:
1. Feeds at discharge are breast milk 28 mixed by concentrate
with Enfacare. Ad lib on demand feeding with a minimum of 140
cc/kg/day.
2. Car seat position screening passed.
3. Immunizations: The patient received hepatitis B
vaccination on [**8-29**]. He did receive HIB, as well as
Prevnar on [**9-25**] and Pediarix on [**9-29**].
4. requires follow-up with pediatrician, urologist,
neurologist.
5. Synagis (see below) should be given during this first
winter.
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
given montly [**Month (only) **] through [**Month (only) 958**] for this infant with 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 all
hospital contacts and out-of-home caregivers.
DISCHARGE DIAGNOSIS:
1. Premature male infant at 28 and 1/7 weeks.
2. Patent ductus arteriosus treated with indomethacin.
3. Status post respiratory distress syndrome.
4. Status post rule out sepsis.
5. In utero growth restriction.
6. Hypospadias.
7. Left inguinal hernia, s/p repair
8. In utero non-immune hydrops.
9. Periventricular leukomalacia.
10. CLD--improving
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Last Name (NamePattern1) 58671**]
MEDQUIST36
D: [**2119-10-11**] 13:54:17
T: [**2119-10-11**] 15:56:28
Job#: [**Job Number 31036**]
ICD9 Codes: 769, 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1336
} | Medical Text: Admission Date: [**2141-5-2**] Discharge Date: [**2141-5-10**]
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
Mr. [**Known lastname **] is an 82 year-old male with a history of diastolic
dysfunction, recent MRSA pneumonia, and asthma, who initially
presented on [**2141-5-1**] with a 1-day history of increased SOB,
productive cough and congestion.
On arrival to the ED, CXR showed moderate CHF. He was
empirically started on Vancomycin, CTX, Prednisone, and Lasix,
with some improvement. However, after several hours in the ED,
he became hypertensive, tachycardic, and hypoxemic, with
desaturation to the 80s. He was started on a nitro drip and
intubated. In ED, he was also noted to have anterolateral EKG
changes, with new TWI in I, aVL, and "pseudonormalization" of T
waves in V3-6. Enzymes elevated. He was admitted to the MICU for
further care.
Past Medical History:
1. Diastolic dysfunction
2. Hypertension
3. Asthma
4. History of bronchiolitis obliterans pneumonia ([**4-/2134**])
5. Chronic renal failure with baseline creatinine high 2s-low 3s
6. History of diverticular bleed, and upper GI bleed in 03/[**2140**].
EGD with gastric erosions.
7. Colonic adenoma
8. Giardia ([**3-/2137**])
9. CVA in [**2127**]
10. MRSA pneumonia in [**2-/2141**]
Social History:
He is originally from [**Country 4812**]. He lives with his daughter in
[**Name (NI) **].
Family History:
Non-contributory.
Physical Exam:
Physical examination at the time of transfer from the ICU:
VITALS: Tm 99.2/98.2, BP 110-140/50-60s, HR 60-70s, RR teens,
Sat 96-100% on face mask 0.50.
GEN: Appears comfortable, sitting in chair.
HEENT: Anicteric, MMM.
NECK: EJV distended, unable to assess JVP.
RESP: Bibasilar ronchi. Bilateral expiratory wheezes.
CVS: RRR. Normal S1, S2. Heart exam limited secondary to breath
sounds.
GI: BS NA. abdomen soft, non-tender.
EXT: Without edema.
Pertinent Results:
Relevant laboratory data on admission:
CBC [**2141-5-2**]:
WBC-17.1*# RBC-3.43* HGB-9.8* HCT-29.1* MCV-85 MCH-28.6
MCHC-33.7 RDW-16.0*
NEUTS-81* BANDS-3 LYMPHS-10* MONOS-6 EOS-0 BASOS-0 ATYPS-0
METAS-0 MYELOS-0
Chemistry:
GLUCOSE-179* UREA N-39* CREAT-2.9* SODIUM-132* POTASSIUM-5.3*
CHLORIDE-98 TOTAL CO2-19* ANION GAP-20
CALCIUM-8.9 PHOSPHATE-3.6 MAGNESIUM-1.4*
Coagulation:
PT-13.9* PTT-24.8 INR(PT)-1.2*
Microbiology:
[**2141-5-9**] URINE negative
[**2141-5-4**] URINE CULTURE negative
[**2141-5-2**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{MORAXELLA CATARRHALIS, PRESUMPTIVE IDENTIFICATION} INPATIENT
[**2141-5-2**] URINE CULTURE negative
[**2141-5-2**] BLOOD CULTURE negative
Other data: HbA1c and PTH pending.
Relevant imaging data:
[**2141-5-2**] CXR: Moderate CHF
[**2141-5-2**] CXR: NG tube, worsened CHF
[**2141-5-2**] CXR: ETT, persistent pulmonary edema
ECHO [**2141-5-2**]: LV thickness normal. Moderate regional LV
systolic dysfunction. Overall LVEF is moderately depressed (LVEF
35%). Resting regional wall motion abnormalities include mid to
distal septal and apical akinesis. RV normal. Aortic valve
leaflets are mildly thickened and there is focal calcification
of the noncoronary cusp. No AS. Mild AR. [**12-19**]+ MR. Compared to
prior, worse EF, new WMA. E/A 1.60.
[**2141-5-3**] CXR: Moderately severe pulmonary edema has changed in
distribution but not in overall severity, accompanied by
persistent small left and small-to-moderate right pleural
effusion and borderline cardiomegaly. ET tube in standard
placement.
[**2141-5-4**] CXR: Markedly improved CHF.
[**2141-5-9**] CXR: Small bilateral plerual effusions, with RLL
atelectasis.
Brief Hospital Course:
82 year-old male with CHF, CRI, prior GI bleed (both upper and
lower), admitted with respiratory failure. His hospital course
will reviewed by problems.
1. Respiratory failure: His acute decompensation was felt most
consistent with flash pulmonary edema, requiring intubation.
While in the ICU, he was diuresed with IV Lasix, switched to
oral Lasix with good results. He was also continued empirically
on Vancomycin and CTX for coverage of CAP. Sputum gram stain
returned positive for GN diplococci, and culture eventually grew
Moraxella catarrhalis. Vancomycin was discontinued on [**2141-5-5**].
He self-extubated on [**2141-5-4**], and did well thereafter. He
completed a 7-day course of CTX on [**2141-5-8**] for Morazella in his
sputum. Please see below for further details on his CHF
management.
2. CAD: His cardiac enzymes on admission were noted to be
trending up, and an EKG was concerning for "pseudonormalization"
of T waves in V3-6 versus 04/[**2140**]. It is of note that cardiac
enzymes were not obtained in [**3-/2141**] in the setting of these
changes. He was briefly started on heparin, which was
discontinued in the setting of a hematocrit drop and probable
demand ischemia rather than ACS. An echo was obtained on
[**2141-5-2**], which revealed new systolic dysfunction with EF 35%,
with mid to distal septal and apical akinesis. Cardiology was
consulted. Review of his records indicated a recent echo with
preserved systolic function in 03/[**2140**]. He was felt to have
likely had a recent anterior MI, with superimposed
demand/subendocardial ischemia. He was deemed a poor
catheterization candidate given his stage IV CKD, and medical
management was advised. His troponin continued to rise in the
ICU, but CK was trending down. He was continued on ASA and
statin. Toprol was changed to Metoprolol (not renally cleared),
which was titrated up. He was started on Captopril while in the
ICU, subsequently discontinued in the setting of an acute rise
in his creatinine. Hydralazine and Isordil were subsequently
started (lower dose than before admission).
3. CHF: As noted above, he was found to have new systolic
dysfunction, felt likely secondary to a recent anterior MI. In
addition, he likely has a component of diastolic dysfunction.
His acute presentation was felt secondary to flash pulmonary
edema, and he responded well to diuresis. He was weaned off
oxygen, and was saturating well on room air at the time of
discharge. He was placed back on Lasix 40 mg daily. Please note
that while in the hospital, his oral Lasix was transiently held
in the setting of hyponatremia, which improved after holding
Lasix for 48 hours. His sodium and creatinine will need to be
closely monitored as an out-patient. He needs to remain on Lasix
from a cardiac standpoint. He was also discharged oh Hydralazine
25 mg PO QID and Imdur 30 mg daily for afterload reduction
(acute rise in creatinine with Captopril).
3. GI bleed: While in the hospital, he was noted to have guaiac
positive stools, associated with a hematocrit drop to 24 on
[**2141-5-2**] (albeit also in the setting of a short course of IV
heparin). He was transfused 2 units of PRBCs on that day. Review
of his recent data indicated an EGD in [**2-/2141**] remarkable for
gastric erosion. He was placed on PRotonix 40 mg twice daily
(initially IV then PO), and Carafate PO QID. His hematocrit
remained stable thereafter, and further work-up was not pursued.
4. CRI: Patient with known CKD with fluctuating creatinine at
baseline, followed by Dr. [**Last Name (STitle) 3271**] as an out-patient. While in
the hospital, his creatinine rose to a peak of 4.2, at one point
with concomitant hyperkalemia and hyperphosphatemia. He was
started on CaCO3 and Sevelamer, with correction of his
hyperphosphatemia. A recent renal U/S in [**2-/2141**] was remarkable
for thin cortices suggestive of parenchymal disease. Prior lab
data were also remarkable for known nephrotic range proteinuria,
negative SPEP/UPEP in [**2139**]. The renal service was consulted on
[**2141-5-9**] for further advice, with an impression of probable
hypertensive nephrosclerosis possibly also with superimposed
FSGS. He had no indication for acute hemodialysis, although it
is likely that he will need long-term hemodialysis in the near
future. His family, however, is very reluctant to consider it.
Follow-up appointment scheduled with Dr. [**Last Name (STitle) 118**] in Nephrology
per Dr. [**Last Name (STitle) 1860**]. PTH pending at the time of discharge.
5) Hyponatremia: On [**2141-5-7**], his sodium was noted to drop to
127. His Lasix was held for 48 hours, with eventual improvement
in his sodium to 131. Urine lytes revealed UNa 25, Uosm 371,
Uurea 646. He was also placed on fluid restriction 1000 mL. He
will need close out-patient follow-up of his sodium and
creatinine. Lasix was restarted at the time of discharge (40 mg
daily).
6) Leukocytosis: His WBC was noted to rise slightly again on
[**2141-5-9**]. A repeat U/A was negative, and a repeat CXR showed
only RLL atelectasis without clear infiltrate. His WBC was back
down to normal on [**2141-5-10**].
7) Hematuria: While in the hospital, he was noted to have
microscopic hematuria. He will need further work-up as an
out-patient.
Medications on Admission:
Albuterol inhaler
Fluticasone inhaler
Salmeterol inhaler
Clonidine TD 0.1 mg
Lasix 40 mg daily
Imdur 60 mg daily
Amlodipine 10 mg daily
Lipitor 10 mg daily
Protonix
Toprol 50 mg daily
Hydralazine 50 mg PO QID
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*6*
3. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 Disk with Device(s)* Refills:*2*
5. Albuterol Sulfate 90 mcg/Actuation Aerosol Sig: [**12-19**]
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
6. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
9. 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*
10. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO
three times a day.
Disp:*90 Tablet(s)* Refills:*2*
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
14. Sevelamer 400 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Congestive heart failure
Probable coronary artery disease
Chronic kidney disease
Hyponatremia
Tracheobronchitis
Gastrointestinal bleeding
Discharge Condition:
Patient discharged home in stable condition, with stable
saturation on room air.
Discharge Instructions:
Please weigh yourself every morning, and [**Name8 (MD) 138**] MD if weight > 3
lbs.
Adhere to 2 gm sodium diet. Fluid Restriction: 1000 mL.
Please note that we have made some changes to your medications.
Please take all medications as prescribed. Briefly, we have
decreased Imdur to 30 mg daily. We have stopped Toprol and
started Metoprolol 100 mg three times daily. We have stopped
Amlodipine. We have finally decreased the dose of Hydralazine to
25 mg four times daily. In addition, please take a full dose
aspirin (325 mg) daily.
We have started 2 medications for your kidneys which help keep
the phosphate level in your body within normal limits. They are
calcium carbonate and Sevelamer. Please take them as prescribed.
You will need close follow-up of your blood work as an
out-patient. In addition, please see below for recommended
follow-up appointments.
Please return to the ED or call your PCP if you develop chest
pain, worsening shortness of breath, or if you notice black or
bloody stools.
Followup Instructions:
1. Please call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] an
appointment to be seen within the next 2 weeks. It is important
that you [**Last Name (Titles) **] this appointment.
2. You also have a scheduled appointment with Dr. [**Last Name (STitle) 118**]
(Nephrology) on Tuesday [**5-16**] at 0830 in the morning. His
office is located on the [**Location (un) 436**] of the [**Hospital Ward Name 23**] Clinical
center, in Medical Specialties.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2141-5-10**]
ICD9 Codes: 5849, 5789, 2761 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1337
} | Medical Text: Admission Date: [**2180-11-22**] Discharge Date: [**2180-11-28**]
Date of Birth: [**2121-2-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
(History is per records and patient's husband, pt is unable to
complete a full sentence [**3-4**] severe dyspnea)
59 yo F, s/p wedge resection [**2180-10-4**] with tracheobronchomalacia
s/p reconstruction. Coming in with 'mild confusion' from rehab
facility but A&O. Also reports pleuritic CP, feels 'not
herself'. She reports being on oxygen and steroid taper since
discharge from the hospital. About one week prior she developed
low grade fever, chills and vomiting. She apparently had several
tests done and a CXR at rehab per her husband, with no clear
etiology. Two days prior to admission, she was taken off her
supplemental O2 and reports feeling worse. She also reported CP,
but this has been somewhat a chronic issue since discharge s/p
thoracotomy. The day of admission, she became acutely SOB while
at rehab, and was transported to [**Hospital1 18**] for further evaluation.
EKG with sinus tachycardia and concern for Q in III, T-wave
changes laterally concerning for acute change. Given need for
large amounts supplemental O2 and dyspnea, concerned about PE.
CTA (per report of ED resident) revealed massive b/l saddle
emboli with R heart strain on CT. ED resident u/s heart with
signs of strain, dilated ventricle with e/o hypokinesis. A&O x 3
now. Upon transfer VS with SBP 94, HR 115, 24 on 95/6L. Given 1L
NS to increase preload, another to hang on way. Heparin given
with a bolus. Access is 18g x 3.
.
Upon arrival to the ICU, patient with severe dyspnea. Cannot
participate in full ROS, but does nod to having CP, but no
abdominal pain or leg pain.
Past Medical History:
[**2180-10-4**]: Right thoracotomy and thoracic tracheoplasty with
mesh, right mainstem bronchus/bronchus intermedius bronchoplasty
with mesh, left mainstem bronchoplasty with mesh, right upper
lobe wedge resection.
OSA
COPD with CPAP, on home O2
Tracheomalacia
Tonsillectomy
Back surgery
Appendectomy
Social History:
Remote smoking history, none currently, quit 6 years ago. No
alcohol or other drug use. Has been at rehab since most recent
discharge.
Family History:
Reports father had a blood clot and was on Coumadin, but cannot
provide further details [**3-4**] dyspnea.
Physical Exam:
98.2, 111, 105/68, 20, 96/4L NC
Gen: Appears distressed, difficulty speaking
HEENT: NCAT, MM mildly dry, symmetric
CV: Tachycardia, regular, without m/g/r
Chest: Well healing incision, CTAB anteriorly without w/r/r;
symmetric shallow expansion with tachypnea
Abd: Active BT, obese, without TTP or masses
Ext: WWP with 2+ DP pulses b/l, symmetric, no erythema, warmth
or TTP
Neuro: Nonfocal, moving all limbs equally, speaking coherently
in short, 2-word sentences
Pertinent Results:
[**2180-11-22**] 04:50PM BLOOD WBC-7.7 RBC-4.29# Hgb-13.1 Hct-37.7
MCV-88# MCH-30.5 MCHC-34.7 RDW-14.7 Plt Ct-168#
[**2180-11-28**] 07:45AM BLOOD WBC-5.6 RBC-3.58* Hgb-10.9* Hct-32.2*
MCV-90 MCH-30.5 MCHC-33.9 RDW-15.6* Plt Ct-183
[**2180-11-22**] 04:50PM BLOOD Neuts-83.4* Lymphs-12.7* Monos-3.3
Eos-0.4 Baso-0.1
[**2180-11-28**] 07:45AM BLOOD PT-23.2* PTT-123.7* INR(PT)-2.2*
[**2180-11-23**] 05:23AM BLOOD Glucose-110* UreaN-18 Creat-0.5 Na-139
K-3.1* Cl-105 HCO3-24 AnGap-13
[**2180-11-28**] 07:45AM BLOOD Glucose-107* UreaN-6 Creat-0.6 Na-142
K-3.4 Cl-107 HCO3-25 AnGap-13
[**2180-11-22**] 04:50PM BLOOD CK(CPK)-31
[**2180-11-22**] 09:00PM BLOOD CK(CPK)-26
[**2180-11-23**] 05:23AM BLOOD CK(CPK)-22*
[**2180-11-22**] 04:50PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 78974**]*
[**2180-11-22**] 04:50PM BLOOD cTropnT-0.04*
[**2180-11-22**] 09:00PM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2180-11-23**] 05:23AM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2180-11-23**] 05:23AM BLOOD Calcium-8.5 Phos-3.9 Mg-1.8
[**2180-11-22**] 05:25PM BLOOD Type-ART O2 Flow-2 pO2-62* pCO2-29*
pH-7.56* calTCO2-27 Base XS-4 Intubat-NOT INTUBA
[**2180-11-22**] 05:05PM BLOOD Glucose-165* Lactate-3.3* Na-140 K-3.7
Cl-94* calHCO3-26
[**2180-11-26**] 08:06AM BLOOD Lactate-1.3
[**2180-11-22**] 05:50PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-7.0 Leuks-NEG
[**2180-11-22**] 05:50PM URINE RBC-0-2 WBC-0-2 Bacteri-OCC Yeast-NONE
Epi-0-2
[**2180-11-23**] 05:24AM URINE Blood-LGE Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-NEG pH-6.5 Leuks-NEG
[**2180-11-23**] 05:24AM URINE RBC->1000 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0-2
.
Blood cultures ([**2180-11-22**]): Pending, no growth to date.
C Diff toxin assay ([**2180-11-23**]): Negative.
.
Head CT noncontrast ([**2180-11-23**]): No acute intracranial
hemorrhage.
.
Bilateral LENI's ([**2180-11-23**]): Bilateral deep vein thromboses.
.
CXR ([**2180-11-23**]): As compared to the previous radiograph, there
are no signs suggesting slight overhydration. Otherwise, the
radiograph is unchanged. No interval appearance of parenchymal
opacity suggestive of pneumonia. Unchanged size of the cardiac
silhouette.
.
TTE ([**2180-11-23**]): Severly dilated right ventricle with moderate
hypokinesis and moderate pulmonary artery systolic hypertension
consistent with hemodynamically significant pulmonary emboli.
Left ventricle has preserved regional and global function and is
probably underfilled.
.
CTA ([**2180-11-22**]): 1. Massive acute pulmonary embolism with CT
signs of right heart strain. 2. Emphysema. 3. Focal area of
airspace opacity in the right lower lobe, and may be infectious,
inflammatory, or secondary to aspiration.
.
EKG ([**2180-11-22**]): Sinus tachycardia. Normal axis and intervals. Q
wave in III. Right bundloid pattern. Prominent S wave in I and q
wave in III compared to prior dated [**2180-9-4**].
.
Brief Hospital Course:
A/P: 59 yo F with tracheobronchomalacia s/p recent thoracic
tracheo- and broncho-plasty with right upper lobe wedge
resection admitted on [**2180-11-22**] with severe dyspnea, found to
have large bilateral PE's and evidence of right heart strain.
.
The patient underwent right thoracotomy with thoracic tracheo-
and broncho-plasty with right upper lobe wedge resection on
[**2180-10-4**]. She was discharged to rehab on [**2180-10-11**]. At rehab the
patient was maintained on supplemental oxygen and a prednisone
taper. One week prior to re-admission she developed some fevers,
shortness of breath and nausea. The patient presented from rehab
on [**2180-11-23**] with acute severe dyspnea and was found to have
bilateral sub-massive PE's with bilateral lower extremity DVT's
and signs of right heart strain on EKG and echo. She received
systemic anticoagulation with marked improvement in her
symptomatic dyspnea and oxygen requirement back to her baseline
home oxygen supplementation by nasal cannula. At the time of
discharge the patient was therapeutic on warfarin with 24 hours
of overlap with therapeutic heparin. The patient will follow-up
with her PCP for further discussion of:
- Ongoing INR monitoring and warfarin dosage adjustment.
- Hypercoaguable work-up and duration of anticoagulation.
- Elective outpatient TTE in the future to evaluate for signs of
resolution of right heart strain.
The patient did have a small amount of hematuria with a single
episode of clot passage in the urine and a nosebleed while on
dual therapeutic anticoagulation with heparin and warfarin. She
was counselled to discuss any ongoing hematuria with her PCP and
to consider outpatient referral to urology if necessary. No
visible blood was seen on urination on the day of discharge.
Of note the patient had some lower extremity edema and a
positive fluid balance while in the hospital and her home lasix
had been held during her hospitalization. The patient was
restarted on her home lasix and will follow-up with her PCP for
ongoing monitoring.
The patient has significant baseline lung diseaes including
COPD. She was continued on an oral prednisone taper consistent
with her admission medications. She was transitioned to 5mg
daily of prednisone for 7 days to complete the taper at the time
of discharge. She did not require insulin while on a sliding
scale in the hospital on 10mg of prednisone and was therefore
not discharged on an insulin regimen. She will also continue on
nebulizer treatments with albuterol and ipratropium as well as
steroid inhalers and tiotropium.
Tracheobronchomalacia s/p recent thoracotomy, resection and
tracheo/bronchoplasty. Thoracic surgery followed the patient in
house. She is scheduled for outpatient follow-up with repeat CT
trachea in the future. Pain from recent surgery was
well-controlled with anti-inflammatories alone at the time of
discharge.
OSA. She continued on her home CPAP.
Medications on Admission:
Acetaminophen 325-650 mg PO Q6H:PRN pain or fever > 101
Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE HS
Acetylcysteine 20% 3-5 mL NEB [**Hospital1 **] AT 6AM AND 9PM
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN
Lasix 80mg po daily (HELD)
Prochlorperazine 25mg PR Q8H PRN nausea
Docusate Sodium 100 mg PO BID Hold for loose stools
PredniSONE 20 mg PO DAILY
Fluticasone-Salmeterol (100/50) 1 INH IH [**Hospital1 **]
Ranitidine 150 mg PO DAILY
Sodium Chloride Nasal [**2-2**] SPRY NU [**Hospital1 **] Order date: [**11-22**] @ 2124
Tiotropium Bromide 1 CAP IH DAILY Order date: [**11-22**] @ 2124
Insulin SC (per Insulin Flowsheet)
Omeprazole 40mg po daily
Oxycodone 10mg po Q6H
Oxycodone 5mg po Q4H PRN:breakthrough
Nasal saline [**Hospital1 **]
Prednisone taper, sheduled to have 20mg [**11-22**], with 10mg x 4days
after
MOM PRN
Bisacodyl PRN
Fleet enema PRN
Senna PRN
Zantac 150mg [**Hospital1 **] PRN:stomach upset
Discharge Medications:
1. Outpatient Lab Work
Lab work: PT/INR. To be drawn at primary care doctor's office
every 3 days until told otherwise by your doctor. Please obtain
recommendations from your doctor based on the results regarding
dosage adjustment of warfarin.
2. Home Oxygen
Please continue your home oxygen by nasal cannula at 3L/min.
3. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or fever > 101.
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation every four (4) hours as
needed.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Disp:*120 nebs* Refills:*5*
7. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
8. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
10. Tessalon Perles 100 mg Capsule Sig: One (1) Capsule PO once
a day as needed for cough.
Disp:*30 Capsule(s)* Refills:*1*
11. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
Disp:*100 ML(s)* Refills:*0*
12. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-2**] Sprays Nasal
[**Hospital1 **] (2 times a day).
13. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM as needed for pulmonary embolism.
Disp:*30 Tablet(s)* Refills:*3*
14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
- Sub-massive pulmonary embolism
- Bilateral DVT's.
Secondary:
- Tracheobronchomalacia s/p tracheobronchoplasty and wedge
resection of the right upper lung lobe
- COPD
- OSA
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with severe shortness of breath. This was due
to blood clots that formed in your legs and travelled to your
lungs. You must take a blood thinning medication called coumadin
to prevent recurrence or enlargement of the blood clots for at
least the next 6 months and potentially longer. Please have your
blood drawn at your primary care doctor's office every 3 days
until further notice from your doctor to monitor the coumadin
level. Discuss the blood results with your doctor and change the
dosing of your coumadin based on their recommendations. Please
discuss a work-up for the cause of your clot formation with your
doctor.
Please discuss scheduling a repeat echocardiogram in the future
for further evaluation of your heart function after this recent
injury.
You did have a small amount of blood in the urine after starting
your blood thinning medication. If this persists please discuss
this further with your primary care doctor.
Follow-up as previously scheduled with your thoracic surgeon
with repeat CT scan in [**Month (only) 1096**].
Take all medications as prescribed.
Follow-up with your primary care doctor and thoracic surgeon.
Call your doctor or return to the hospital for any new or
worsening shortness of breath, chest pain, significant blood
clots in the urine or difficulty making urine or any other
concerning findings.
Followup Instructions:
Dr. [**Last Name (STitle) 11907**] Wednesday, [**2180-11-29**] 2:15PM. Please discuss:
- Ongoing monitoring of your coumadin level and dosage changes
in your coumadin.
- A work-up for the cause of your clot formation.
- Scheduling an echocardiogram in the future to re-evaluate your
heart function.
- Blood in the urine and whether or not you should see a
urologist.
Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2181-1-9**] 9:00
Provider: [**Name10 (NameIs) 17853**] CLINIC INTERVENTIONAL PULMONARY (SB)
Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2181-1-9**] 9:30
Provider: [**Name10 (NameIs) **] INTAKE,ONE [**Name10 (NameIs) **] ROOMS/BAYS Date/Time:[**2181-1-9**] 10:00
ICD9 Codes: 2768, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1338
} | Medical Text: Admission Date: [**2152-4-20**] Discharge Date: [**2152-4-23**]
Date of Birth: [**2069-4-30**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9824**]
Chief Complaint:
Tachypnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is an 82F with hx COPD on 4 L NC at baseline. Patient
had been having increased difficulty breathing for the past few
days, then developed cough today with brown sputum 9no
hemoptysis). She has not had any fevers or chills, and her
oxygen saturation had remained greater than 90% on her usual 4L
of oxygen. Yesterday patient's son [**Name (NI) 653**] her PCP to inform
him of this change, and prescription for Z pack and prednisone
40 was started (on chronic prednisone 5 qd). Patient took one
dose of these but overnight was noted to have increasing work of
breathing and to be breathing more rapidly so presented to ED.
Last hospitalization in [**1-2**] for SVT, on Dilt [**Hospital1 **] for rate
control.
In the ED, initial vs were: 99.7, 180/90, 118, 26, 96% on 4 L
NC. She received Levaquin 750, Solumedrol 125, nebs, ASA, and
ativan 1.5 mg total. On arrival to the ICU, pt and family note
breathing is better. Pt is claustrophobic and would likely not
tolerate BiPAP.
Past Medical History:
- AVNRT
- COPD, on home O2 4L at baseline
- Diabetes mellitus, type 2
- Hypothyroidism
- Psoriasis
- Osteoarthritis
- Hyperlipidemia
- Anxiety
- Atypical chest pain
- Obesity
- Anemia
Social History:
Does not currently smoke or drink. Smoked 1 to 1-1/2 packs per
day, quit in [**2133**].
Family History:
Noncontributory
Physical Exam:
ADMISSION
Vitals: 97.8 110 118/94 22 100% 4 L NC
General: Alert, oriented, tachypneic, speaking in short
sentences
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Scattered wheezes and rhonchi bilaterally
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
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&O x3, MAE, nonfocal
Pertinent Results:
ADMISSION
[**2152-4-20**] 08:00AM WBC-13.5* RBC-4.82 HGB-10.3* HCT-33.8*
MCV-70* MCH-21.3* MCHC-30.3* RDW-16.4*
[**2152-4-20**] 08:00AM NEUTS-82.7* LYMPHS-12.6* MONOS-4.1 EOS-0.5
BASOS-0.2
[**2152-4-20**] 08:00AM GLUCOSE-158* UREA N-10 CREAT-0.6 SODIUM-138
POTASSIUM-4.3 CHLORIDE-92* TOTAL CO2-36* ANION GAP-14
[**2152-4-20**] 08:00AM TOT PROT-7.7 PHOSPHATE-4.5 MAGNESIUM-1.8
[**2152-4-20**] 08:00AM CK(CPK)-46
[**2152-4-20**] 08:00AM CK-MB-NotDone
[**2152-4-20**] 09:45AM TYPE-ART O2 FLOW-4 PO2-87 PCO2-67* PH-7.38
TOTAL CO2-41* BASE XS-10 INTUBATED-NOT INTUBA COMMENTS-NC
CHEST (PORTABLE AP) Study Date of [**2152-4-20**] 8:00 AM
The cardiac, mediastinal and hilar contours are unchanged. The
cardiac silhouette is not enlarged. Prominent left epicardial
fat pad is present. The lungs are hyperinflated with flattening
of the diaphragms re-demonstrated compatible with patient's
history of COPD. Pulmonary vascularity is within normal limits
without evidence of pulmonary
edema. Minimal bibasilar atelectasis is demonstrated. No pleural
effusion or pneumothorax is present. The osseous structures are
unremarkable.
IMPRESSION: No acute cardiopulmonary abnormality. COPD.
Brief Hospital Course:
Ms [**Known lastname 28070**] is an 82 year old woman with history of severe COPD
(on 4L NC at home), diabetes, obesity, presenting with
respiratory distress consistent with COPD exacerbation, in fair
condition.
#. COPD EXACERBATION: Patient with well known COPD and poor
functional reserve with decreased FEV1 and FEV1/FVC ratios.
Infection appears most likely diagnosis for etiology of
exacerbation. She was most recently treated in [**Month (only) **] with Avelox
and steroids, improved. She also has a history of pseudomonas
infection in [**2147**]. Baseline sats 92 per pt. Initial chest x-ray
as above without evidence of infiltrate. Most likely this
represents worsening bronchitis causing inflammatory response.
Started on IV Solumedrol for flair and she was started on
Levofloxacin and Vancomycin empirically until culture data
returned. Sputum culture grew out coag+ staph on [**4-22**]. Given
her improvement, the lack of infiltrate on CXR, lack of findings
consistent with an aggressive pneumonia such as one would find
with MRSA, this was felt to be a contaminant. She was then
transferred out of the ICU for further monitoring. On the floor,
her vancomycin was discontinued and she was transitioned to oral
steroids. She was discharged on 1 more day of levofloxacin to
finish 5 day course. She was also given a 2 wk steroid taper and
instructions to follow up with her PCP. [**Name10 (NameIs) **] the time of
discharge, she was on her home requirement of 4L NC.
#. DIABETES: Glucophage was initially held in case of need for
contrast. Once more stable, her Glucophage was restarted. She
was also on an insulin sliding scale for supplemental glucose
control given her steroids as above.
#. SUPRAVENTRICULAR TACHYCARDIA / AVNRT: Well controlled on
Verapamil, has not had any symptomatic episodes or procedures
for this. Was initially on short acting until it was clear she
was hemodynamically stable. She was then continued on her home
dose of Verapimil 180mg SR [**Hospital1 **].
# ANXIETY: On ativan daily at home, 0.5mg TID. While inpatient,
continued to have significant anxiety and this was increased to
0.5mg QID PRN.
#. HYPOTHYROIDISM: Continued hormone replacement at her regular
dose of Levothyroxine 100mcg daily.
Medications on Admission:
ACETAMINOPHEN-CODEINE - 300 mg-30 mg Tablet - 1 (One) Tablet(s)
by mouth up to four times a day as needed for pain
ALENDRONATE - 35 mg Tablet - 1 Tablet(s) by mouth q week
BETAMETHASONE-CALCIPOTRIENE [TACLONEX SCALP] - 0.05 % (0.064
%)-0.005 % Suspension - apply qd to scalp
BETAMETHASONE-CALCIPOTRIENE [TACLONEX] - 0.05 % (0.064 %)-0.005
%
Ointment - apply once a day
BUDESONIDE [PULMICORT] - 0.5 mg/2 mL Suspension for Nebulization
- 1 (One) vial inhaled via nebulizaiton twice a day (this dose
covered by medicare)
FLUTICASONE - 50 mcg Spray, Suspension - 2 sprays(s) in each
nostril once a day
FLUTICASONE [FLOVENT HFA] - 220 mcg Aerosol - 2 puffs twice a
day when out of the house
HUMIDIFIER FOR HOME O2 DELIVERY SYSTEM - use whenever using O2
IPRATROPIUM-ALBUTEROL [COMBIVENT] - 18 mcg-103 mcg
(90mcg)/Actuation Aerosol - 3 puffs 3 -4 times day when out of
the house
IPRATROPIUM-ALBUTEROL [DUONEB] - 2.5 mg-0.5 mg/3 mL Solution for
Nebulization - 1 (One) vial inhaled via nebulizaiton up to four
times a day as needed for and as needed for wheezing and
shortness of breath
LEVOTHYROXINE [LEVOXYL] - 100 mcg Tablet - 1 Tablet(s) by mouth
daily
LORAZEPAM [ATIVAN] - 0.5 mg Tablet - 1 (One) Tablet(s) by mouth
2-3 times daily
METFORMIN [GLUCOPHAGE] - 850 mg Tablet - 1 Tablet(s) by mouth
twice a day
OXYGEN -4 Liters/min continuous flow 02 24 hrs daily and 5 by
pulse dose 02
PREDNISONE - 5 mg Tablet - 1 Tablet(s) by mouth once a day
PREDNISONE - 10 mg Tablet - 4 (Four) Tablet(s) by mouth once a
day Taper as directed over 10 days
SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth qpm
VERAPAMIL - (Prescribed by Other Provider) - 180 mg Cap,24 hr
Sust Release Pellets - 1 Cap(s) by mouth twice a day
CALCIUM CARBONATE-VITAMIN D3 600mg-400 unit Tablet - [**Hospital1 **]
GUAIFENESIN [MUCINEX] - 600 mg Tablet Sustained Release - 1
(One)
Tablet(s) by mouth once or twice a day as needed for thick mucus
POLYSACCHARIDE IRON COMPLEX [NIFEREX] - 60 mg Capsule - 1
Capsule(s) by mouth once a day
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 1 days.
Disp:*1 Tablet(s)* Refills:*0*
3. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO
four times a day as needed for pain.
4. Alendronate 35 mg Tablet Sig: One (1) Tablet PO once a week.
5. Taclonex 0.05-0.005 % Ointment Sig: One (1) application
Topical once a day.
6. Taclonex Scalp 0.05-0.005 % Suspension Sig: One (1)
application to scalp Topical once a day.
7. Pulmicort 0.5 mg/2 mL Suspension for Nebulization Sig: One
(1) neb Inhalation twice a day.
8. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
9. Flovent HFA 220 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation twice a day.
10. Combivent 18-103 mcg/Actuation Aerosol Sig: Three (3) puffs
Inhalation 3-4 times daily.
11. DuoNeb 0.5-2.5 mg/3 mL Solution for Nebulization Sig: One
(1) nebulizer Inhalation four times a day as needed for
shortness of breath or wheezing.
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO 2-3 times
daily as needed for anxiety.
13. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
15. Verapamil 180 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
16. Prednisone 20 mg Tablet Sig: One (1) taper PO DAILY (Daily):
Take 3 tablets daily for 3 days. Then 2 tabs daily for 4 days.
Then 1 tab daily for 4 days. Then half tab daily for 4 days.
Then resume prednisone 5 mg daily. .
Disp:*23 tabs* Refills:*0*
17. Calcium 600 with Vitamin D3 600 mg(1,500mg) -400 unit
Capsule Sig: One (1) Capsule PO twice a day.
18. Mucinex 600 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO twice a day as needed for thick mucus.
19. Niferex 60 mg Capsule Sig: One (1) Capsule PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary diagnosis:
COPD exacerbation
Secondary diagnoses:
Severe COPD
Diabetes Mellitus type 2
Anxiety
Hypothyroidism
Discharge Condition:
Good. Stable with O2 sats in mid 90's on 4L NC.
Discharge Instructions:
You were admitted with shortness of breath. We think this was
due to an exacerbation of your COPD. We also treated you with
antibiotics for a possible pneumonia. You are being discharged
home on your baseline amount of oxygen.
.
We are putting you on a taper of prednisone over the next 2
weeks.
We are giving you 1 more day of the antibiotic Levaquin. Please
be careful when taking this medication as it can cause tendon
problems. Report any joint, muscle, ankle or other unusual pain
to your doctor immediately or go to the emergency room.
.
Please follow up as below.
.
Please call your doctor or return to the ED if you have any
chest pain, increasing shortness of breath, lightheadedness,
headache, worstening cough, nausea, vomitting, fever or any
other concerning symptoms.
Followup Instructions:
Please call Dr. [**First Name (STitle) **] on Monday morning at [**Telephone/Fax (1) 1247**] to
arrange follow up within 1 week.
.
Please call Dr. [**Last Name (STitle) 575**] at [**Telephone/Fax (1) 612**] to arrange follow up
within 1 month.
Completed by:[**2152-4-25**]
ICD9 Codes: 486, 2449, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1339
} | Medical Text: Admission Date: [**2193-9-13**] Discharge Date: [**2193-9-24**]
Service: Medicine
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: Patient is a 79 year old female
with multiple medical problems including coronary artery
disease, type-2 diabetes, hypertension, a remote history of
breast cancer 28 years ago, atrial fibrillation who
transferred from an outside hospital ([**Hospital 1562**] Hospital) to
[**Hospital1 69**] for management of her
recurrent pleural effusion.
Patient reported that she began being diagnosed with
effusions about one year ago, however, did not develop
shortness of breath until [**2193-6-11**]. She noted that she
had dyspnea on exertion, that has been gradually worsening.
She denied any cough or chest pain. She denied any
orthopnea. She had undergone paracentesis three or four
times prior to presentation at [**Hospital1 18**], and reports relief
after the procedures. Recently, the patient was at [**Hospital 1562**]
Hospital with a gastrointestinal bleed and hematocrit down to
16. During that admission, she had a thoracentesis which
drained 1800 cc of fluid.
She was discharged on [**2193-9-12**] and returned on [**9-13**] because
her shortness of breath had not resolved, however, it was not
any worse than it was on the discharge. Per the note,
patient had oxygen saturation of 80 percent in the ambulance
on the way to [**Hospital1 18**]. In the outside hospital she had oxygen
saturations of 96 to 99 percent on one liter. She was then
transferred to [**Hospital1 18**] for possible Pleurax catheter placement
and management of this recurrent effusion.
PAST MEDICAL HISTORY:
1. Sick sinus syndrome, status post pacer placement in [**2189**].
2. Hypothyroidism.
3. Hypertension.
4. Diabetes mellitus type-2.
5. Cerebrovascular accident in [**2192-6-11**].
6. Atrial fibrillation.
7. Coronary artery disease, status post myocardial
infarction [**2188**].
8. Congestive heart failure.
9. Gastrointestinal bleed with a hematocrit down to 16 at
the [**Hospital 1562**] Hospital.
10. Breast cancer, status post a right mastectomy 28 years
ago and radiation therapy.
11. Bilateral pleural effusions.
12. Hypercholesterolemia.
13. Osteoporosis.
14. Chronic right arm lymphedema.
15. Anxiety.
16. Chronic obstructive pulmonary disease.
17. Multiple thoracenteses including one on [**8-11**] (1500 cc),
[**8-26**] (1500 cc), and [**9-8**] (1800 cc), all of which were
transudative.
18. Left ankle fracture.
ADMISSION MEDICATIONS:
1. Protonix 40 mg p.o. once daily.
2. Xanax 5 mg p.o. twice a day, 1 mg p.o. q. h.s.
3. Potassium chloride 20 mEq once daily.
4. Lasix 20 mg once daily.
5. Synthroid 0.088 mg p.o. once daily.
6. Multivitamin once daily.
7. Atenolol 25 mg p.o. once daily.
8. Diovan 160 mg p.o. once daily.
9. Aspirin 81 mg p.o. once daily.
10. Iron sulfate 325 mg p.o. once daily.
11. Ambien 5 mg p.o. q. h.s.
12. Glyburide 10 mg p.o. q. a.m. and 5 mg p.o. q noon.
ALLERGIES:
NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY:
Patient quit smoking one pack per day 35 years ago, denies
any alcohol use, and lives with her husband.
FAMILY HISTORY:
Noncontributory.
PHYSICAL EXAMINATION:
VITAL SIGNS: On admission, temperature 97.5, heart rate 66,
blood pressure 151/45, respiratory rate 26, oxygen saturation
96 percent on two liters of oxygen by nasal cannula.
GENERAL: Patient is a pleasant female in no acute distress,
alert and oriented times three.
HEENT: Patient had pupils equal, round, and reactive to
light, extraocular muscles were intact, mucus membranes
moist.
NECK: No jugular venous distention, no lymphadenopathy,
supple.
LUNGS: Decreased breath sounds two-thirds of the way on the
right, at the left base, positive dullness to percussion.
CARDIAC: Irregularly irregular rhythm, no murmurs, rubs, or
gallops.
ABDOMEN: Soft, nontender, obese, nondistended, positive
bowel sounds.
EXTREMITIES: Trace left ankle edema, 2+ pedal pulses.
NEUROLOGICAL: Alert and oriented times three, cranial nerves
II-XII intact.
RECTAL: Guaiac negative.
LABORATORY VALUES ON ADMISSION: CBC - white blood cell count
11.9, hematocrit 30.5, platelets 347 with 77 percent
neutrophils and 10 percent lymphocytes. Electrolytes and
renals are as follows: Sodium 141, potassium 4.9, chloride
107, bicarbonate 25, BUN 33, creatinine 1.4, glucose 156,
calcium 8.6, phosphorus 3.6, magnesium 2.3. Liver function
tests as follows: ALT 35, AST 38, LDL 299, albumin 3.2,
alkaline phosphatase 85, total bilirubin 0.1, INR 1.1. Chest
x-ray on admission: Large right-sided pleural effusion, no
left-sided effusion, shifted trachea. EKG patient is paced.
IMPRESSION: Patient is a 79 year old female with a history
of coronary artery disease, atrial fibrillation,
hypertension, cerebrovascular accident, gastrointestinal
bleed, recurrent pleural effusions, and a remote history of
breast cancer presenting for symptomatic treatment of her
recurrent right-sided pleural effusion.
HOSPITALIZATION COURSE BY SYSTEM:
1. Pulmonary: Patient underwent a therapeutic thoracentesis
on [**2193-9-14**] which was consistent with a transudate and
revealed 222 white blood cells, 2,000 red blood cells, 11
percent polys, 72 percent lymphocytes, total protein of 2.0,
glucose 152, LD 114, amylase 56, albumin 1.2, triglycerides
18. Serum albumin was 3.3 and LD was 338. Cultures were
collected but not evaluated due to laboratory error. Patient
underwent serial evaluations of her effusion via chest x-ray
and repeat x-rays on [**9-15**] and [**9-19**] revealed increasing in
the size of the right-sided effusion.
Patient initially required oxygen of about four liters, and
decreased her oxygen requirements down to one liter with
oxygen saturations of 99 percent by the time of discharge.
Patient was evaluated by Interventional Pulmonology who
planned to insert a permanent Pleurax catheter for self
draining to prevent future recurrence of the effusion.
However, this procedure was deferred to the day of discharge
as the patient developed chest pain and underwent a cardiac
workup as listed below.
The cause of the effusion remained unknown. It was unlikely
due to recurrence of malignancy as the patient has had no
other signs or symptoms or laboratory evidence of malignancy.
An ultrasound of the liver and gallbladder was performed to
see if the changes were consistent with cirrhosis which could
be a contributing etiology. However, this study was negative
for any such change. An infectious etiology was also
considered and therefore the patient was placed on
prophylactic antibiotics for perhaps an underlying pneumonia.
Congestive heart failure was also a possible etiology and
therefore an echocardiogram was repeated which was consistent
with right ventricular dysfunction, pulmonary hypertension,
and mild mitral regurgitation, mild left atrial dilatation
with an ejection fraction of 50 percent, but not consistent
with florid congestive heart failure.
Lymphatic syndrome was also unlikely given the patient's
albumin. Lymphedema was also entertained as a possibility,
however, this would be an unusual cause of the effusion given
the remote history of cancer nearly 30 years ago. Patient
continued to improve symptomatically, particularly after the
Pleurax catheter was placed and she was instructed on how to
use this catheter as an outpatient.
2. Cardiovascular: The patient has history of atrial
fibrillation. However, Coumadin was held for an INR of 5.0
and a recent history of gastrointestinal bleed. The Coumadin
will need to be restarted as an outpatient, and one might
want to consider rhythm control with digoxin. The patient
was also maintained on aspirin and later Plavix was started
for anticoagulation.
On [**9-15**], the patient was evaluated multiple times for chest
pain and shortness of breath. She had a Troponin of 0.5,
0.46, 0.56 with CK values of 86, 72, 98. At the outside
hospital, the patient has had a Troponin level of 0.1 to
0.23. EKG changes were very nonspecific. The patient was
treated for her symptoms with an aspirin, Beta blocker,
Nitroglycerin, oxygen. However, due to her recent
gastrointestinal bleed, IV heparin could not be started.
It was thought that the patient underwent a non-ST elevation
myocardial infarction at that point. An echocardiogram on
[**9-17**] showed right ventricular dysfunction, pulmonary
hypertension, mild mitral regurgitation, and mild left atrial
dilatation with an ejection fraction of 50 percent. On [**9-19**]
the patient underwent serial cardiac enzymes one more time,
again for development of chest pain symptoms. Since that
point, the Troponin levels are 0.47, 0.48, 0.50, 0.51 with CK
values of 79, 72, 70, 60. Again, the EKG remained stable.
Due to these continual symptoms and is suspected non-ST
elevation myocardial infarction, the patient underwent a
Persantine stress test on [**9-20**]. During this test, the
patient had no anginal symptoms, and no ST segment changes.
The patient had an ejection fraction of 51 percent with
hypokinesis of the inferior wall, a fixed lateral inferior
wall defect, a defect to the inferior portion of the lateral
wall with slight reversibility, moderate left ventricular
cavity defect with lateral inferior wall defect. Patient was
also begun on Aldactone and Lasix during her stay for
possible congestive heart failure. She diuresed well with
stabilization of her electrolytes and relief of her symptoms
of shortness of breath. Patient's blood pressure was well
controlled with metoprolol which has been increased to 75 mg
p.o. twice a day at the time of this dictation.
3. Fluid, electrolytes, nutrition/Gastroenterology: Patient
was status post a gastrointestinal bleed recorded on
[**2193-9-13**]. An esophagogastroduodenoscopy at the outside
hospital was consistent with a hiatal hernia, gastritis, an
inflamed duodenal bulb, but no active bleeding. Patient
underwent an ultrasound of the gallbladder and liver on [**9-20**]
which showed a normal liver, gallbladder, pancreas, and
kidneys and a large right-sided pleural effusion. Patient
also developed nausea on [**9-19**] which was relieved with
Zofran. Electrolytes remained stable throughout the stay and
were repleted accordingly. An elevated potassium on [**9-16**]
was treated with Kayexalate. The patient initially had
guaiac positive stools, however, these went into negative a
few days prior to discharge. Protonix was continued, 40 mg
p.o. twice a day, for the patient's recent gastrointestinal
bleed and gastritis. She also developed diarrhea on [**9-20**],
and C-difficile was negative. H. pylori was also checked and
was negative.
4. Genitourinary: The patient had a urinary tract infection
on admission, and this was treated with Levofloxacin for a
total of seven days. This was discontinued on day seven,
[**9-23**].
5. Hypothyroidism: Patient had an elevated TSH of 5.5, but
a normal free T4. The Synthroid dose was not increased or
changed during this admission as it was believed the abnormal
TSH could be due to euthyroid sick syndrome.
6. Diabetes mellitus: The patient was maintained on sliding
scale insulin throughout her stay. She had several episodes
of hypoglycemia which were treated with [**Location (un) 2452**] juice and an
amp of dextrose as needed. Her glyburide was decreased to
2.5 mg p.o. twice a day due to increasing renal dysfunction
and rising creatinine. The patient had a hemoglobin-A1c of
5.4 on this admission.
7. Renal: Patient was found to have a baseline creatinine
of about 1.5. The cause of her chronic renal insufficiency
was not known. Her creatinine had decreased to 1.4 or
essentially remained stable throughout admission.
8. Anemia: Patient was initially anemic with an hematocrit
of 28 with the outside hospital and 30.5 at our hospital.
She did not undergo a transfusion. However, she was started
on Epogen 40,000 units subq times one, and responded nicely
with an increased hematocrit to 34. The patient should
continue on 20,000 units of Epogen q week q Friday after this
admission. Patient was also started on FeSO4 on [**9-20**].
Patient also had hemolysis laboratory, vitamin B-12, ferritin
levels drawn, all of which were within normal limits.
9. Psychiatric: Patient had symptoms of anxiety. These
were eventually controlled using lorazepam p.o. q. h.s.
p.r.n. and the patient's home dose of Xanax p.o. q. h.s.
10. Hypercholesterolemia: The patient had a triglyceride of
120, HDL 51, LDL 81. She was started on Lipitor 20 mg p.o.
once daily given her history of hypercholesterolemia.
CONDITION ON DISCHARGE:
Good.
DISCHARGE STATUS:
Rehabilitation facility at [**Hospital6 85**],
[**Street Address(1) 50211**] in [**Location (un) 86**].
DISCHARGE DIAGNOSES:
1. Recurrent pleural effusions.
2. Non-ST elevation myocardial infarction.
3. Anemia.
4. Hypothyroidism.
5. Anxiety.
6. Urinary tract infection.
DISCHARGE MEDICATIONS:
1. Multivitamin p.o. once daily.
2, Valsartan 160 mg p.o. once daily.
3. Levothyroxine sodium 88 mcg p.o. once daily.
4. Protonix 40 mg p.o. twice a day.
5. Spironolactone 25 mg p.o. once daily.
6. Plavix 75 mg p.o. once daily.
7. Atorvastatin 20 mg p.o. once daily.
8. Lorazepam 0.5 mg p.o. q. h.s. p.r.n.
9. Ferrous sulfate 325 mg p.o. once daily.
10. Folic acid 1 mg p.o. once daily.
11. Aspirin 325 mg p.o. once daily.
12. Furosemide 30 mg p.o. twice a day.
13. Alprazolam 1 mg p.o. q. h.s.
14. Glyburide 2.5 mg p.o. twice a day.
15. Metoprolol 75 mg p.o. twice a day.
16. Epoetin Alfa 20,000 units subq once a week q Friday.
17. Insulin sliding scale.
FOLLOW-UP PLANS:
Patient discharged to the [**Hospital3 **] Facility
for physical therapy as well as training in the use of her
Pleurax catheter.
[**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1775**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1776**]
Dictated By:[**Last Name (NamePattern4) **]
MEDQUIST36
D: [**2193-9-23**] 19:45
T: [**2193-9-24**] 03:19
JOB#: [**Job Number 50212**]
cc:[**Hospital6 25137**]
ICD9 Codes: 5119, 4280, 496, 5990, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1340
} | Medical Text: Admission Date: [**2141-10-6**] Discharge Date: [**2141-10-15**]
Date of Birth: [**2082-7-24**] Sex: F
Service: CT [**Doctor First Name 147**]
CHIEF COMPLAINT: Chest pain, unstable angina.
HISTORY OF PRESENT ILLNESS: 59-year-old female with known
coronary artery disease, who was scheduled for and underwent
a stress sestamibi on the a.m. on [**2141-10-5**]. She had
experienced chest pressure and tightness, suggestive of
ischemia. She also had an abnormal EKG while on the
treadmill. She underwent a cardiac cath back in [**2141-4-10**] that had already revealed a right coronary artery
stenosis which was stented at that time with three separate
stents. She also had a severely diseased circumflex vessel
which was noted back in [**Month (only) 956**] which was not treated. She
was seen in the hospital in [**Doctor First Name 5256**] two weeks prior
to her stress test on [**2141-10-5**] with symptoms of chest pain
after she had walked up 8 flights of stairs and became
diaphoretic, dyspneic, and developed chest heaviness in her
anterior chest wall. This was not relieved with
nitroglycerin. She was admitted and discharged through the
emergency department in [**Doctor First Name 5256**] and was ruled out for
an acute MI with two sets of cardiac enzymes. She was given
the recommendation of followup with her primary care and
cardiologist in [**Location (un) 3844**] when she returned home. She
was seen by Dr. [**Last Name (STitle) 102249**] in the office on [**2141-9-12**] and was
scheduled for a stress mibi test which was done on [**2141-10-5**]
that was abnormal as noted above. She was, therefore,
admitted to the Cardiac Associates, scheduled for repeat
catheterization.
PAST MEDICAL HISTORY: Significant for known coronary artery
disease, history of four cervical fusion surgeries, status
post appendectomy, cholecystectomy, TAH-BSO, removal of
throat polyps. She also has a history of hypertension,
stress incontinence, hyperlipidemia, and depression.
MEDICATIONS ON ADMISSION:
1) Lipitor 40 mg q.day.
2) Zoloft 100 mg q.day.
3) Ditropan 10 mg q.day.
4) Aspirin 325 mg q.day.
5) Alprazolam 10 mg q.day.
6) Nitrofurantoin q.day.
7) Atenolol 100 mg q.day.
8) Plavix 75 mg q.day.
SOCIAL HISTORY: She is employed at the American Legion. She
has a 50 pack-year history of tobacco use. She now has quit
times six months. She denies any alcohol use.
FAMILY HISTORY: She has a positive family history for
premature coronary disease, her parents having had acute MIs
in their 50s.
REVIEW OF SYSTEMS: Unremarkable except for that mentioned
above.
PHYSICAL EXAMINATION: On admission, pupils equal, round,
reactive to light and accommodation. Extraocular movements
are intact. Fundi are benign. Oropharynx is clear, moist,
without lesions. Neck was supple, no adenopathy. There is a
well-healed cervical scar posteriorly, no bruit, no JVD.
Lungs were clear to auscultation. Heart had regular rate and
rhythm, no murmur, rub or gallop. Normal S1 and S2. Abdomen
soft, nontender, with positive bowel sounds. No
hepatosplenomegaly. No bruit. No pulsatile mass.
Extremities: No clubbing, cyanosis, or edema. Palpable
pulses throughout.
DIAGNOSTIC STUDIES: Baseline EKG showed sinus bradycardia,
53, with no Q-waves noted, no ST segment changes.
She was admitted with a diagnosis of unstable angina. She
underwent a catheterization on [**2141-10-6**] for brachytherapy to
her RCA stent, which had shown a 99% in-stent restenosis,
+/- distal left circumflex disease, after being cathed at her
outside hospital. While here, it was revealed that she did
have an EF of approximately 68%, disease in her circumflex
of 95%, long terminating marginal branch noted to be diseased
as well. The RCA was 90% to 95% stenosed within the actual
stent.
On [**2141-10-6**], she underwent cardiac brachytherapy.
Post-procedure she was complaining of chest pain. EKG showed
no ischemic changes. The cardiac cath fellow had seen the
patient and the chest pain was resolving spontaneously. The
patient additionally complained of back discomfort. Her
blood pressure was in the 90's systolic. She was treated
with one sublingual nitroglycerin with questionable effect
and was noted to be very sensitive to the short-acting
nitrates. The systolic pressure went into the 80s. The cath
attending recommended Imdur and morphine. On the afternoon
of [**2141-10-6**], which is the day of admission when she
presented for intra-stent brachytherapy to her RCA stent, she
did also have further chest pain and hypotension. It was
revealed that she actually had a RCA rupture from her
intrastent brachytherapy procedure. Emergent cardiac surgery
consultation was obtained. She was brought to the cath lab
emergently and showed tamponade, which was appropriately
evacuated. Cath showed bleeding in the PL branch of RCA, and
50% RCA in-stent stenosis. She underwent emergent coronary
artery bypass surgery at this time. She had a CABG x1 and
repair of her posterolateral branch in her heart. She came
off the pump. She was sent to the ICU in critical condition.
On post-op day #1, her temperature was 99.2??????. She was 82 and
sinus. Her blood pressure was 95/53. She was on nitro drip
with 0.5 and Propofol. She was on ventilatory support with
appropriate gases. She was making adequate urine. Her chest
tubes had put out 300. Her post-procedure hematocrit was 28
with a BUN and creatinine of 8 and 0.6. The vent was weaned.
She had started her diuresis. The chest x-ray was checked.
By post-op day #2, again she was weaned. Her PEEP
requirements were serially decreased. Her chest tubes were
DC'd. She was begun on a b.i.d. Lasix regimen. At this
time, she was on a Lasix drip at 2 per hour, neo drip of 0.5
for some labile blood pressures after her diuresis had begun.
Ultimately, by post-op day #4 status post her emergent CABG
with a ruptured RCA, she was stable and extubated, doing
well. Her indexes were appropriately 2.6. Her diuresis was
adequate, making greater than 2 liters per day. Her crit was
stable at 30. Her BUN and creatinine were 12 and 0.6. She
was still neo-requiring at 0.25 and was on Levaquin which had
been started on [**2141-10-9**] secondary to a temperature of
101.1?????? and some questionable findings on x-ray, 4+
gram-negative rods in the sputum, and also 1+ gram-positive
cocci that had grown from her sputum cultures. She was
continued for a total of 7 days of therapy.
She was ultimately transferred to the floor thereafter, where
she continued her diuresis. She was out of bed ambulating.
She was working with physical therapy, after which time she
was cleared to go home with physical therapy at home.
Followup plans include seeing Dr. [**Last Name (STitle) 70**] in approximately
30 days. At the time of discharge, she was doing well and
feeling well, afebrile, vitals stable. Heart rate was in the
70s and sinus. Blood pressures 110/70, stable. Her exam
was otherwise unremarkable. She had a stable sternum, no
drainage. Staples in place.
DISCHARGE MEDICATIONS:
1) Lipitor 40 mg q.day.
2) Zoloft 100 mg q.day.
3) Ditropan 10 mg q.day.
4) Aspirin 325 mg q.day.
5) Alprazolam 10 mg q.day.
6) Nitrofurantoin as previously taken preoperatively.
7) Lopressor 25 mg p.o. b.i.d. times one week. She can
change back to her Atenolol when she follows up with her PCP.
8) Plavix 75 mg q.day.
9) Lasix 20 mg p.o. b.i.d. times seven days for post-op
diuresis.
10) K-Dur 20 mEq p.o. b.i.d. times seven days.
11) Percocet as needed.
12) Colace as needed.
13) Imdur 30 mg p.o. q.day.
She will receive blood pressure monitoring and home PT
evaluation. She will have her staples out in approximately 7
to 10 days from the time of discharge. These should be taken
out by the visiting nurse, after which time the wound should
be Benzoin-ed and Steri-Strips applied. She should not do
any heavy lifting greater than 10 - 15 pounds. She should
assume a cardiac heart-healthy diet as well and follow up
with her PCP in approximately one week from the time of
discharge.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2141-10-15**] 11:09
T: [**2141-10-15**] 11:37
JOB#: [**Job Number 102250**]
ICD9 Codes: 5990, 4111, 4589, 2720, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1341
} | Medical Text: Admission Date: [**2151-5-11**] Discharge Date: [**2151-5-12**]
Date of Birth: [**2084-10-10**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 1402**]
Chief Complaint:
s/p PVI for refractory atrial fibrillation with hypotension and
bradycardia
Major Surgical or Invasive Procedure:
Pulmonary vein isolation for atrial fibrillation ([**2151-5-11**])
History of Present Illness:
66 year old male with hx of paroxysmal atrial fibrillation since
[**2148**] s/p numerous failed chemical and electrical cardioversions
presents with fatigue. He has been cardioverted a total of 3
times, last on [**3-12**], and he has been on amiodarone since [**8-25**]
(previously on sotalol and dronedarone). He presented for PVI
today and was found to be bradycardic to 40s-50s with junctional
escape beats and hypotensive to SBPs 80-90s in the PACU,
requiring dopamine. Attempts to wean off dopamine were
unsuccessful. His INRs are generally followed by his PCP, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 14522**], and his last dose on [**5-10**] was held prior to the
procedure.
He normally takes 5mg of Coumadin on Mondays, 2.5mg all
other days of the week.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. Denies recent fevers, chills or rigors.
Denies exertional buttock or calf pain. All of the other review
of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: + Dyslipidemia, + Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS: [**2147**] cardiac
catheterization (NEBH): mild CAD, Normal LVEF
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
-Atrial fibrillation diagnosed initially in [**2148**] s/p
cardioversion in [**2148-12-16**], treated with sotalol with
subsequent recurrence. s/p 2nd cardioversion ([**2150-8-16**])
after the initiation dronedarone. Recent DCCV in [**2151-2-16**]
unsuccessful.
- Prostate cancer s/p brachytherapy ([**2143-8-16**])
- ? Sleep apnea (has not had sleep study yet)
- Kidney stone
- Resection of basal skin cancers
- Appendectomy
Social History:
Patient is married with three children. He is
retired as airline pilot for Delta.
-Tobacco: Denies
-ETOH: 2 drinks per day
Family History:
Father with heart disease and siblings with atrial fibrillation.
Physical Exam:
On admission:
VS: T=98.0, BP=118/59, HR=74, RR=15, O2 sat=94% on RA
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with no JVD.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB over anterior and
lateral lung fields (cannot lean forward [**2-17**] femoral cath
sites), no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NT/ND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c. Trace edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Vitiligo over hands and neck
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
On discharge: unchanged, vital signs stable
Pertinent Results:
On admission:
[**2151-5-11**] 07:10AM BLOOD WBC-6.5 RBC-4.50* Hgb-16.1 Hct-45.1
MCV-100* MCH-35.7* MCHC-35.6* RDW-13.1 Plt Ct-215
[**2151-5-11**] 07:10AM BLOOD PT-30.0* INR(PT)-2.9*
[**2151-5-11**] 07:10AM BLOOD Glucose-128* UreaN-22* Creat-1.0 Na-141
K-4.2 Cl-102 HCO3-27 AnGap-16
MICROBIOLOGY: none
IMAGING: none
Brief Hospital Course:
Mr. [**Known firstname **] [**Known lastname 11312**] underwent pulmonary vein isolation,
electrical cardioversion, and right atrial flutter ablation
yesterday. He was hypotensive upon anesthesia induction and
required mild pressor support with dopamine during the
procedure. After cardioversion his sinus rate was slow (30-40)
with junctional escape rhythm associated with hypotension. Upon
extubation his sinus rate improved to 60, but needed continued
pressor support. In the CCU, he was weaned off dopamine and his
systolic blood pressures were steady off dopamine.
.
ACTIVE ISSUES
.
# Hypotension s/p PVI: After PVI procedure, patient became
bradycardic and hypotensive in the PACU, requiring pressor
support with dopamine. This hypotension may have been secondary
to the anesthesia medications, which may needed time to wear
off, or related to the bradycardia [**2-17**] to the procedure itself.
He was transferred to the CCU on dopamine, but completely
asymptomatic and feeling quite well. He was weaned from
3mcg/kg/min to off prior to discharge. Upon discharge, his
B-blocker and [**Last Name (un) **]/thiazide were held. He will restart his
Diovan 1 day after discharge and will follow up with [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] in Dr.[**Name (NI) 1565**] office.
.
# RHYTHM / bradycardia s/p PVI for atrial fibrillation: The
patient had bradycardia to the 50s-60s, with some junctional
escapes. Bradycardia is not a common occurrence s/p PVI, as we
are generally more concerned about more mechanical consequences
such as tamponade or pulmonary vein stenosis, rather than
electrical disturbances that may cause a bradyarrythmia. Though
is some debate and a paucity of data about chronic
anticoagulation s/p PVI, most agree to continue anticoagulation
based on CHADS2 score (=1). Upon discharge, we have cut his
amiodarone is half to 100mg daily and he will follow-up in
Zimetbaum's office as above. He was also discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
of Hearts holter monitor. He will continue on warfarin + ASA
for anticoagulation, long-term course to be decided as
outpatient possibly with argatoban, to be discussed with PCP.
[**Name10 (NameIs) **] will have his INR followed up in [**2-18**] days as an outpatient.
.
# PUMP: Mildly depressed EF of 50% on recent cardiac MR (done
prior to PVI). Current medication regimen is actually quite
appropriate for systolic HF, even though this is a recent
finding. We will defer medical management of this to his PCP
and cardiologist.
.
INACTIVE ISSUES
.
# Hyperlipidemia: Last lipid panel checked about 6 months ago,
per patient. He has a scheduled appointment with his PCP, [**Name10 (NameIs) **]
he will get it rechecked. He has been on a statin for control
of his hyperlipidemia and was continued on this during his
hospitalization.
.
TRANSITIONAL ISSUES
.
Communication: [**Name (NI) 7346**] [**Name (NI) 11312**] (wife - [**Telephone/Fax (1) 51159**] cell)
Medications on Admission:
AMIODARONE 200 mg daily
METOPROLOL SUCCINATE 100 mg daily
SIMVASTATIN 40 mg daily
VALSARTAN-HYDROCHLOROTHIAZIDE [DIOVAN HCT] 320 mg-25 mg daily
WARFARIN 5 mg on Mondays, 2.5 all other days qPM
ASPIRIN 81 mg daily
MULTIVITAMIN daily
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. warfarin 5 mg Tablet Sig: One (1) Tablet PO every Monday.
3. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: on
Tuesday, Wednesday, Thursday, Friday, Saturday, Sunday .
4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
6. amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: atrial fibrillation, hypotension
Secondary: hypertension, dyslipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 11312**], it was a pleaure taking care of you in the hospital.
You were admitted for pulmonary vein isolation for your atrial
fibrillation. Your blood pressure was noticed to be low, and you
were monitored in the cardiac care unit overnight.
It is important to follow-up with your primary care doctor and
have your INR (warfarin level) checked in the next **[**2-18**]** days.
Please read the post-procedure information sheet for activity
restrictions and danger signs.
You will also be wearing [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts Monitor to monitor
your heart rhythm.
Medications:
STOP metoprolol succinate 100 mg by mouth daily
STOP valsartan-hydroclorothiazine (Diovan)
CHANGE amiodarone from 200 mg by mouth daily TO 100 mg by mouth
daily
CHANGE aspirin 81 to 325 mg by mouth daily
Followup Instructions:
** Please visit Dr.[**Name (NI) 51160**] office to get your INR checked
within the next 2-3 days.
Department: CARDIAC SERVICES
When: FRIDAY [**2151-5-14**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5855**], NP [**Telephone/Fax (1) 285**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **],[**First Name3 (LF) **]
Location: [**Location (un) **] CARDIOVASCULAR ASSOCIATES
[**Hospital6 **]
Address: [**Apartment Address(1) 14524**], [**Location (un) **],[**Numeric Identifier 9749**]
Phone: [**Telephone/Fax (1) 14525**]
Appt: We are working on an appt for you within the next week.
THe office will call you at home with an appt. If you dont hear
from them by tomorrow, please call them directly to book one.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2151-5-26**] at 10:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5855**], NP [**Telephone/Fax (1) 285**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1342
} | Medical Text: Admission Date: [**2104-9-6**] Discharge Date: [**2104-12-11**]
Date of Birth: [**2104-9-6**] Sex: M
Service: NEONATOLOGY
HISTORY OF THE PRESENT ILLNESS: [**Known lastname **] [**Known lastname **] is now 96
days old, a former 25 [**5-16**] week premature infant who was twin
number one born to a 34-year-old gravida I, para 0 now II
woman. The mother's prenatal screens were blood type AB
negative, antibody negative, rubella immune, RPR nonreactive,
unknown. The pregnancy was complicated by gestational
diabetes and cervical shortening and preterm labor. The
mother received a complete course of betamethasone prior to
delivery.
On the day of delivery, labor progressed. This infant
emerged by spontaneous vaginal delivery, Apgar scores of four
The birth weight was 744 grams, birth length 32 cm and birth
head circumference 23 cm.
HOSPITAL COURSE: The patient was intubated in the Delivery
Room. He received two doses of Surfactant. He weaned to
nasopharyngeal continuous positive airway pressure on day of
life number 31. He was reintubated for gastrointestinal
surgery on [**2104-10-20**]. Postoperatively, he required
high-frequency ventilation and then weaned to continuous
positive airway pressure again on [**2104-10-27**] and then weaned to
nasal cannula oxygen and has consistently been in room air
for the last three days.
He was treated with caffeine citrate for apnea of prematurity
from day of life number four to day of life number 76. He
currently does not have apnea of prematurity but does have
apnea spells after his ophthalmology examinations.
On examination, he has some mild subcostal retractions. His
lung sounds are clear and equal.
CARDIOVASCULAR: He required dopamine for blood pressure
support for the first 36 hours of life. He again required
dopamine postoperatively but has remained normotensive since
that time. An echocardiogram on [**2104-10-31**] done for widened
pulse pressure showed no patent ductus arteriosus.
FLUIDS, ELECTROLYTES, AND NUTRITION: At the time of
transfer, his weight is 2,330 grams, length 42.5 cm, and his
head circumference 32 cm. At the time of transfer, he is
n.p.o. for anticipation of surgery. Prior to that, his
current feedings were breast milk of 26 calories per ounce on
an ad lib schedule. He was taking 140 to 190 cc per kilogram
per day. His last electrolytes on [**2104-11-26**] revealed a sodium
of 140, potassium 4.4, chloride 106, bicarbonate 25, calcium
9.1, phosphorus 5.9, and alkaline phosphatase 587.
GASTROINTESTINAL: [**Known lastname **] was treated with phototherapy for
hyperbilirubinemia from day of life number one until day of
life number ten. His peak bilirubin occurred on day of life
number eight with a total of 6 and direct 0.4. On day of
life number 22, he had frankly bloody stools and a shifted
differential on his complete blood count and lethargy. He
was then treated for 14 days with ampicillin, gentamicin, and
clindamycin for presumed necrotizing enterocolitis. He
remained n.p.o. with bowel decompression during that time.
When feeds were reinitiated, he had abdominal distention and
a KUB showed a probable ascending colonic stricture. He was
transferred to [**Hospital3 1810**] on [**2104-10-20**] and had a
right hemicolectomy with primary anastomosis by Dr. [**Last Name (STitle) 5715**]. He
was transferred back to [**Hospital6 256**]
on [**2104-11-8**]. Bilateral inguinal hernias were noted on
[**2104-12-4**] and those are the reason for transfer today.
He also had an abdominal ultrasound on [**2104-11-12**] due to
[**Male First Name (un) 1658**]-colored stools. The ultrasound showed a small but
normal gallbladder. The stools have normalized to yellow and
brown color since that time.
On examination, his abdomen was soft with a lot of inguinal
edema. His hernias were soft and easily reducible.
HEMATOLOGICAL: He has received multiple transfusions of
packed red blood cells, last on [**2104-10-31**]. His last
hematocrit on [**2104-12-2**] was 32, platelet count 560,000, white
blood cell count 12.3 with 20 polys, 0 bands. He was
receiving supplemental iron at 2 mg per kilogram per day.
INFECTIOUS DISEASE: [**Known lastname **] was started on ampicillin and
gentamicin at the time of admission to the NICU due to sepsis
risk factors. He completed seven days of antibiotics for
presumed sepsis, blood cultures, and cerebrospinal fluid
cultures remained negative.
On day of life number 17, he was started on vancomycin and
gentamicin for clinical presentation of sepsis. On day of
life number 22, he presented clinically with necrotizing
enterocolitis and the antibiotics were changed to ampicillin,
gentamicin, and Clindamycin and continued for 14 more days.
During that course, his blood and cerebrospinal fluid
cultures remained negative. He then received seven days of
ampicillin, gentamicin, and Clindamycin again postoperatively
after his hemicolectomy. He has remained off of antibiotics
since that time.
NEUROLOGICAL: Head ultrasounds done on [**2104-9-8**], [**2104-9-15**],
and [**2104-10-7**] were all within normal limits.
AUDIOLOGY: A hearing screen was performed with automated
auditory brain stem responses and the infant passed in both
ears on [**2104-11-29**].
OPHTHALMOLOGY: The eyes were examined most recently on
[**2104-12-9**] by Dr. [**Last Name (STitle) 5444**] revealing retinopathy of
prematurity, O.D., being stage III, zone II, one o'clock
hour, and O.S. stage II, zone II, five o'clock hour. He also
has some plus disease which was slightly improved on this
examination from the previous examination three days prior to
that. The next examination is recommended for [**2104-12-12**].
PSYCHOSOCIAL STATUS: The parents are [**Doctor First Name 2184**] and [**Doctor Last Name **].
They have been very involved in the infant's care throughout
his NICU stay. Currently, [**Known lastname 45501**] twin, [**Known lastname **], is at
[**Hospital6 1129**] in their NICU after undergoing
surgery following bilateral retinal detachment.
CONDITION AT DISCHARGE: Stable.
The infant is being transferred to [**Hospital3 1810**] for
repair of bilateral inguinal hernias.
Primary pediatric care will be provided by Dr. [**First Name4 (NamePattern1) 43909**]
[**Last Name (NamePattern1) 45503**] of [**Location (un) 8072**] [**State 350**], telephone number
[**Telephone/Fax (1) 36012**].
CARE AND RECOMMENDATIONS: At the time of transfer, the
infant is n.p.o. with IV fluids of D10W with 2 mEq per 100 cc
of sodium chloride and 1 mEq of potassium chloride per 100
cc. Total fluids were at 130 cc per kilogram per day through
a peripheral IV. Feedings prior to that were breast milk 26
calories per ounce with 4 calories per ounce made with human
milk fortifier and 2 calories per ounce of medium chain
triglyceride oil. The infant was eating on an ad lib
schedule every three to four hours, taking 150-190 cc per
kilogram per day.
MEDICATIONS:
1. Fer-In-[**Male First Name (un) **] 0.2 cc p.o. q.d. (concentration 25 mg per 1
cc).
2. Vitamin E 5 international units p.o. q.d.
The infant has not yet had a car seat position screening
test.
The last state newborn screen was sent on [**2104-11-16**] and was
within normal limits.
The infant has received his two month immunizations; on
[**2104-11-15**], he received his first hepatitis B vaccine,
first DTaP, HiB, IPV, and Pneumococcal 7-Valent conjugate
vaccine.
RECOMMENDED IMMUNIZATIONS:
1. Synagis RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the following three
criteria; (1) Born at less than 32 weeks. (2) Born between
32 and 35 weeks with plans for DayCare during the RSV season,
with a smoker in the household, or with preschool siblings.
(3) With chronic lung disease.
2. Influenza immunizations should be considered annually in
the fall for preterm infants with chronic lung disease once
they reach six months of age. Before this age, the family
and other care givers should be considered for immunization
against Influenza to protect the infant.
DISCHARGE DIAGNOSIS:
1. Prematurity at 25 6/7 weeks.
2. Twin number one.
3. Status post hyaline membrane disease.
4. Status post apnea of prematurity.
5. Status post hypotension.
6. Anemia of prematurity.
7. Status post presumed sepsis.
8. Status post presumed necrotizing enterocolitis.
9. Status post right hemicolectomy with primary anastomosis
due to intestinal stricture.
10. Retinopathy of prematurity.
11. Status post physiologic hyperbilirubinemia.
12. Status post chronic lung disease.
[**Doctor Last Name **] [**Last Name (NamePattern5) 36094**], M.D. [**MD Number(1) **]
Dictated By:[**Last Name (NamePattern1) 37333**]
MEDQUIST36
D: [**2104-12-11**] 05:14
T: [**2104-12-11**] 05:50
JOB#: [**Job Number 41265**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1343
} | Medical Text: Admission Date: [**2136-5-24**] Discharge Date: [**2136-5-29**]
Date of Birth: [**2068-11-24**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 24666**] underwent aortic
valve replacement and coronary artery bypass graft times two
in [**4-24**] with sternal dehiscence and bilateral pectoral flap
repair at that time. She has been followed by Dr. [**Last Name (STitle) 13797**]
since she represented in [**1-26**] with sternal wound drainage and
extruding suture. At that time she was brought to the
Operating Room with removal of that suture and some removal
of superficial pledgets and was discharged to home. She
represented at this time with ongoing drainage from her
sternum.
PAST MEDICAL HISTORY: Aortic valve replacement and coronary
artery bypass graft times two in [**4-24**] with pectoral flap
status post dehiscence.
Congestive heart failure.
Cholelithiasis.
Headaches.
Osteoarthritis.
Uterine fibroids.
Psoriasis.
Obesity.
MEDICATIONS:
1. Metoprolol.
2. Aspirin.
3. Lisinopril.
4. Furosemide.
5. Lipitor.
ALLERGIES: No known dietary or drug allergies.
PHYSICAL EXAMINATION: Heart rate 80 and regular. Blood
pressure 144/80. Height 4'9" tall, weight 200 pounds.
General, obese elderly woman. Skin no obvious lesions. Well
healed leg scars. HEENT pupils are equal, round, and
reactive to light and accommodation. Nonicteric.
Noninjected. Slight erythema in her oropharynx. Neck no
jugular venous distension. Thick obese neck. Chest clear to
auscultation bilaterally. Healed sternum with 1 cm opening
at superior aspect. Heart regular rate and rhythm. S1 and
S2. No murmur. Abdomen obese, nontender, nondistended. No
costovertebral angle tenderness. Extremities obese, warm and
well perfuse. Plus one bilateral pedal edema. Varicosities
none noted. Neurological Cranial nerves II through XII
grossly intact, nonfocal. Pulses plus 2 right and left
femoral. Plus 1 right and left posterior tibial pulse. Plus
2 right radial.
HOSPITAL COURSE: Mrs. [**Known lastname 24666**] was admitted on [**5-24**] and
brought to the Operating Room with Dr. [**Last Name (STitle) 952**] and Dr.
[**Last Name (STitle) 70**] with a diagnosis of draining sinus status post
aortic valve replacement coronary artery bypass graft and
pectoral flaps. At this time she underwent deep sternal
exploration with sinus that extended to the anterior aorta
where pledgets were involved and excised. She was
transferred to the CSRU on Propofol and neo and she was
extubated two hours after she left the Operating Room and she
was weaned off of her intravenous drip medications at that
time as well. On [**5-25**] she was transferred to the inpatient
floor and had an uneventful hospital course. On [**5-27**] her
sternal wound culture grew staph aureus. She was Vancomycin
and on [**5-29**] she was discharged to home and plans for a two
week course of Linezolid.
CONDITION ON DISCHARGE: Alert and oriented times three,
grossly intact. Cardiovascular normal sinus rhythm.
Respirations clear to auscultation, room air O2 sat 93
percent. Abdomen soft, nontender, nondistended, positive
bowel sounds. Wound sternal incision with clips, JP draining
to bulb suction draining scant amount of serosanguinous
drainage.
LABORATORIES ON DISCHARGE: White blood cell 10.3, hematocrit
36.7, platelets 192, sodium 139, potassium 3.6, chloride 96,
HCO3 30, BUN 22, creatinine 1.0, glucose 115, calcium 9.1,
phos 4.0, magnesium 1.9.
DISCHARGE STATUS: Mrs. [**Known lastname 24666**] is discharged to home with
VNA in stable condition.
DISCHARGE DIAGNOSES: Coronary artery disease status post
aortic valve replacement coronary artery bypass graft ni [**4-24**]
with pectoral flap status post dehiscence and now status post
sternal wound exploration with removal of deep pledgets.
Congestive heart failure.
Obesity.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg q.d.
2. Lopressor 25 mg b.i.d.
3. Furosemide 40 mg po b.i.d.
4. Linezolid at 600 mg po b.i.d. for two weeks.
FOLLOW UP: Dr. [**Last Name (STitle) 952**] in one week for removal of JP drain
and assessment of wound. Dr. [**Last Name (STitle) 70**] in six weeks and
visiting nurse at home with plans to check CBC q three days
and fax results to Dr. [**Last Name (STitle) 952**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2136-5-30**] 11:23:16
T: [**2136-5-30**] 13:13:55
Job#: [**Job Number **]
ICD9 Codes: 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1344
} | Medical Text: Admission Date: [**2152-6-20**] Discharge Date: [**2152-6-23**]
Date of Birth: [**2152-6-20**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: This is a 3390-gram, 36 and [**7-17**]
week, estimated gestation age female born to a 25-year-old
gravida 2, para 0 (now 1) mother with prenatal screens O
positive, antibody negative, rapid plasma reagin nonreactive,
Rubella immune, hepatitis B surface antigen negative, and
group B strep status negative. Estimated date of confinement
of [**2152-7-11**].
The pregnancy was complicated by a congenital cystic
adenomatous malformation noted in the middle left lung on
serial prenatal ultrasounds, diminishing in size, and
measured at less than 1 cm on the last ultrasound on [**2152-5-2**]. Fetal magnetic resonance imaging on [**5-8**]
showed an unremarkable central nervous system. Antenatal
consultation with Dr. [**Last Name (STitle) 37080**] at [**Hospital3 1810**].
Mother was induced on [**2152-6-19**] secondary to congenital
cystic adenomatoid malformation. Assisted rupture of
membranes ten hours prior to delivery for clear fluid. No
maternal fever or antepartum antibiotic prophylaxis. She
initially received blow-by oxygen and routine care; however,
she was noted to have mild grunting, flaring, and retracting;
for which she was transferred to the Neonatal Intensive Care
Unit.
PHYSICAL EXAMINATION ON PRESENTATION: Notable for grunting,
flaring, and retracting. Breath sounds were slightly
diminished, faint crackles symmetric throughout. Otherwise,
a nondysmorphic term female. The anterior fontanel was soft
and flat. The palate was intact. Heart was in a regular
rate and rhythm. There were no murmurs. There were 2 plus
peripheral pulses including femoral pulses. The abdomen was
benign without hepatosplenomegaly. There were no masses.
Back was without sacral dimple or hair [**Hospital1 **]. The skin was
pink and well perfused. The extremities were intact. She
had normal tone and normal neonatal reflexes.
SUMMARY OF HOSPITAL COURSE BY ISSUES-SYSTEMS:
1. RESPIRATORY ISSUES: The infant was initially placed on
continuous positive airway pressure at 6. She had an
initial chest x-ray which was unremarkable. On day of
life one, she was weaned from continuous positive airway
pressure to room air. A follow-up chest x-ray with
lateral on day of life one did not show any masses or
hyperlucencies. She has been on room air since and has
had no further respiratory issues.
1. CONGENITAL CYSTIC ADENOMATOID MALFORMATION ISSUES: The
infant will be followed by Dr. [**First Name8 (NamePattern2) 1169**] [**Last Name (NamePattern1) 37080**] (with
Pediatric Surgery at [**Hospital 86**] [**Hospital3 1810**]). She
will follow up in six weeks and have an ultrasound of her
chest as well as a chest computer tomography. Dr.
[**Last Name (STitle) 37922**] office telephone number is [**Telephone/Fax (1) 43145**].
1. CARDIOVASCULAR ISSUES: The infant has remained
cardiovascularly stable throughout her hospitalization.
1. GASTROENTEROLOGY/FLUIDS/ELECTROLYTES/NUTRITION ISSUES:
The infant was initially nothing by mouth on D-10-W. Once
she was taken off of continuous positive airway pressure,
enteral feedings were started on day of life two. She has
since been taking by mouth ad lib breast milk/Enfamil 20.
She is currently taken by mouth ad lib well. She has been
off of intravenous fluids since [**2152-6-22**]. Initial
electrolytes were unremarkable. Her Dextrostix have been
within a good range. The infant's weight on discharge is
3190g.
Serial bilirubin levels were followed. Her peak bilirubin
was 16.2 on 5.14. Received phototherapy until day of d/c.
Recent bili of 13.5. will have follow-up bilirubin [**6-25**] at
[**Hospital 55447**] [**Hospital3 **].
1. HEMATOLOGIC ISSUES: The infant's initial hematocrit was
55. She has had no hematologic issues.
1. INFECTIOUS DISEASE ISSUES: The infant had an initial
complete blood count with a white blood cell count of 22.7
(with 5 bands and 58 percent segs). A blood culture was
drawn, and she was treated with 48 hours of ampicillin and
gentamicin while awaiting blood culture results. The
blood culture was negative, and the antibiotics were
discontinued. The infant has no further signs of
infection.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) **] with [**Hospital **] Pediatrics
(telephone number [**Telephone/Fax (3) 55448**].
CARE RECOMMENDATIONS:
1. Feedings at discharge: Breast feed by mouth ad lib to be
followed by Enfamil 20 until mother's breast milk comes
in.
2. Medications: None.
3. Car seat position screen will be performed.
4. State newborn screen was sent [**2152-6-23**]; the results
were pending at the time of this dictation.
5. Immunizations received: The infant received a hepatitis B
vaccine on.
IMMUNIZATIONS RECOMMENDED: Synagis respiratory syncytial
virus prophylaxis should be considered from [**Month (only) 359**] through
[**Month (only) 547**] for infants who meet any of the following three
criteria: (1) born at less than 32 weeks gestation; (2) born
between 32 and 35 weeks gestation with 2/3 of the following:
Plans for day care during respiratory syncytial virus season,
a smoker in the household, neuromuscular disease, airway
abnormalities, or with school-age siblings; and/or (3) with
chronic lung disease.
Influenza immunization should be considered annually in the
Fall for preterm infants with chronic lung disease once they
reach six months of age. Before this age, and for the first
24 months of the child's life, immunization against influenza
is recommended for household contacts and out of home
caregivers to protect the infant.
DISCHARGE INSTRUCTIONS-FOLLOWUP:
1. Dr. [**Last Name (STitle) **] with [**Hospital **] Pediatrics
2. Dr. [**First Name8 (NamePattern2) 1169**] [**Last Name (NamePattern1) 37080**] (telephone number [**Telephone/Fax (1) 43145**]);
appointment to be scheduled six weeks from discharge.
3. A chest computer tomography.
4. A chest ultrasound.
5. bilirubin on [**6-25**] at [**Hospital6 3105**].
DISCHARGE DIAGNOSES:
1. Congenital cystic adenomatoid malformation on antenatal
ultrasound.
2. Initial respiratory distress syndrome; resolved.
3. Hyperbilirubinemia.
4. Sepsis evaluation negative.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 43886**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2152-6-22**] 18:17:32
T: [**2152-6-22**] 19:58:05
Job#: [**Job Number **]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1345
} | Medical Text: Admission Date: [**2145-3-29**] Discharge Date: [**2145-4-3**]
Date of Birth: [**2095-6-24**] Sex: F
Service: SURGERY
Allergies:
Mirtazapine
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
HPI (per Dr. [**First Name (STitle) **] [**Name (STitle) **]): Ms. [**Known lastname 28119**] is a 49 year old female s/p OLT
in [**5-/2142**] for
fulminant hepatitis due to unknown etiology c/b post-op biliary
stricture required multiple [**Year (4 digits) **] and stents. Patient was
recently admitted on [**2145-2-19**] for pan colitis and UTI and was
treated with Cipro and Flagyl. Her diarrhea resolved and she was
discharged on [**2145-2-24**] with Bactrim for her UTI. Two to three
days prior to this presentation, patient reported having
effusive diarrhea, almost every 2-3 hrs. She felt weak and
fatigue but denied any fever/chills/nausea/vomiting. She has
been trying to drink more fluid to keep up with her diarrhea but
admitted that she hasn't been doing enough. Patient was
evaluated in the ED, given Cipro/Flagyl and resuscitated with
IVF.
ROS:
(+): per HPI, chronic headache, generalized fatigue/weakness
(-): change in vision, sob, chest pain, dyspnea, abdominal pain,
nausea, vomiting, dysuria.
Past Medical History:
1. Severe acute hepatitis in [**2134**] (with ascites, coagulopathy)
ultimately attributed to ditropan (diagnosis by exclusion after
workup including: hep a,b,c serologies, ebv, cmv, hsv
serologies, cerulosplasmin, 24 hr urine [**Last Name (LF) 32276**], [**First Name3 (LF) **], [**Last Name (un) 15412**] was
negative and liver bx with bridging necrosis but no viral
cytopathic changes or fatty change). Initially, liver function
improved with no specific intervention, but a recurrent episode
of fulminant hepatitis led to OLT in [**2142-5-3**], complicated by
stenosis of the bile duct anastomosis in [**2142-6-3**], which
required stenting.
2. Multiple sclerosis, primary progressive, diagnosed in [**2133**].
3. Status post C-section.
Social History:
Tobacco - quit [**9-/2136**]; smoked 1PPD for 20 years.
Alcohol - Not in several months; previous had approximately 1
glass of wine per month.
Drugs - Remote hx of marijuana use; no drug use recently.
Married, has two children ages 10 and 11 at home. On disability.
Family History:
Mother with stroke at age 45. Maternal aunt with diabetes
mellitus. No family history of GI disorders (IBD, celiac, etc.)
Physical Exam:
97.9 97.1 82 142/78 18 94ra
NAD, A/Ox3
CTA anterior
RRR
soft, well healed scars, NT/ND
WWP
Pertinent Results:
LABS:
[**2145-3-29**]
12.2 137 103 19
11.8 >----< 165 -------------< 112
34.7 3.7 25 .7
Tacro 6.1
[**2145-4-3**]
10.8 141 114 17
5.5 >----< 194 -------------< 94
30.5 3.5 23 .8
Tacro 9.4
IMAGING:
CT scan w/o contrast Date: [**2145-3-29**]
IMPRESSION:
1. Right lower lobe pneumonia.
2. Pancolitis.
3. Mild peripancreatic fluid adjacent to the tail; please
correlate
clinically for pancreatitis.
4. 6-mm right renal lower pole hypodensity increased in size
from [**2142**] study may represent an enlarging simple renal cyst;
however, attention to this lesion is advised on followup
imaging.
MICRO:
FECAL CULTURE (Final [**2145-3-31**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2145-3-31**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2145-3-30**]):
NO OVA AND PARASITES SEEN.
FEW POLYMORPHONUCLEAR LEUKOCYTES.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2145-3-30**]):
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference
Range-Negative).
A positive result in a recently treated patient is of uncertain
significance unless the patient is currently symptomatic
(relapse).
Brief Hospital Course:
The patient was admitted to the Tranplant Surgical Service for
evaluation and treatment of large volume watery stool.
Neuro: The patient received dilaudid with good effect and
adequate pain control. When tolerating oral intake, the patient
was transitioned to oral pain medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, and incentive spirometry were encouraged throughout
hospitalization. Supplemental oxygen was weaned gradually to
room air.
GI/GU/FEN: Diet was advanced when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Due to large volume
watery stool, stool cultures were sent which were positive for C
Difficile. PO Vancomycin was started empirically with subsequent
gradual decrease in stool output.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Immunology: Tacrolimus was continued and levels monitored daily
with dosing adjustments as needed.
Prophylaxis: Venodyne boots were used during this stay; was
encouraged to get up and ambulate as early as possible.
Disposition: Pt worked extensively with physical therapy with a
plan to continue follow-up at her rehab facility.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Discharge Medications:
1. baclofen 10 mg Tablet Sig: Two (2) Tablet PO QAM (once a day
(in the morning)).
2. baclofen 10 mg Tablet Sig: One (1) Tablet PO LUNCH (Lunch).
3. baclofen 10 mg Tablet Sig: One (1) Tablet PO DINNER (Dinner).
4. baclofen 10 mg Tablet Sig: Four (4) Tablet PO QHS (once a day
(at bedtime)).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
7. pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO Daily ().
8. loperamide 2 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. vancomycin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) for 2 weeks: 500 mg q6hours for 10 more days (through
[**4-12**]).
Disp:*136 Capsule(s)* Refills:*0*
10. venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO QHS (once
a day (at bedtime)).
11. vancomycin 250 mg Capsule Sig: One (1) Capsule PO every six
(6) hours for 7 days: To start [**4-13**]. 1 tab daily for 7 days.
12. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours). Capsule(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Primary Diagnosis:
C. difficile colitis
.
Secondary Diagnosis:
Multiple Sclerosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 28119**],
It was a pleasure taking care of you during your
hospitalization. You were admitted to the hospital after
developing severe diarrhea. During your hospitalization, we
determined that your diarrhea was most likely secondary to a
Clostridium Difficile (C.diff) infection. You were hydrated and
started on an oral antibiotic, vancomycin. We recommend
continuing this antibiotic for a total of 3 weeks. Your diarrhea
has improved and we recommend that you follow up with Dr. [**Last Name (STitle) **]
in 2 weeks after discharge.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in 2 to 3 weeks after discharge.
Please see below for the dates of your next appointment:
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2145-4-21**] 10:40
Provider: [**Name10 (NameIs) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2145-8-11**] 10:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2145-4-3**]
ICD9 Codes: 0389, 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1346
} | Medical Text: Admission Date: [**2126-12-5**] Discharge Date: [**2126-12-8**]
Date of Birth: [**2126-12-5**] Sex: M
Service: NB
HISTORY OF PRESENT ILLNESS: This patient, baby boy [**Name (NI) 7049**]
[**Name (NI) 33681**] is the former 4.730 kilogram product of term
gestation pregnancy admitted to the neonatal intensive care
unit for treatment of hypoglycemia. This infant was born at
39-4/7 weeks to a 24-year-old G2, P1 now 2 woman. Prenatal
screens: Blood type O positive, antibody negative, rubella
immune, RPR nonreactive, hepatitis B surface antigen
negative, group A Strep status unknown. Mother's maternal
history is notable for [**Doctor Last Name 933**] disease which was treated with
PTU during her pregnancy. She is also a type 1 diabetic with
onset at the age of 9. She was treated with an insulin pump
during the pregnancy. The pregnancy was otherwise
unremarkable. The infant was delivered by repeat cesarean
section. Apgar's were nine at 1 minute and nine at 5 minutes.
His initial blood sugar was 22 for which he was fed, and
repeat was 24. He was also noted to have some cyanotic
episodes. He was admitted to the neonatal intensive care unit
for further treatment of his hypoglycemia.
PHYSICAL EXAMINATION UPON ADMISSION TO THE NEONATAL INTENSIVE
CARE UNIT: Weight 4.730 kilograms, length 20 inches.
GENERAL: Non dysmorphic, large for gestational age infant in
no obvious distress. HEAD, EYES, EARS, NOSE AND THROAT:
Normocephalic. Anterior fontanel open and flat. [**Last Name (un) 20696**]
intact. NECK: Supple. CHEST: Lungs clear bilaterally.
CARDIOVASCULAR: Regular rate and rhythm. Grade 1/6 systolic
murmur noted. Femoral pulses +2 bilaterally. GU: Normal male
external genitalia. Testes descended bilaterally. SPINE:
Midline. No dimple. HIPS: Stable. Clavicles intact. SKIN:
Pink, intact. EXTREMITIES: Warm, well perfused. Brisk
capillary refill. NEUROLOGIC: Normal tone. Symmetric
reflexes.
HOSPITAL COURSE BY SYSTEM INCLUDING PERTINENT LABORATORY
DATA:
1. RESPIRATORY: This infant required treatment with nasal
cannula upon admission to the neonatal intensive care
unit. He was able to breathe through room air by day of
life #1. He has been breathing comfortably with a
baseline respiratory rate of 40-50 breaths per minute,
maintaining oxygen saturations greater than 96%.
2. CARDIOVASCULAR: The murmur noted upon admission
resolved. This infant maintained normal heart rates and
blood pressures. Baseline heart rate is 140-150 beats
per minute with a recent blood pressure of 65/34 mmHg,
mean arterial pressure of 46 mmHg.
3. FLUIDS, ELECTROLYTES, AND NUTRITION: This infant
required intravenous glucose to help stabilize his blood
sugars. He also was fed ad lib p.o. He was able to wean
off the intravenous glucose on day of life #2. He has
been ad lib p.o. feedings, Enfamil 24 calorie per ounce
formula plus some additional expressed breast milk.
Whole blood glucoses have been maintaining 55-75. Weight
at the time of transfer 4.423 kilograms.
4. INFECTIOUS DISEASE: Due to the unknown group B Strep
status of the mother and the symptoms of cyanosis and
hypoglycemia, this infant was evaluated for sepsis upon
admission to the neonatal intensive care unit. A
complete blood count and white blood cell differential
were within normal limits. A blood culture was obtained
prior to starting intravenous ampicillin and gentamycin.
The blood culture was no growth at 48 hours and the
antibiotics were discontinued.
5. HEMATOLOGICAL: Hematocrit at birth was 66.5%.
6. GASTROINTESTINAL: Serum bilirubin was obtained on day of
life #3, a total of 5.7 mg/dL.
7. NEUROLOGY: This infant has maintained a normal
neurological exam and there are no neurological concerns
at the time of transfer.
8. SENSORY/AUDIOLOGY: Hearing screening has not yet been
performed and is recommended prior to discharge.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: Transfer to the newborn nursery for
continuing care.
PRIMARY PEDIATRICIAN: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 48015**], M.D., [**Apartment Address(1) 77100**], [**Location (un) 1456**], [**Numeric Identifier 65820**]. Phone
number [**Telephone/Fax (1) 48012**].
CARE RECOMMENDATIONS AT TIME OF DISCHARGE:
1. Feeding: Ad lib p.o. feeding every 3-4 hours. Enfamil 24
calorie per ounce formula.
2. No medications.
3. Iron and vitamin D supplementation:
Iron supplementation is recommended for preterm and low birth
weight infants until 12-months corrected age.
All infants fed predominantly breast milk should receive
vitamin D supplementation at 200 international units (may be
provided as a multivitamin preparation) daily until 12-months
corrected age.
1. Car seat position screening is not indicated.
2. State newborn screen was sent on [**2126-12-8**].
3. Immunizations received: No immunizations administered
thus far.
4. Immunizations recommended:
Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet any of the following 4
criteria: First, born at less than 32 weeks; second, born
between 32 and 35-0/7 weeks with two of the following:
Daycare during RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities, or school age
siblings; thirdly, chronic lung disease; or, fourth,
hemodynamically significant congenital heart disease.
Influenza immunization is recommended annually in the fall
for all infants once they reach 6 months of age. Before this
age and for the first 24-months of the child's life,
immunization against influenza is recommended for household
contacts and out of home caregivers.
This infant has not received Rotavirus vaccine. The American
Academy of Pediatrics recommends initial vaccination of
preterm infants at or following discharge from the hospital
if they are clinically stable and at least 6 weeks but fewer
than 12 weeks of age.
DISCHARGE DIAGNOSIS:
1. Infant of a diabetic mother.
2. Hypoglycemia.
3. Large for gestational age.
4. Transitional respiratory distress.
5. Suspicion for sepsis ruled out.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55780**]
Dictated By:[**Name8 (MD) 75740**]
MEDQUIST36
D: [**2126-12-8**] 07:23:25
T: [**2126-12-8**] 10:10:12
Job#: [**Job Number 56069**]
ICD9 Codes: V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1347
} | Medical Text: Admission Date: [**2180-3-22**] Discharge Date: [**2180-3-27**]
Date of Birth: [**2110-8-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 66279**] is a 69 year old man with a history of peripheral
vascular disease, hypertension, and hypercholesterolemia who
presented to [**Hospital3 **] with a complaint of sudden onset
severe back pain that occurred last evening and that remitted on
its own. A non non-contrast CT scan suggested Type A dissection
and he was transferred to [**Hospital1 69**]
for for further evaluation.
Past Medical History:
hypertension, hypercholesterolemia, AAA,
glaucoma, right CEA, prostate seeding for cancer
Physical Exam:
Pulse: Resp:18 O2 sat:95% (3 L)
B/P Right: 138/56 Left:
General:NAD, alert and cooperative
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 [] No Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[]
Extremities: Warm []x, well-perfused [x] Edema [] _____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: not palpable Left:not palpable
DP Right: not palpable Left:not palpable
PT [**Name (NI) 167**]:not palpable Left:not palpable
Radial Right: +2 Left:+2
Carotid Bruit Right:none Left:none
Pertinent Results:
[**2180-3-23**] MR brain
1. Acute infarcts involving the right parietal and occipital
lobes as well as right cerebellum, likely embolic in nature. The
main embolus probably has a central origin, going through the
right ICA into the right fetal PCA.
2. Focal stenosis of the posterior cerebral arteries
bilaterally.
3. Stenosis at the origin of the left vertebral artery and a
possible focal narrowing of the left V3 segment.
[**2180-3-23**] Echo
The left atrium is mildly dilated. 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. The aortic root is
mildly dilated at the sinus level. 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. There is no
mitral valve prolapse. The estimated pulmonary artery systolic
pressure is normal. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: There is an aneurysm/ulcer of the ascending aorta
(seen best on images # 56-62. There are mobile elements seen in
this area - likely thrombus/atheroma. No dissection is seen
(trans-thoracic echo cannot exclude). Mild symmetric left
ventricular hypertrophy with preserved global and regional
biventricular systolic function. No pathologic valvular
abnormality seen.
Compared with the prior study (images reviewed) of [**2180-3-22**],
the prior study was a TEE and showed this area more clearly.
There is no other likely source of embolism seen.
Radiology Report PORTABLE ABDOMEN Study Date of [**2180-3-26**] 7:29 AM
[**Hospital 93**] MEDICAL CONDITION: 69 yo man with distended and
tender abd
Final Report: There are dilated loops of predominantly small
bowel with relative paucity of large bowel gas. This raises the
possibility of partial or early small-bowel obstruction.
Nasogastric tube has not extended to the stomach.
Radioactive seeds are seen in the region of the prostate.
IMPRESSION: Possible small-bowel obstruction. If this is
consistent with the clinical finding, CT should be obtained.
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
There is no report history available for viewing.
Admission labs
[**2180-3-22**] 04:15PM PT-11.7 PTT-57.3* INR(PT)-1.1
[**2180-3-22**] 04:15PM PLT COUNT-236
[**2180-3-22**] 04:15PM WBC-6.9 RBC-3.56* HGB-11.8* HCT-34.6* MCV-97
MCH-33.0* MCHC-34.0 RDW-11.7
[**2180-3-22**] 04:15PM GLUCOSE-125* UREA N-20 CREAT-1.5* SODIUM-138
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-21* ANION GAP-14
[**2180-3-22**] 06:00PM %HbA1c-5.9 eAG-123
[**2180-3-22**] 06:00PM LIPASE-869*
Brief Hospital Course:
The patient is a 69 year-old R-handed man with a past medical
history of hypertension, hyperlipidemia, abdominal aortic
aneurysm and diabetes who presented initially for concern of an
aortic dissection, found instead to have a penetrating aortic
ulcer at the root, who is now s/p a R MCA/PCA territory
infarction likely from an embolic source given his impressive
atherosclerotic disease and his recent catheterization. His MRI
showed MCA/PCA territory infarction on his R side. He was not
felt to be a candidate for an intervention as his vertebral clot
could break off and cause basilar occlusion if attempted to be
intervened on and no other clots were identified on vessel
imaging. Given his coughing up of blood from earlier in the day
and his known aortic ulcer, heparin was not started. The
neurological insult left him hemiparetic on the left side,
responding to verbal command, alert and oriented times one or
two. The clot in his vertebral artery is on the left side and
felt not to be related to the right sided pathology. Hemoptysis
was noted on the night of admission which since resolved.
Further, anticoagulation was felt to be too risky due to concern
for aortic root penetrating ulcer, so heparin was not started.
His BUN and creatinine were also noted to be elevated at 25/1.5,
likely due to exposure to a significant amount of contrast
during the catheterization. He continued to make good urine
output. Renal toxins were avoided. On hospital day four his
mental status began to deteriorate further such that he ceased
to speak. A head CT revealed a question of a new infarct by
radiology read, but the neurology service felt it was largely
unchanged. On the following morning he began to develop
persistent fevers, his white blood cell count decreased from
normal to 3.5, and his abdomen was noted to be distended. A
urine analysis returned positive so he was placed on cipro. An
NG tube was placed and 600ml of bilious fluid returned
immediately. A KUB revealed possible air under the left
hemidiaphram. General surgery was called and an abdominal CT
was recommended, however on talking with the family, they did
not wish to pursue surgery under any circumstances. The family
felt he was uncomfortable and requested that morphine be given.
After several long discussion with Mr. [**Known lastname 66280**] wife and son,
they decided that he would not want further treatment. He was
made comfort measures only and placed on a morphine infusion. He
expired at 9:20AM on [**3-27**]
Medications on Admission:
amlodipine, atorvastatin, aggrenox, metformin
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Penetrating ulcer at aortic root
Right Middle Cerebral Artery/Posterior Cerebral Artery Embolic
Cerebral Vascular Accident
Discharge Condition:
expired
Discharge Instructions:
expired.
Followup Instructions:
expired
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2180-3-27**]
ICD9 Codes: 5849, 4019, 2720, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1348
} | Medical Text: Admission Date: [**2108-2-18**] Discharge Date: [**2108-2-20**]
Date of Birth: [**2039-3-9**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Productive cough.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
68yM s/p OLT [**2104**] with ESRD on HD who presented to an OSH
with a history of seizure. Per patientand records, he has a
remote history of seizure after receiving a liver transplant in
[**2104**] after which he was on Keppra for an unknown amount of time,
although patient thinks he was on Keppra for around a year. Pt
was taken to OSH where he was diagnosed with a pneumonia and
transferred to
[**Hospital1 **] for further care given his history of liver transplant and
recent GI bleed with admission to [**Hospital1 **]. Denies recent fevers,
V/D.
Notes new productive cough over the last 3 days. No CP/SOB/abd
pain, UTI symptoms.
Pt was recently admitted to the surgical service with an UGI
bleed. He had an EGD which identified a doudenal bulb ulcer
which was clipped and injected. He reports no blood per rectum
or hematemesis.
Past Medical History:
HCC, EtOH Cirrhosis s/p OLT, CAD, HTN, CHF/Cardiomyopathy (EF
25-30%) with frequent admissions for systolic heart failure,
Stage IV CKD (Baseline Cr 3.6), pancreatic insufficiency,
Anemia, Bronchitis, COPD, Tube feeds at home through G-tube,
COPD
Social History:
Married, lives at home with wife. Previously smoked 1PPD, now
trying to quit smoking. No current EtOH use for past 5 years.
Family History:
Father died of prostate cancer.
Physical Exam:
Vitals-WNL
Gen-AxOx3, NAD
CV-RRR, No MRG
[**Hospital1 **]-CTABL
Abd-Soft NT, ND
Ext-no C/D/E
Pertinent Results:
[**2108-2-18**] 08:37PM TYPE-ART PO2-146* PCO2-30* PH-7.52* TOTAL
CO2-25 BASE XS-2 INTUBATED-NOT INTUBA COMMENTS-O2 DELIVER
[**2108-2-18**] 08:25PM HCT-36.0*
[**2108-2-18**] 05:41PM TYPE-ART PO2-232* PCO2-35 PH-7.53* TOTAL
CO2-30 BASE XS-7
[**2108-2-18**] 05:28PM HCT-30.6*
[**2108-2-18**] 12:15PM VANCO-21.5*
[**2108-2-18**] 12:10PM STOOL BLOOD-NEGATIVE
[**2108-2-18**] 11:42AM GLUCOSE-109* UREA N-39* CREAT-3.5* SODIUM-136
POTASSIUM-4.1 CHLORIDE-95* TOTAL CO2-32 ANION GAP-13
[**2108-2-18**] 11:42AM ALT(SGPT)-14 AST(SGOT)-47* CK(CPK)-63 ALK
PHOS-148* TOT BILI-0.4
[**2108-2-18**] 11:42AM CK-MB-1
[**2108-2-18**] 11:42AM ALBUMIN-2.8* CALCIUM-8.0* PHOSPHATE-2.3*
MAGNESIUM-1.5*
[**2108-2-18**] 11:42AM WBC-16.4* RBC-3.06*# HGB-8.8*# HCT-24.8*#
MCV-81* MCH-28.7 MCHC-35.4* RDW-15.5
[**2108-2-18**] 11:42AM PLT COUNT-143*
[**2108-2-18**] 11:42AM PT-13.9* PTT-32.1 INR(PT)-1.2*
[**2108-2-18**] 11:42AM FIBRINOGE-620*
[**2108-2-18**] 01:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2108-2-18**] 01:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-150
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-9.0*
LEUK-NEG
[**2108-2-18**] 01:30AM URINE RBC-[**4-14**]* WBC-0-2 BACTERIA-NONE
YEAST-NONE EPI-0-2
[**2108-2-18**] 01:20AM PT-13.9* PTT-33.6 INR(PT)-1.2*
[**2108-2-18**] 01:13AM LACTATE-0.8
[**2108-2-18**] 01:05AM GLUCOSE-101* UREA N-37* CREAT-3.2* SODIUM-133
POTASSIUM-4.2 CHLORIDE-91* TOTAL CO2-34* ANION GAP-12
[**2108-2-18**] 01:05AM ALT(SGPT)-13 AST(SGOT)-47* ALK PHOS-139* TOT
BILI-0.5
[**2108-2-18**] 01:05AM LIPASE-33
[**2108-2-18**] 01:05AM CALCIUM-8.2* PHOSPHATE-1.2*
[**2108-2-18**] 01:05AM WBC-17.3* RBC-2.19*# HGB-6.2*# HCT-17.8*#
MCV-81* MCH-28.3 MCHC-34.8 RDW-15.9*
[**2108-2-18**] 01:05AM NEUTS-30* BANDS-2 LYMPHS-28 MONOS-12* EOS-1
BASOS-1 ATYPS-0 METAS-0 MYELOS-0 BLASTS-11* NUC RBCS-6*
OTHER-15*
[**2108-2-18**] 01:05AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL SPHEROCYT-1+
[**2108-2-18**] 01:05AM PLT SMR-LOW PLT COUNT-145*
Brief Hospital Course:
Pt was aditted via the ED on [**2108-2-18**] with complants of
productive cough. Pt was noted to have a Hct of 17.8 on
admission and due a history of recent GI bleed he was
transferred to the ICU and give blood transfusions with an
appropriate increase in his HCT to 30.0 which remained stable
throughout his hospital course. When he received this blood
transfusion he began to have respiratory compromise and he was
started on BiPAP in the ICU and he was dialysed and 3L offluid
was removed. This resolved his respiratory symptoms and he
subsequently was able to oxygenate without supplemental oxygen.
His Hct remained stable and he had no evidece of bleeding from
his GI tract and he was transferred out of the ICU. He did have
evidence of a possible continued pneumonia on a CXR and he was
continued on IV antibiotics while in the hospital. Because of
previous findings on blood work indicating a possible
myelodysplastic disorder of some type we discussed the
possibility of a bone marrow biopsy. However, on mulitple
occasions MR. [**Name13 (STitle) 68078**] refused to have this procedure done. On
HD 3 pt remained hemodynamically stable, tolerating a regular
diet with vital signs within the normal range. He was dischrged
home on a 10 days course of oral antibiotics.
Medications on Admission:
Carvedilol 3.125", Sirolimus 2g', prednisone 5', simvastatin
10', loperamide 2'prn diarrhea, tube feeds (vivonex@100/hr x
900cc at night), omeprazole 20", zofran 8'prn, mirtazapine 15',
testosterone 2.5mg patch', renal caps soft gel', creon 10'''
Discharge Medications:
1. sirolimus 1 mg/mL Solution Sig: One (1) PO DAILY (Daily).
2. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO EVERY OTHER DAY (Every Other Day).
3. furosemide 80 mg Tablet Sig: Two (2) Tablet PO MWF
(Monday-Wednesday-Friday).
4. prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. isosorbide mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. metolazone 2.5 mg Tablet Sig: One (1) Tablet PO MWF
(Monday-Wednesday-Friday).
9. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO Q8H (every 8 hours).
10. loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day) as needed for diarrhea.
11. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. testosterone 2.5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24
hr Transdermal DAILY (Daily).
14. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
15. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
16. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
17. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Stable.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze.
*You are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 10
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2108-2-29**] 1:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6952**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2108-2-29**] 2:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 11058**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2108-2-29**]
2:40
ICD9 Codes: 5856, 486, 4254, 4280, 2768, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1349
} | Medical Text: Admission Date: [**2156-8-18**] Discharge Date: [**2156-8-26**]
Date of Birth: [**2109-4-21**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
worsening gait over last 3 weeks
Major Surgical or Invasive Procedure:
[**8-23**] Right VP shunt placement
History of Present Illness:
The pt is a 47 year-old right handed woman with a past
medical history significant for HTN, HLD, DMII who presents with
3 weeks of worsening gait after a fall. The patient was in her
usual state of health 3 weeks ago when she slipped on a wet
surface at her job, falling backwards and striking the back of
her head on the floor.
The patient was in her usual state of health until [**7-25**],
when she was at work as a housekeeper in a hotel. She was
cleaning a bathroom when she fell backwards on a wet area in the
bathroom and struck the back of her head. She did not loose
consciousness and had a mild headache briefly afterwards but
fell
like she had some difficulty getting up, and was slightly
unsteady walking afterwards. Her family came to pick her up
from
work and they felt she seemed a little out of it, and someone
needed to stay nearby to help her walk. At this point she was
able to walk on her own power she just needed someone to help
steady her. She went to a local ED the next day with complaints
mostly of knee and ankle pain. Her head was not scanned, and
she
reportedly had xrays of her ankles which was normal by report.
She was discharged home.
Over the next three weeks she has had increasing difficulty with
her walking. She has a difficult time describing the problem.
She feels very unsteady as if she is going to fall when she
walks
or stands up. Her daughter noted that she was paying a lot of
attention to her walk, and was very hesitant, looking down. She
has has at least 2 more falls over the last few weeks, and a few
near misses. She does not think any of the other falls had head
strikes or any other major injuries. When she falls she does
not
fall to any particular direction. Her daughter has also noted
that she has been cognitively slower in the last few weeks than
prior to the fall. She takes longer to process and respond to
questions. She has also had episodes of confusion - one example
is that she has intermittently forgotten one of her [**Hospital1 **]
names. She eventually remembered it, but this is very unusual
for her. The daughter also notes that she has had some
difficulty going up and down stairs, but is not clear if this is
do to weakness or the patient's unsteadiness. The patient
herself denies any weakness in her legs or her arms. She denies
any headache or neck pain. She denies any urinary incontinence
or retention. She has had no change in stool (she was initially
constipated after taking a vicodin for her leg pain soon after
her fall, but this has since resolved. She denies any numbness.
She has normal saddle sensation. She denies lightheadedness or
vertigo. She reports moderate pain in both knees, but no
current
back pain. She has had no visual symptoms.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies numbness,
parasthesiae. No bowel or bladder incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
- HTN
- HLD
- DMII
Social History:
She lives with her 3 children. She works as a
housekeeper in a hotel. She denies tob, etoh, drug use.
Family History:
Multiple family members with DM, no history of stroke
known.
Physical Exam:
At admission:
Vitals: T: 97.5 P:68 R: 16 BP:160/100 SaO2:100
General: Awake, alert, no distress, cooperative daughter helping
with translation when the patient does not understand.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: mild limited ROM, supple. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to give a pretty
detailed history. Somewhat inattentive, difficulty with [**Doctor Last Name 1841**] and
DOW backwards, unlikely to be a language problem but not
preservative just confused, can to task in small chunks, three
days at a time. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high frequency objects, difficulty
with
some low frequency objects, hammock. Able to read simple
sentence. Speech was not dysarthric. Able to follow both
midline and appendicular commands. Pt. was able to register 3
objects and recall [**2-2**] at 5 minutes. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed large discs, can see the temporal border of both
eyes, slight blurring on the nasal side.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, normal tone throughout. No pronator drift
bilaterally but hands drift around when eyes are closed. No
adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 4+ 5 5- 5 5 5- 5 5 5 5 5
R 5 5 5 5 5 5 4+ 5 4+ 5- 5
-Sensory: No deficits to light touch, pinprick, cold sensation.
On proprioception she has proprioceptive difficulties on the
worse on the right than left, makes significant errors with both
feet but worse on the left. No extinction to DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 3 2
R 2 2 2 3 2
Plantar response was flexor on right, upgoing on left
-Coordination: No dysmetria on FNF
-Gait: Decent initiation, wide base and very unsteady. Has a
floridly positive Romberg, sways when eyes closed when sitting
upright, but with eyes open can maintain position.
Discharge exam : aaox3, perrl, face symmetric, incision c/d/i
slight LLE weakness 5-/5, RLE [**6-3**], UE [**6-3**] b/l. Sensory intact,
no drift,
Incission c/d/i
Pertinent Results:
At admission:
[**2156-8-18**] 12:33PM WBC-10.7 RBC-4.76 HGB-13.0 HCT-36.7 MCV-77*
MCH-27.3 MCHC-35.4* RDW-12.8
[**2156-8-18**] 12:33PM NEUTS-57.5 LYMPHS-36.9 MONOS-4.3 EOS-0.9
BASOS-0.5
[**2156-8-18**] 12:33PM FREE T4-1.4
[**2156-8-18**] 12:33PM TSH-1.4
[**2156-8-18**] 12:33PM VIT B12-1001*
[**2156-8-18**] 12:33PM TOT PROT-6.9 ALBUMIN-4.2 GLOBULIN-2.7
CALCIUM-9.9 PHOSPHATE-3.5 MAGNESIUM-1.6
[**2156-8-18**] 12:33PM ALT(SGPT)-22 AST(SGOT)-26 CK(CPK)-307* ALK
PHOS-55 TOT BILI-0.2
[**2156-8-18**] 12:33PM GLUCOSE-140* UREA N-24* CREAT-1.1 SODIUM-138
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-24 ANION GAP-17
[**2156-8-18**] 04:29PM URINE RBC-0 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-3
[**2156-8-18**] 04:29PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2156-8-18**] 04:29PM URINE UCG-NEGATIVE
NCHCT: [**8-18**] severe hydrocephalus, sulcal effacement, all 4 vents
appear open so ?communicating, but given sulcal effacement seems
new. Possible blockage is past 4th vent
C-spine Ct [**8-18**] - 1. No fracture.A small lucency is noted in the
left side of C4 body, 5x4mm which is of uncertain nature-
cyst/fat deposit/lesion. ( se 601b, im 32) See subsequent MR
study.
2. Heterogeneous right lobe of thyroid. Consider thyroid
ultrasound in a
nonurgent setting.
3. Fullness in the piriform sinus- correlate with ENT
examination
MRI C-spine [**8-19**] - 1. Mild degenerative changes as described
above. No abnormal cord signal.
2. 7 mm Nodular lesion in the right thyroid. Ultrasound can be
obtained if
clinically warranted for further characterization.
Brain MRI [**8-19**] - 1. Massive dilatation of the 4th, 3rd and
lateral ventricles with no evidence of obstruction. Pulsation
artifact at the 3rd ventricle and foramen of Magendie suggest
Communicating Hydrocephalus. CSF flow MR imaging may be obtained
for further evaluation if clinically warranted.
2. Old left occipital infarct.
Thoraco/lumbar MRI [**8-20**] - T4 and T5 intradural extramedullary
mass compressing the spinal cord and displacing it to the right.
This is incompletely imaged due to motion artifact and the
absence of intravenous contrast. Based on the available images,
it is most suggestive of a meningioma. The differential
diagnosis includes nerve sheath tumor, metastasis and
hemangioblastoma. The spinal cord is difficult to evaluate at
this level but likely demonstrates an area of hyperintensity
perhaps reflecting edema or myelomalacia.
Thoracic MRI with contrast [**8-21**] - - The T4-5 intradural
extramedullary mass previously identified is seen to enhance
intensely after contrast administration.
CT C/a/P with and without contrast - 1. Enhancing nodule within
the spinal canal, better evaluated on recent MR.
2. Status post left hemithyroidectomy.
3. Slight fullness of the medial limb of the left adrenal,
possibly
hyperplasia or a small adenoma; suspicion for malignancy is low,
but attention
in follow-up imaging surveillance is recommended within six
months.
4. Fibroid uterus; mildly prominent endometrium is likely within
normal
limits for a premenopausal patient. However, if the patient is
perimenopausal
or postmenopausal, pelvic ultrasound assessment could be
considered.
[**8-23**] CT brain - 1. Interval placement of a right frontal
approach intraventricular shunt
terminating in the frontal [**Doctor Last Name 534**] of the right lateral ventricle,
with
associated postop pneumocephalus. No new hemorrhage.
2. Moderate communicating hydrocephalus with enlargement of the
lateral
ventricles, third, and fourth ventricle, which is slightly
decreased from
prior study
CXR [**8-24**]
1. VP shunt coursing inferiorly, just right of midline, looping
in RUQ.
2. unchanged L paratracheal clips.
3. no evidence of pneumonia or pleural effusion.
4. no subdiaphragmatic free air.
LENS [**8-24**]
No evidence of DVT in bilateral lower extremities
Hematology
GENERAL URINE INFORMATION Type Color Appear Sp [**Last Name (un) **]
[**2156-8-25**] 10:57 Straw Clear 1.003
Source: Catheter
[**2156-8-24**] 23:36 Straw Clear 1.005
Source: CVS
[**2156-8-18**] 23:00 Straw Clear 1.004
[**2156-8-18**] 16:29 Straw Clear 1.004
DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone
Bilirub Urobiln pH Leuks
[**2156-8-25**] 10:57 NEG NEG NEG NEG NEG NEG NEG 6.0 NEG
Source: Catheter
[**2156-8-24**] 23:36 NEG NEG NEG NEG NEG NEG NEG 6.0 NEG
Source: CVS
[**2156-8-18**] 23:00 NEG NEG NEG NEG NEG NEG NEG 5.5 NEG
[**2156-8-18**] 16:29 NEG NEG NEG NEG NEG NEG NEG 5.0 TR
MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE
RenalEp
[**2156-8-18**] 16:29 0 2 FEW NONE 3
CSF [**8-19**]
GRAM STAIN (Final [**2156-8-19**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2156-8-22**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST CULTURE (Preliminary):
The sensitivity of an AFB smear on CSF is very low..
If present, AFB may take 3-8 weeks to grow..
NO MYCOBACTERIA ISOLATED.
CSF [**8-19**]
CRYPTOCOCCAL ANTIGEN (Final [**2156-8-19**]):
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
Performed by latex agglutination.
Results should be evaluated in light of culture results
and clinical
presentation.
[**2156-8-20**]
RAPID PLASMA REAGIN TEST (Final [**2156-8-23**]):
NONREACTIVE.
Reference Range: Non-Reactive.
Brief Hospital Course:
The patient is a 47 year-old right handed woman with a past
medical history significant for HTN, HLD, DMII who presents with
3 weeks of worsening gait after a fall.
Here her exam is notable for left sided weakness in in both
upper and lower extremities. She has noticeable proprioceptive
loss in the hands, right a little worse than left, and in the
feet bilaterally. She does not report any other sensory loss.
Additionally she is somewhat inattentive and distractible, but
language is intact and she is able to give a decent history.
The edge of her fundi are
slightly blurred on the nasal side, but otherwise intact. Her CT
shows significant amount of hydrocephalus with sulcal
effacement. All the ventricles including the 4th are open.
Cervical spine CT fails to show any obstruction. Repeat MRI
imaging of both the head and cervical spine fail to elucidate
the cause of hydrocephalus. Neurosurgery was consulted and
initially the patient was admitted to the ICU for possible
elective intubation followed by EVD placement, however given
that the patient is currently awake and alert, the decision was
made to defer the EVD. Ophthalmology was consulted who confirmed
the finding of mild papilledema. An LP was done that showed an
opening pressure of 26 (not fully relaxed), with elevated
protein of 292. Neurosurgery would be willing to place a VP
shunt on Monday to relieve a what they believe is a chronic
process. The patient was transferred to the general neurology
floor [**8-20**] for further work up.
On [**8-23**] Pt udnerwent the above stated procedure. she tolerated
the procedure well. Please review dictated operative report for
details. She was extubated and transferred to pacu then floor
in stable condition. Post op Ct shows good placement of right
VP shunt. No infarct or hemorrhage.
She developed a fever of 101.5 on [**8-24**]. UA was negative but
review of lab work showed a few bacteria on [**8-18**]. Urine culture
was sent and is pending.
She failed voiding trials and required a Foley catheter. PT saw
her and recommended Rehab.
Now DOD, patient is afebrile, VSS, and neurologically stable.
Patient's pain is well-controlled and the patient is tolerating
a good oral diet. She reported constipation and lactulose and a
fleet enema were given along with her other bowel meds.
Her incision is clean, dry and inctact without evidence of
infection. She is set for discharge to rehab and was transfered
on [**8-26**].
****Please call [**Telephone/Fax (1) 1272**] to follow up on her urine culture.
Please monitor for continued constipation
Medications on Admission:
- Lantus 32U daily, humalog sliding scale
- Metformin 1000mg [**Hospital1 **]
- Simvastatin 20mg qd
- HCTZ 25mg qd
- enalapril maleate 20mg [**Hospital1 **]
- amlodipine 2.5mg qd
Discharge Medications:
1. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
2. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. enalapril maleate 10 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for headache or pain.
Disp:*60 Tablet(s)* Refills:*0*
6. docusate sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*0*
7. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
Disp:*20 Tablet(s)* Refills:*0*
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever: mx 4g/24 hrs.
10. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
11. labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for SBP>140: :PRN SBP>140
HR <60 and SBP <90
.
12. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours) as needed for constipation.
13. insulin glargine 100 unit/mL Solution Sig: Thirty Two (32)
units Subcutaneous at bedtime.
14. insulin glargine 100 unit/mL Solution Sig: Two (2) units
Subcutaneous once a day: please see sliding scale and administer
per scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Hydrocephalus
T4-5 extramedullary lesion
High blood pressure
Urinary retention
constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures 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.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, you may
safely resume taking this on XXXXXXXXXXX.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? 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:
??????Please have your sutures removed at rehab on [**2156-8-31**]. ??????Please
call ([**Telephone/Fax (1) 88**] for information about your spine surgery on
[**9-28**]. We will image your brain to follow up on your shunt at
that time.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2156-8-26**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1350
} | Medical Text: Admission Date: [**2125-10-5**] Discharge Date: [**2125-10-8**]
Date of Birth: [**2105-5-5**] Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
20 yo F with DM type 1 w/ hx of med noncompliance and freq
admissions for DKA sent here from [**Hospital3 **] for
management of her DKA. Pt was resistant to answering questions
so most of information is from chart review. Pt followed by Dr.
[**Last Name (STitle) 58215**] at [**Last Name (un) **]. Pt has a hx of freq DKA (last at [**Hospital1 **] was
[**9-22**], last at [**Hospital1 **] was [**8-3**]. Furthermore the pt has a
history of leaving AMA.
1 day PTA pt N/Vx1 and had diarrhea x 3. She noticed small
amount of blood on TP once. Unclear if from vagina or rectum
but stopped after this once incident. Morning of admission she
had V x 3 with crampy abdominal pain in the RUQ that radiates to
back. Also the pt reported dizziness and occasional cough. She
denied fevers chills, dysuria, vaginal discharge. No LMP b/c on
depoprovera.
On admission to the [**Hospital1 **] ED:
[**Last Name (un) **]
VBG pH Na K HCO3 Cl AG Blood Glucose
8am 7.07 143 5.7 <5 81 >45 to high to measure
UA + for glucose ketones and blood, 1L NS given, insulin drip at
5.5u/hr started
9:30am 7.09
10:30am 7.11 148 5.6 <5 96 >38 to high to measure
pt had both emesis and diarrhea both non bloody (given zofran
and protonix)
11:30am 149 5.2 <5 97 >39 to high to measure
12:30pm 7.16 146 5 <5 98 >37 to high to measure
1:30pm 7.22 144 4.9 <5 98 >35 399
Then pt transfered to [**Hospital3 **] Emergency after receiving a
500 cc bolus on top of her fluids.
Upon arrival to ICU pt was somnolent but easily arousable. She
complained of thirst and fatigue. She denied pain, nausea or
any other complaints. No fevers, dysuria, vaginal
discharge/bleeding, diarrhea.
[**Name (NI) 1094**] mother claimed that until today her glucose has been
running in the 140's. Upon arival FS 230, she was started on NS
wide open while waiting for initial chemistries and insulin drip
at 0.5 cc with instructions to titrate up with a goal glucose
between 80-120.
Past Medical History:
1. Diabetes Type I diagnosed in [**2120**] after her first pregnancy.
Most recent Hgb A1C 11.5% ([**7-/2125**]), Multiple DAK admissions.
2. Hyperlipidemia
3. S/P MVA [**5-4**] - lower back pain since then. + back muscle
spasm treated with tylenol.
4. Goiter
5. Depression
6. HSV - pt has genital herpes dx [**7-4**]
7. G2P1Ab1, s/p miscarriage in 06/00 3rd trimester, s/p
C-section in [**2122**], not menstruating secondary to being on
Depo-Provera shots
Social History:
Completed high school in [**2122**]. She has a two-year-old son with
her current partner. [**Name (NI) 1139**]: [**12-1**] ppd x 3 years. No EtOH. No
marijuana, cocaine, heroin or other recreational drugs.
Unemployed. Sexually active. 4 life partners. Currently
monogamous over 1 year.
tested negative for STD 2 weeks ago.
Family History:
GM with Type I diabetes. Otherwise non-contributory. Relatives
with "acid in blood" not related to diabetes.
Physical Exam:
T 98.6 P 118 BP 87/49 R 21 O2 99 on RA
Gen - somnolent, answers appropriately when cajoled
HEENT - dry mucous membranes
Neck - supple
Chest - CTAB
Cor - RRR no m/r/g
Abd - S/NT/ND +BS
Ext - no c/c/e , w/wp, +2 distal pulses bilat
Pertinent Results:
See HPI for complete labs while she was at [**Hospital1 **]
Also from [**Hospital1 **] [**10-5**]
WBC 25.5 Hct 42.5 Plt 276 N67 L30 M1
ALT 31 AST 45 TB 0.5 DB 0.1
UHCG negative
Cr 2.0 on admiission and 1.8 on transfer.
[**2125-10-5**] 04:58PM WBC-23.3*# RBC-4.60 HGB-13.6 HCT-42.9 MCV-93
MCH-29.6 MCHC-31.7 RDW-14.1
[**2125-10-5**] 04:58PM NEUTS-70 BANDS-0 LYMPHS-21 MONOS-8 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-1*
[**2125-10-5**] 04:58PM PLT COUNT-325#
[**2125-10-5**] 04:58PM GLUCOSE-178* UREA N-45* CREAT-1.8*#
SODIUM-141 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-13* ANION
GAP-32*
[**2125-10-5**] 04:58PM CALCIUM-9.2 PHOSPHATE-4.6*# MAGNESIUM-2.5
ALT 22 AST 28 TB 0.4 AP 106 LD 167 Alb 5.0
EKG ST, Jpoint elevation V2,3
[**2125-10-6**] 12:10AM BLOOD Glucose-100 UreaN-26* Creat-1.0 Na-140
K-3.7 Cl-106 HCO3-16* AnGap-22*
[**2125-10-6**] 08:37AM BLOOD Glucose-31* UreaN-16 Creat-0.8 Na-140
K-3.0* Cl-108 HCO3-17* AnGap-18
[**2125-10-6**] 02:28PM BLOOD Glucose-295* UreaN-11 Creat-0.8 Na-135
K-3.9 Cl-107 HCO3-20* AnGap-12
[**2125-10-6**] 07:35PM BLOOD Glucose-96 UreaN-8 Creat-0.9 Na-138 K-3.7
Cl-110* HCO3-21* AnGap-11
[**2125-10-7**] 04:20AM BLOOD Glucose-148* UreaN-6 Creat-0.6 Na-136
K-3.5 Cl-105 HCO3-21* AnGap-14
[**2125-10-8**] 06:55AM BLOOD Glucose-82 UreaN-7 Creat-0.5 Na-140 K-3.3
Cl-102 HCO3-30* AnGap-11
[**2125-10-6**] 12:59AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2125-10-6**] 12:59AM URINE Blood-LGE Nitrite-NEG Protein-TR
Glucose-NEG Ketone-150 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
[**2125-10-6**] 12:59AM URINE RBC-18* WBC-10* Bacteri-MOD Yeast-NONE
Epi-1
Brief Hospital Course:
1) DKA - Pt has had multiple episodes of DKA with multiple
hospitalizations. She may have had an infection (the UTI, see
below) which precipitated this episode; however, there is also
question about pt's compliance with her medications. Pt was
immediately placed on NS and insulin drip which was titrated to
5u/hr. Her blood sugars were in the 180's with AG of 28. Pt
resistant to frequent blood draws, attemted to place an arterial
line in order to draw frequent pH, HCO3 but failed after
numerous attempts. Followed the pt's K, bicarb, and anion gap
via venipuncture. Anion gap ultimately closed, and pt was
transferred to the floor off an insulin drip. Pt was then
stable from an electrolyte standpoint, still with glucose in the
high 200s. She strongly requested to leave on the day of
transfer to the floor, and was ultimately escorted to her [**Last Name (un) **]
appointment immediately on discharge.
2) ARF - Given the BUN/Cr ratio is high and that the pt is
dehydrated, this was likely pre renal. Pt was fluid
resuscitated, and her Cr came down to 0.5.
3) Abd Pain/N/V - Pt symptoms have resolved. They were likely
due to the DKA. Pt denied abdominal pain, nausea, and vomiting
on discharge.
4) Hypercholesterolemia - Pt had slightly elevated ALT/AST at
[**Hospital1 **] which was questioned to be secondary to statin therapy
but LFTs normal here. Nonetheless, the Lipitor was held while
in the hospital.
5) urinary tract infection - pt's urinalysis appeared to be
consistent with a UTI. However, her cultures were contaminated.
She was treated empirically with a three-day course of
levofloxacin for an uncomplicated UTI.
Medications on Admission:
Depoprovera (last shot [**2125-8-10**])
Lantus 28u qam
Humalog Carbcounting (1:8 in AM, 1:10 at lunch and dinner)
Also according to last [**Last Name (un) **] Note([**2125-9-17**]):
ASA 325 qd
Lipitor 40mg qd
Zestril 10mg qd
Discharge Medications:
1. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Phenol-Phenolate Sodium 1.4 % Mouthwash Sig: One (1) Spray
Mucous membrane Q8H (every 8 hours) as needed.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Home
Discharge Diagnosis:
1) diabetic ketoacidosis
2) urinary tract infection
Discharge Condition:
stable, tolerating po intake
Discharge Instructions:
Please call your PCP if your sugars get very high, if you
develop symptoms of a urinary tract infectin (burning with
urination, urinating frequently, a feeling of urgent urination),
or if you have any other symptoms that are concerning to you.
Please continue to take your home insulin regimen and check your
insulin four times a day.
Followup Instructions:
Please follow up with your primary care doctor in [**12-1**] weeks.
You should also keep all of your appointments in the [**Hospital **]
Clinic.
You have received three days of levofloxacin, so you do not need
to take any more antibiotics as you have finished your course.
ICD9 Codes: 5849, 5990, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1351
} | Medical Text: Admission Date: [**2200-5-13**] Discharge Date: [**2200-5-29**]
Date of Birth: [**2121-7-8**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Lansoprazole
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
Pt is a 78 yo male with p-ANCA vasculitis, history of
interstitial lung disease, recent d/c from [**Hospital1 **] at the end of
[**Month (only) 547**] who presents with frank hemoptysis, transfer from an OSH.
Pt was admitted to [**Hospital1 **] from [**Date range (3) 18455**] when he presented
with chills, wt loss, muscle cramps, night sweats. He was found
to be in ARF with creatinine of 2.7, CRP 113, ESR >100, mildly
elevated transaminases in the lower 100s, CK 785. He was found
to have a positive p anca (mpo specificity, negative pr3). Renal
biopsy had "evidence of fibrinoid necrosis of the small/medium
vessels. This was consistent with a pauci-immune vasculitis of
the medium vessels. "(per d/c summary. No report in computer).
Pt was started on prednisone (60mg qday) and received one dose
of cytoxan. This admission was also complicated by anemia and
hematuria.
Patient was seen in both rhematology and renal clinic yesterday
and looked and felt well per report. Today, he presented to
[**Hospital1 **] Hospiatl by EMS from home when he had a sudden
onset of difficulty breathing and frothy hemoptysis (per NW
note). He was only able to answer in one word answers,
tachycardic in the 140s, and hypertensive to 190/110. SaO2 was
50s per report (ambulance tx) and pt was having frank hemoptysis
or BRB (150-200 cc) and pt was emergently intubated. He was
given 5 mg versed, 20 etomidate, 120 mg succinylcholine prior to
intubation. ABG at NWH was 7.34/37/180 on an FiO2 of 100%. Labs
were notable for potassium 5.5, BUN/cr of 86/3.8, lactate of
3.6, wbc of 28.2. He was also give protonix 40 mg IV and 1 gram
of IV solumedrol. He received 3.375 mg IV zosyn, 1 gram of IV
vancomycin. Patient was then transferred to [**Hospital1 18**].
In the ED at [**Hospital1 **], VS on arrival were: T: 99.0 HR: 80, BP:
146/83; RR 18; O2: 94-97%RA.
Past Medical History:
1. Interstitial lung disease- diagnosed four years ago with
restrictive pattern on PFTs.
2. Bladder cancer-transitional cell, low grade
3. HTN
4. GERD
5. Hyperlipidemia
6. 4 mm subpleural chest nodule
7. p-anca vaculitis as above.
Social History:
Per last d/c summary (cannot obtain info from pt now as he is
intubated). No smoking. 6 drinks/week. No drugs. Retired stock
broker.
Family History:
Sister with crohns
Physical Exam:
VS: T: 97.5; HR: 72; BP: 125/73; RR: 17; O2: 98 on AC
500/16/80/13
Gen: Intubated, sedated though can follow commands. Does not
open eyes.
HEENT: Pupils reactive 3-->2. ETT in place.
Neck: No LAD
CV: RRR S1S2. No M/R/G
Lungs: posteriorly: bronchial breath sounds throughout though
good aeration. There are dry crackles scattered bilaterally.
Abd: Soft, nondistended. No grimaces to palpation
Back: No lesions.
Ext: trace edema pitting b/l. DP 1+ b/l.
Neuro: intubated, sedated though arousable. Can squeeze hands,
wiggle toes. Dorsiflexion strength is intact. biceps, brachio,
patellar [**1-6**] reflexes.
Pertinent Results:
EKG: Sinus rhythm at 85. Normal axis. Normal intervas. No acute
ST=t wave changes. Upsloping of St in V2, v3, nonspecific.
.
Radiology:
CXR AP [**2200-5-13**]-Marked progression to diffuse parenchymal
opacities. Differential includes severe infectious etiology
including PCP in immunocompromised patient, pulmonary hemorrhage
with asymmetric diffuse alveolar edema felt less likely. Mild
over distention of endotracheal tube balloon cuff.
Labs on admission:
[**2200-5-13**] 08:19PM BLOOD freeCa-1.04*
[**2200-5-13**] 03:13PM BLOOD Lactate-2.5*
[**2200-5-14**] 12:31AM BLOOD Type-ART Temp-36.2 Rates-/4 Tidal V-500
PEEP-13 FiO2-50 pO2-129* pCO2-36 pH-7.46* calTCO2-26 Base XS-2
Intubat-INTUBATED Vent-CONTROLLED
[**2200-5-12**] 02:45PM BLOOD CRP-29.1*
[**2200-5-12**] 02:45PM BLOOD WBC-16.5* RBC-3.97* Hgb-11.7* Hct-37.3*#
MCV-94 MCH-29.4 MCHC-31.3 RDW-17.8* Plt Ct-204
[**2200-5-12**] 02:45PM BLOOD Neuts-95.4* Bands-0 Lymphs-2.1* Monos-2.1
Eos-0.4 Baso-0
Echo
The left atrium is mildly dilated. The estimated right atrial
pressure is [**5-15**] mmHg. 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%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets are mildly thickened. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is an anterior space which most likely represents a fat
pad.
CXR [**2200-5-13**] There has been interval progression of diffuse
parenchymal opacities involving majority of the lung fields
bilaterally with scattered air bronchograms and without evidence
of overt cardiac enlargement or pleural effusions. Endotracheal
tube is approximately 6 cm from the carina and there is mild
over distention of the balloon cuff. Orogastric true terminates
within the stomach fundus. There is no evidence of a
pneumothorax and the hemidiaphragms are well visualized.
CXR [**2200-5-28**]
Endotracheal tube terminates approximately 3.9 cm above the
carina. A right subclavian line terminates at the level of the
mid superior vena cava. A Dobbhoff tube courses below the
diaphragm and out of view of the film.
Right lung opacity may demonstrate more confluence today with
persistent left retrocardiac and perihilar opacity with air
bronchograms. Low lung volumes are noted bilaterally and there
is no evidence of pneumothorax. Left costophrenic angle is cut
off on this film; however, a right-sided effusion likely
persists. Cardiomediastinal silhouette is unchanged. Compared
with the prior there is massive increase in the amount of air
within the stomach.
Brief Hospital Course:
Pt is a 78 yo male with a history of interstitial lung disease,
newly diagnosed P-ANCA vasculitis presented with respiratory
failure from hemoptysis. He received plasmapheresis, pulse dose
steroids, and cytoxan. Now s/p extubation, episode of AFlutter
s/p cardioversion.
1. Respiratory failure- Patient intubated with likely pulmonary
hemorrhage secondary to vasculitis (capillary alveoli leak) on
admission. He was bronched on HD 3 which did not show active
bleeding. He was treated broadly for possible infection with
vancomycin, levaquin, and flagyl (14 day course) as well as the
fact that blood is a nidus of infection. He had pressure support
trial on HD2 and was extubated on HD3, failing extubation and
had to be reintubated 8 hours later. His ABG showed good
ventilation and it was purely hypoxic failure and tiring out.
Based on BNP >assay, CXR, and physical exam, it was thought that
fluid overload played a large part in the failed extubation. He
was diuresed aggressively. A repeat echo did not show any wall
motion abnormalities and enzymes checked showed an elevated
troponin but not thought to be ischemia. Rebronch on HD 7 showed
no active hemorrhage and patient was successfully extubated on
HD 8. He continued to need aggressive suctioning (including
nasally) as he was having large mucus plugs. On [**5-27**] he became
neutorpenic with increased secretions. He was started on
vancomycin and aztreonam. On [**5-28**] during a change in his central
line developed respiratory distress with profound hypoxia. Was
intubated. Bronchoscopy showed coupious secretions throughout.
After meeting with family, given overall poor prognosis and
patients prior voiced wishes, care was withdrawn. Patient was
extubated and expired within in minutes.
2. Anca positive non-eosinphilic vasculitis with hemoptysis-
microangiopathic vasculitis vs. wegeners vs. other. He had
respiratory failure as above. He was treated with three courses
of plasmapheresis (HD1, HD3, HD4) and with pulse dose steroids
on admission (1 gram of solumedrol x 3 days). The solumedrol was
tapered down and PO prednisone was started on HD 13. ANCA levels
per [**Hospital1 2025**] lab were decreased from last admission;
antimyeloperoxidase ab on [**2200-4-25**] 76--> [**2200-5-13**] values of 14. Pt
received his second dose of cytoxan on [**2200-5-23**] (560 mg/m2 -1000
mg) with mesna and prehydration. Secondary to steroids, bactrim
prophylaxis was started which was changed to atovaquine when pt
had thrombocytopenia (see below).
Renal, rheumatology,and transfusion medicine were all heavily
involved in patients care of above.
3. Aflutter- History of aflutter on last admission. Patient had
his Toprol XL changed to metoprolol tid. On HD 8 he had aflutter
to the 170s, hemodynamically stable treated with a diltiazem
drip. He was cadioverted on HD 10 and was in sinus from then. He
was initially dig loaded but this was stopped
post-cardioversion.
He was started on amiodarone gtt at the time of cardioversion
and was on an amiodarone taper.
4. Renal failure- followed by renal. Creatinine remained
relatively stable, though BUN increased. Medications were
renally dosed for creatinine clearance of 15-20. Pholo and
epogen were started. BUN rose steadily to mid 140s.
5. Hypertension. patient with known hypertension. His
metoprolol was uptitrated to 75 tid and amlodipine and
hydralazine were started.
6. Hypernatremia- intermittent hypernatremia to upper 140s
likely from decreased PO intake when failed S&S. He got free
water boluses via Dobhoff and D5W IVF as needed.
7. [**Name (NI) 18456**] Pt with overall weakness post extubation. Overall
normal neurological exam though with decreased strength. CPK was
checked and normal. Head CT was negative for an acute event
(evidence of encephalomalcia from trauma from boating accident
20 years ago).
8. Thrombocytopenia- nadir 65 on HD 7. Pt's bactrim was switched
to atovaquine. HIT ab was sent and negative. Platelets improved.
However dropped again secondary to cytoxan and was low at the
time of death.
9. F/E/[**Name (NI) **] Pt failed a S&S study on HD 10 and a dubhoff was
placed the next day.
Medications on Admission:
Prednisone 60 mg po qday
Cyanocobalamin 500 mcg po qday
Chlorphenirmaine 4 mg po qday
Citalopram 10 mg po qday
Bactrim DS qMonday, Wednesday, Friday
Protonix 40 mg po qday
Epoetin 10,000 qweek
Ferrous sulfate 325 po qday
Toprol XL 75 mg po qday
ASA 325 mg po qday
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
pneumonia
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2200-5-29**]
ICD9 Codes: 5849, 2760, 4280, 486, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1352
} | Medical Text: Admission Date: [**2116-9-7**] Discharge Date: [**2116-9-17**]
Date of Birth: [**2116-9-7**] Sex: M
Service:
NOTE: This is an interim Discharge Summary from [**2116-9-7**] to [**2116-9-15**].
HISTORY OF PRESENT ILLNESS: This delightful is now eight
days old. He was born at 30 weeks and 1 day gestation,
weighing 1435 grams, to a 34-year-old gravida 8, para 5-9-6
mother.
Her prenatal laboratories were B positive, antibody negative,
rapid plasma reagin nonreactive, hepatitis B surface antigen
negative. The pregnancy was complicated by premature rupture
of membranes at 23 weeks gestation. The mother was followed
on the Antepartum Service. She was betamethasone complete.
[**Hospital 37544**] medical problems included hypothyroidism, chronic
hypertension, and insulin-dependent gestational diabetes.
The infant was born by cesarean section for breech
presentation, concerns for maternal chorioamnionitis and
vaginal bleeding. He emerged with good respiratory effort
and required bag mask ventilation with a good response. His
Apgar scores were 5 at one minute of age and 7 at five
minutes of age.
Of note, in the mother past obstetric history, she had a
fetal demise secondary to a car accident one year ago, and
she also lost an infant at the age of six months with
.................... about 10 years ago.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed the infant's birth weight was 1435 grams, length was
39 cm, and his head circumference was 29 cm. He appeared
nondysmorphic with an intact palate. His heart rate was
regular in rate and rhythm. His heart sounds were normal
with no audible murmurs. His femorals were easily palpable.
He had mild grunting and retractions with some inspiratory
crackles on auscultation. His abdomen was soft and
nondistended. No organomegaly. He had normal premature male
genitalia with bilateral descended testicles. His anus was
patent. The anterior fontanel was open, soft, and flat. His
tone and movements were appropriate for his gestational age.
He was warm and well perfused and was moving all extremities.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The
infant was admitted to the Neonatal Intensive Care Unit for
further management of his prematurity, respiratory distress,
and to evaluate him for sepsis.
1. RESPIRATORY ISSUES: The infant had clinical and
radiological evidence of hyaline membrane disease. He was
initially placed on a trial of continuous positive airway
pressure, but in view of escalating respiratory distress he
was intubated and ventilated. He received two doses of
surfactant. He required ventilation for one day; following
which he was on nasal prong continuous positive airway
pressure for one day. Subsequent to this, he had continued
on nasal cannula oxygen at a flow of 13 cc to 25 cc per
minute. He was given a trial off nasal cannula on [**2116-9-15**] but developed desaturations and was therefore placed
back on nasal cannula. He has occasional bradycardic
episodes, ranging from zero to four per day. His is
currently not on any caffeine.
2. CARDIOVASCULAR ISSUES: The infant has remained
cardiovascularly stable throughout.
3. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The infant was
initially nothing by mouth and commenced on hyperalimentation
via a peripheral intravenous line. Feeds were introduced on
day of life two. His is currently advancing on his enteral
feeds at 120 cc/kg per day at the time of this dictation.
His total fluid intake was 150 cc/kg per day. The difference
is made up with intravenous fluids.
The infant's admission weight was 1435 grams. His weight on
[**2116-9-15**] was 1445 grams which is just above his
birth weight.
4. GASTROINTESTINAL ISSUES: The infant developed
hyperbilirubinemia of prematurity and required phototherapy
from day of life two onward. His maximum bilirubin was 12.7
on day of life three.
5. HEMATOLOGIC ISSUES: The infant's initial complete blood
count revealed a hematocrit of 51.6, platelets were 183, and
white blood cell count was 7. Differential with no
neutrophils, no bands, and 96% lymphocytes.
Of note, during this admission, his initial absolute
neutrophil count was zero and has not increased above 500.
We initially felt that this may be due to a combination of
his prematurity, maternal chronic hypertension, and sepsis.
However, in view of the lack of increase in his absolute
neutrophil count following a 7-day course of antibiotic
therapy, the Hematology Service was consulted.
In our differential diagnosis, there were also concerns that
possible congenital neutropenia syndrome or the presence of
antineutrophil antibodies. On [**2116-9-14**] his
absolute neutrophil count was 100 (his white blood cell count
was 5.7, neutrophils of 2%, bands 0, lymphocytes of 77). He
received one dose subcutaneous granulocyte colony-stimulating
factor. Within 24 hours his absolute neutrophil count had
increased to 2800 (white blood cell count was 14, neutrophils
of 16, bands of 4, lymphocytes of 56). We will continue to
monitor his absolute neutrophil count closely. His
antineutrophil antibodies will be sent. If his neutrophil
count falls within the neutropenic range, we will investigate
this further with input from the Hematology Service.
6. INFECTIOUS DISEASE ISSUES: In view of the unknown group
B strep status, premature rupture of membranes, and concern
about possible maternal chorioamnionitis, as well as
respiratory distress the infant underwent an initial sepsis
evaluation and was begun on ampicillin and gentamicin.
As mentioned, he presented with a neutropenia with an
absolute neutrophil count of zero, and his neutrophil count
remained persistently low during the course of his antibiotic
therapy. His blood cultures were negative to date.
A lumbar puncture, which was performed on day of life seven,
was essentially unremarkable with 3 white blood cells and 3
red blood cells.
As mentioned, he received one dose of subcutaneous
granulocyte colony-stimulating factor on day of life seven
with a good response in his absolute neutrophil count. Our
plan would be to initially complete a 10-day course of
antibiotic therapy; however, if his neutrophil count falls
within the neutropenic range, we would consider restarting
his antibiotics and continue these with further input from
the Hematology Service.
Regarding other possible etiologies for his neutropenia, such
as circulating maternal antineutrophil antibodies or a severe
congenital neutropenic syndrome (such as [**Location (un) 3100**] syndrome).
A head ultrasound on day of life three and day of life seven
were both within normal limits.
7. LABORATORY ISSUES: Complete blood count on [**2116-9-7**] revealed a white blood cell count of 7 (with a
differential of 0 neutrophils, 0 bands, and lymphocytes 96),
hematocrit was 51.6, and platelets were 183. Complete blood
count on [**2116-9-14**] revealed his white blood cell
count was 5.7 (with a differential of neutrophils 2, 0 bands,
77 lymphocytes, and absolute neutrophil count was 100).
Complete blood count on [**2116-9-15**] revealed his white
blood cell count was 14 (with a differential of 16
neutrophils, 4 bands, 56 lymphocytes, and absolute neutrophil
count of 2800), his hematocrit was 39.4, and his platelets
were 233. Bilirubin on [**2116-9-14**] was 5.8/0.2.
Electrolytes on [**2116-9-15**] revealed his sodium was
138, potassium was 5.2, chloride was 104, and bicarbonate was
26.
INTERIM SUMMARY DIAGNOSES:
1. Prematurity.
2. Hyaline membrane disease.
3. Apnea of prematurity.
4. Presumed sepsis.
5. Severe neutropenia.
6. Hyperbilirubinemia of prematurity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2116-9-17**] 13:03
T: [**2116-9-17**] 15:17
JOB#: [**Job Number 50912**]
ICD9 Codes: 769, 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1353
} | Medical Text: Admission Date: [**2124-4-9**] Discharge Date: [**2124-5-3**]
Date of Birth: [**2066-7-8**] Sex: M
Service: SURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
abdominal pain and jaundice
Major Surgical or Invasive Procedure:
[**2124-4-9**]:
1. Ultrasound-guided puncture of the left radial artery.
2. Selective catheterization of the superior mesenteric artery.
3. Selective arteriogram of superior mesenteric artery and its
branches.
[**2124-4-11**]: PTC placement
[**2124-4-12**]: Ultrasound-guided thrombosis of a large pseudoaneurysm
arising off a branch of the superior mesenteric artery
[**2124-4-13**]: 1. Ultrasound-guided thrombin injection of the SMA
pseudoaneurysm percutaneously.
2. Internalization of the right-sided PTBD using 8.5 French
Cook's pigtail catheter which was modified with extra sideholes.
[**2124-4-17**]: Exchange of the PTBD
[**2124-4-19**]: Exchange of PTBD
[**2124-4-21**]: angiography
[**2124-4-25**]: coil embolization of pseudoaneurysm x2
[**2124-4-26**]: left brachial artery thrombectomy
History of Present Illness:
Mr. [**Known lastname 96679**] is a 57M who presented to an outside hospital with
3 weeks of abdominal pain and jaundice. His pain was similar to
previous episodes of alcohol-induced pancreatitis. He
complained of dark urine, acholic stools, and a 15-pound weight
loss over 6 weeks. A CT scan performed at the outside hospital
showed a large SMA branch pseudoaneurysm, compressing the CBD.
He was transferred to [**Hospital1 18**] for further evaluation and
management.
Past Medical History:
PMH: laryngeal cancer s/p XRT, hypertension, pancreatitis, TB as
a child
PSH: left knee fracture repair ([**2080**]), excision TB mass from
mandible ([**2077**]), drainage of purulent maxillary sinus
Social History:
Smokes 2 ppd for many years.
H/O 20-30 beers per week, states 1 per week for the past 4
months.
Family History:
Non-contributory.
Physical Exam:
Vitals: T 98.4, P 84, BP 160/82, RR 20, O2 97RA
Gen: AO, NAD, pleasant; obvious jaundice
HEENT: normocephalic, raspy voice, no LAD; CN II-XII intact, +
scleral icterus
Chest: CTAB, no wheeze/rhonchi/rales
CV: RRR, no r/m/g; distal pulses palp
ABD: +BS, S/ND; tender bilateral LQ; RUQ minimally tender with
hepatomegally 5cm below costal margin; not peritoneal, no fluid
wave
Ext: no edema, gross NVI; PT/DP palp; no asterixis.
Pertinent Results:
Due to length of hospital stay, please see OMR for specific
laboratory values.
Admission labs:
WBC-7.2 RBC-4.22* Hgb-13.7* Hct-38.9* MCV-92 MCH-32.4*
MCHC-35.1* RDW-14.0 Plt Ct-231
PT-18.9* PTT-25.4 INR(PT)-1.7*
Glucose-126* UreaN-10 Creat-0.8 Na-133 K-3.6 Cl-97 HCO3-29
AnGap-11
ALT-117* AST-78* AlkPhos-712* Amylase-324* TotBili-15.7*
Lipase-352*
Discharge labs:
WBC-7.0 RBC-2.84* Hgb-9.3* Hct-27.4* MCV-97 MCH-32.7* MCHC-33.9
RDW-16.1* Plt Ct-416
Glucose-95 UreaN-13 Creat-0.6 Na-135 K-4.4 Cl-103 HCO3-27
AnGap-9
ALT-85* AST-71* AlkPhos-544* TotBili-2.8*
Lipase-29
Pertinent Laboratory Trends (admission->discharge)
Hematocrit:
3
8
.
9
-
3
2
.
4
-30.1-25.5-30.6-26.8-31-21.5-28.8-20.9-36.5-22.5-30.2-26-29-27.7
Total bilirubin:
15.7-17.6-10.7-12.1-9.8-14.8-10.2-12.1-7.3-12-5.6-2.8
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
Mr. [**Known lastname 96679**] was admitted to the West 2a surgical service for
evaluation and management of his biliary obstruction and SMA
branch pseudoaneurysm. His hospital course was very
complicated, involving multiple vascular and interventional
radiology procedures, as well as multiple GI bleeds and ICU
transfers. He was ultimately discharged home on hospital day
25. Vascular surgery, gastroenterology, and interventional
radiology were all consulted and were intimately involved in his
care.
Events:
*HD1 - Vascular surgery consulted for assistance in management.
Taken to endovascular suite for angiography and attempted
definitive management. Unsuccessful due to location and risk of
damage to jejunal blood supply with occlusion.
*HD3 - Percutaneous transhepatic cholecystostomy tube placed by
interventional radiology for biliary decompression.
*HD4 - First ultrasound guided thrombin injection into
pseudoaneurysm by IR.
*HD5 - Second thrombin injection, PTC internalized.
*HD6 - Follow-up ultrasound showed 99% thrombosis of
pseudoaneurysm.
*HD7 - 4-unit GI bleed per rectum; no source identified on CTA;
resuscitated in the ICU without further bleeding
*HD9 - PTC exchanged by IR for larger catheter
*HD10 - Febrile to 101.7, blood cultures and bile cultures grew
E. coli; zosyn started
*HD11 - PTC exchanged due to kinking of catheter
*HD12 - 5-unit GI bleed per rectum; transferred to ICU for
resuscitation; EGD showed active bleeding through ampulla;
obvious blood in PTC drain; CTA showed no extravasation and
partial reconstitution of the pseudoaneurysm
*HD16 - 5-unit melenic/bloody stool and bloody PTC drain output;
transferred to ICU
*HD17 - Pseudoaneurysm coil-embolized x2 by IR
*HD18 - Left brachial artery thrombectomy and repair by vascular
surgery
*HD22 - Medium melenic stool, no change in hematocrit
NEURO: Mr. [**Known lastname 96680**] mental status remained intact throughout
his hospital stay. His pain was well-controlled with iv and
oral pain medications.
CV: He was generally hypertensive on the floor, requiring
multiple agents to keep his bp below 140/100. Each time he
bled, his pressure dropped to 80's/40's, and responded quickly
to fluids. During his first ICU admission, he needed a nitro
drip to control his hypertension. He was stabilized on a
regimen of amlodipine and clonidine, on which he was discharged.
RESP: His respiratory status remained stable throughout his
admission. Incentive spirometry was encouraged.
FEN: Mr. [**Known lastname 96679**] was kept NPO until his pseudoaneurysm and
bleeding were stabilized. He was given TPN for nutrition. Once
stable, he was advanced to a regular diet, which he tolerated
well.
GI: Mr. [**Known lastname 96679**] had several large GI bleeds during his
admission. After investigation, these appear to be due to
hemobilia from biliary instrumentation. He had several CTA's,
none of which demonstrated a bleeding source. An upper
endoscopy showed fresh blood from the ampulla, as well as
significant old blood in the duodenum. He had a PTC drain
placed for biliary decompression, which was kept to drainage
until his bleeding stopped and his bilirubin began to decrease.
The PTC was internalized and he did not have further obstructive
symptoms. His admission bilirubin was 17.6, and had decreased
to 2.8 at the time of discharge. He will go home with his PTC
capped.
HEME: He had several GI bleeds. He received a total of 14
units of PRBC's and 3 units of FFP. His hematocrit on discharge
was stable at 27.7. He developed a left radial artery occlusion
after an access procedure, and was taken to the operating room
with vascular surgery for a left brachial artery thrombectomy
and repair.
ID: He became bacteremic with E. coli after biliary
instrumentation, and was given a course of zosyn, which he
completed in-house.
PROPHYLAXIS: He was kept on protomix and venodyne boots.
Incentive spirometry and early ambulation were encouraged. He
was not given heparin subcutaneously due to his bleeding.
Medications on Admission:
xanax 0.5mg QID
Discharge Medications:
1. alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO QID (4 times
a day) as needed for anxiety.
2. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
4. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
SMA branch pseudoaneurysm
Hemobilia
Left radial artery occlusion
GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to Dr.[**Name (NI) 5067**] surgery service for management
of your pseudoaneurysm and bile duct obstruction. You are now
being discharged home with visiting nursing services. Please
follow these instructions to aid in your recovery.
If you have bloody or dark stools, please immediately contact
our office or go directly to the emergency room. This could
represent a very serious condition.
Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze.
*You are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 10
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Catheter care:
Please clean the insertion site of your biliary catheter daily.
Please cover the insertion site as needed to prevent catching or
dislodging.
Followup Instructions:
[**2124-5-29**] 02:45p [**Last Name (LF) **],[**First Name3 (LF) **] S.
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] SURGICAL SPECIALTIES CC-3
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] (ST-3) GI ROOMS Date/Time:[**2124-5-18**] 10:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2124-5-18**] 10:30
Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4012**], MD Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2124-5-19**] 4:00
Completed by:[**2124-5-3**]
ICD9 Codes: 2851, 7907, 5990, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1354
} | Medical Text: Admission Date: [**2205-4-30**] Discharge Date: [**2205-5-16**]
Date of Birth: [**2158-6-23**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bactrim / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 4232**]
Chief Complaint:
elective admit for gyn procedure, transfered for acute renal
failure from gyn service, volume assessment
Major Surgical or Invasive Procedure:
- elective operative ablation of vulvar and anal dysplastic
lesions on [**4-30**]
- continuous renal replacement therapy
- paracentesis
History of Present Illness:
46 year old woman with CVID, h/o lymphoma s/p CHOP,
granulomatous hepatitis with portal hypertension, primary
pulmonary hypertension and
refractory HPV related vulvo-/anal disease admitted to the
hospital for elective operative ablation of vulvar and anal
dysplastic lesions on [**4-30**]. She maintained a baseline Creatinine
baseline in the range of 0.7-1.1 until very recently.
.
Her postoperative Creatinine was noted to be increased to 2.2
and
peaked at 3.5 on [**5-2**]. Her potassium levels have also
intermittently increased to 6.0, but are currently down after
Kayexalate.
.
The Surgery itself was uncomplicated and was conducted under
general anesthesia. She remained hemodynamically stable and
other than a single blood pressure drop to 70's systolic and few
readings in the 90's systolic, there were no major hypotensive
events. She received about 300 ml LR and no colloids or blood
products. The EBL was 3 ml. She received e-Aminocaproic acid
before the case as a prophylaxis for her bleeding disorder,
while her Lasix, Spironolactone and Nadolol were held.
.
She has been transfered to the West ICU team due to concern of
renal failure and difficult to monitor fluid status in the
setting of pulmonary HTN. On day of transfer she had a
therapeutic paracentesis of 1L. She received 200cc of 25%
albumin.
.
On [**5-2**], UOP was 20-45 cc/hr, on 1-2L oxygen, BPs 90-106/60-76.
This morning, UOP was 0-40 cc/hr for 233 UOP in 11 hours. She
has had 30 cc/2hr of UOP after arival on the floor.
.
Patient states she states that she had one problem with renal
failure in the past but it resolved on its own (in the setting
of pneumonia). She denied CP but reports some mild dyspnea which
had been worsening since her surgery on [**4-30**]. She stated that her
abdomen was much distended from baseline but better than it was
before the paracentesis the morning of MICU transfer.
Past Medical History:
Past Medical History (per ID note):
1. Common variable immunodeficiency complicated by:
-E. coli bacteremia [**11-1**] treated with 3 days IV cefepime
switched to oral cipro for 14-day course, presumed source was GI
-recurrent CMV disease (adenopathy, [**Month/Year (2) 15482**] suppression, colitis)
requiring IV foscarnet, now on valganciclovir suppression
-HPV related vulvo-anal and vocal cord disease s/p laser
fulguration
-[**Doctor First Name **] adenitis and recurrence with [**Doctor First Name **] enteritis on
[**Doctor First Name 107290**] for secondary PPX due to intolerance/failure of
azithromycin
-granulomatous hepatitis with cholangitic overlay presumed to
be from CVID, and clinical cirrhosis
-pulmonary disease with some fibrosis s/p wedge resection [**6-25**]
with chronic interstitial pneumonitis with mild-moderate
inflammatory component interstitial fibrosis, patchy acute
organizing pneumonitis
-intermittent recurrent diarrhea
2. Bleeding disorder - possible PAI-1 deficiency
3. S/p splenectomy for symptomatic hypersplenism and refractory
ITP; incidentally found large B cell lymphoma with splenectomy
-s/p 6 cycles of CHOP [**10-27**] - [**2-26**]
4. Chronic LE lymphedema
5. Bilateral arthropathy
Past Surgical history:
1. hysterectomy [**3-/2198**] for intractable HPV cervical disease
2. Splenectomy [**9-/2198**] for ITP
3. Multiple colposcopies/laser cervical operations and partial
vulvectomy
4. Exploratory laparotomy for small bowel obstruction on [**12-3**]
[**2202**]
Social History:
Married and living with husband. Previously employed as a
paralegal, but now on disability secondary to multiple medical
conditions. Has VNA assistance for medication management. Denies
tobacco or alcohol.
Family History:
Common variable immune deficiency in twin sister who passed from
metastatic anal carcinoma and in older brother. [**Name (NI) **] brother
is healthy without immunodeficiecny. [**Name (NI) 1094**] mother died of
lymphoma at 52 and had similar symptoms, but was never diagnosed
with CVID. Father with hypertension.
Physical Exam:
Admission Exam:
Vitals: 97.7 67 105/66 24 94/3L 60.1 kg
General: Alert, oriented, no acute distress, breathing
comfortable
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP elevated to mandible
Lungs: Clear to auscultation except for decreased at lung bases
R>L
CV: Regular rate and rhythm, normal S1 + S2, occassional S3, no
murmurs, rubs, gallops
Abdomen: + ascites, not tense, nontender, +BS
GU: foley in place
Ext: warm, well perfused, 2+ pulses,+ clubbing, blue tinge of
hands and feet b/l
Pertinent Results:
[**2205-5-7**] 02:37AM BLOOD WBC-7.3 RBC-4.03* Hgb-11.6* Hct-36.0
MCV-89 MCH-28.8 MCHC-32.2 RDW-19.7* Plt Ct-126*
[**2205-5-7**] 02:37AM BLOOD Plt Ct-126*
[**2205-5-7**] 02:37AM BLOOD Glucose-106* UreaN-17 Creat-0.8 Na-136
K-3.6 Cl-97 HCO3-26 AnGap-17
[**2205-5-6**] 02:01AM BLOOD ALT-27 AST-58* LD(LDH)-251* AlkPhos-218*
TotBili-1.5
[**2205-5-7**] 02:37AM BLOOD Calcium-10.9* Phos-2.3* Mg-1.7
[**2205-5-7**] 02:55AM BLOOD Type-ART pO2-103 pCO2-34* pH-7.51*
calTCO2-28 Base XS-4
[**2205-5-7**] 02:55AM BLOOD Glucose-101 K-3.4*
[**2205-5-7**] 02:55AM BLOOD O2 Sat-97
.
Micro:
[**2205-5-4**] 12:01 am BLOOD CULTURE Source: Line-tlc.
Blood Culture, Routine (Preliminary):
PSEUDOMONAS AERUGINOSA. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 2 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
Aerobic Bottle Gram Stain (Final [**2205-5-4**]):
GRAM NEGATIVE ROD(S).
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Numeric Identifier 83961**]).
.
[**2205-5-11**] 1:53 pm Immunology (CMV) Source: Line-VIP HD line
.
**FINAL REPORT [**2205-5-14**]**
CMV Viral Load (Final [**2205-5-14**]):
CMV DNA not detected.
.
[**2205-5-11**] 5:29 pm URINE Source: CVS.
**FINAL REPORT [**2205-5-14**]**
URINE CULTURE (Final [**2205-5-14**]):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES PERFORMED ON CULTURE # 324-5996F
[**2205-5-10**].
This was not treated b/c concern this was likely contaminant and
pt not having symptoms.
.
Imaging:
CHEST (PA & LAT) Study Date of [**2205-5-13**] 8:42 PM
FINDINGS: In comparison with study of [**5-4**], the monitoring and
support
devices have been removed. Blunting of the left costophrenic
angle
posteriorly could reflect pleural effusion or pleural scarring.
Low lung
volumes most likely account for the prominence of the transverse
diameter of the heart. No acute focal pneumonia or vascular
congestion.
.
MRI of head limited study -52 REDUCED SERVICES Study Date of
[**2205-5-11**] 5:51 PM
FINDINGS: This is a non-diagnostic and incomplete examination,
the axial
images demonstrate significant motion, however high-signal
intensity is
visualized in both basal ganglia, suggesting changes due to
hepatic
encephalopathy. A trace of high signal intensity is demonstrated
on FLAIR on the right insular region (image 12, 13, 14, series
#7), suggesting possible proteinaceous material versus
subarachnoid hemorrhage, please consider repeat examination
under conscious sedation. Bilateral opacities are demonstrated
in the maxillary sinuses and left mastoid air cells.
IMPRESSION: Non-diagnostic examination due to patient motion.
Questionable high signal intensity demonstrated on the right
insular region, suggesting proteinaceous material versus
subarachnoid hemorrhage. High-signal intensity visualized in the
basal ganglia, these type of findings have been described in
patients with hepatic encephalopathy.
.
CT HEAD W/O CONTRAST Study Date of [**2205-5-10**] 5:30 PM
There is no intracranial hemorrhage, and no parenchymal edema or
mass effect. The [**Doctor Last Name 352**] and white matter are normal in
attenuation, without evidence of territorial infarct on CT.
There are no abnormal extra-axial fluid collections. There is no
shift of midline structures, and the basal cisterns remain
patent. Ventricles and sulci are normal in size and
configuration. There are no lytic or sclerotic osseous lesions
identified concerning for malignancy. There is partial
opacification of the mastoid air cells, without osseous
destruction. There is complete opacification of the visualized
left and right maxillary sinuses. The sphenoid sinuses and
ethmoid air cells are clear. The frontal sinuses are
underpneumatized.
IMPRESSION:
1. No hemorrhage, edema, mass effect, or other acute
intracranial process.
2. Complete opacification of the right and left maxillary
sinuses, progressed from [**2203-11-25**]. Clinically correlate to
exclude acute sinusitis.
3. Partial left and right mastoid air cell opacification.
CXR [**5-3**]
FINDINGS: In comparison with study of [**4-15**], there is continued
enlargement of
the cardiac silhouette. Prominence of interstitial markings is
consistent
with elevated pulmonary venous pressure and renal failure. More
coalescent
area of opacification at the right base medially could represent
a supervening
pneumonia in the appropriate clinical setting. Patchy area of
opacification
in the left mid zone could also represent atelectasis or
possible supervening
pneumonia.
.
US abd [**5-3**]
of note, discussed with rads and no evidence for hepatic vein
obstruction.
FINDINGS: The liver demonstrates coarsened heterogeneous
echotexture,
consistent with known cirrhosis. The main portal vein is patent
with
hepatopetal flow; of note, evaluation is slightly suboptimal
given patient's
difficulty holding breath. The gallbladder wall is edematous,
likely
secondary to third spacing. There is a large amount of ascites.
The pancreas
is not well seen due to overlying bowel gas. The common duct is
not dilated.
IMPRESSION:
1. Coarse heterogeneous hepatic echotexture, consistent with
known cirrhosis.
2. Gallbladder wall edema likely secondary to third spacing.
3. Ascites. At the time of the study paracentesis is scheduled.
.
[**5-3**] LE U/S right
FINDINGS: The right common femoral, superficial femoral, and
popliteal veins
demonstrate normal flow and compressibility. The right
superficial femoral
and popliteal veins demonstrate normal augmentation. The right
peroneal and
posterior tibial veins demonstrate normal flow.
IMPRESSION: No evidence for DVT.
.
[**5-2**] 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 markedly
dilated with moderate global free wall hypokinesis. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. 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. Trace 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 fail to fully coapt. Moderate to
severe [3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. [In the setting of at
least moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] The end-diastolic pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension.
IMPRESSION: At least moderate (and probably severe) pulmonary
hypertension with right ventricular dilation, systolic
dysfunction and pressure/volume overload. Moderate to severe
functional tricuspid regurgitation. Normal global and regional
left ventricular systolic function.
.
Renal U/S [**5-1**]
FINDINGS: The right kidney measures 10.1 cm. The left kidney
measures 11.9
cm. Neither kidney demonstrates hydronephrosis, stones, or large
masses. The
bladder is grossly unremarkable. Ascites is noted.
IMPRESSION: Ascites, without evidence for renal abnormality.
[**2205-5-1**] 06:30AM BLOOD Glucose-147* UreaN-57* Creat-2.2* Na-128*
K-6.0* Cl-101 HCO3-19* AnGap-14
[**2205-5-2**] 04:10AM BLOOD Glucose-125* UreaN-69* Creat-3.5* Na-132*
K-4.9 Cl-102 HCO3-17* AnGap-18
[**2205-5-4**] 01:10AM BLOOD Glucose-142* UreaN-85* Creat-3.8* Na-128*
K-4.6 Cl-97 HCO3-12* AnGap-24*
[**2205-5-5**] 08:18PM BLOOD UreaN-25* Creat-1.3*
[**2205-5-6**] 02:37PM BLOOD Glucose-88 UreaN-18 Creat-1.0 Na-136
K-4.0 Cl-99 HCO3-23 AnGap-18
[**2205-5-8**] 06:06AM BLOOD Glucose-78 UreaN-21* Creat-0.8 Na-133
K-3.5 Cl-96 HCO3-29 AnGap-12
[**2205-5-14**] 07:50AM BLOOD Glucose-73 UreaN-38* Creat-1.2* Na-138
K-4.0 Cl-108 HCO3-19* AnGap-15
[**2205-5-16**] 06:10AM BLOOD Glucose-81 UreaN-35* Creat-1.0 Na-134
K-4.1 Cl-107 HCO3-19* AnGap-12
[**2205-5-6**] 02:01AM BLOOD WBC-7.3 RBC-3.78* Hgb-11.4* Hct-34.0*
MCV-90 MCH-30.1 MCHC-33.4 RDW-19.4* Plt Ct-123*
[**2205-5-4**] 04:46AM BLOOD ALT-34 AST-82* AlkPhos-254* TotBili-2.6*
[**2205-5-5**] 04:00AM BLOOD ALT-34 AST-77* AlkPhos-243* TotBili-1.9*
[**2205-5-14**] 07:50AM BLOOD ALT-13 AST-49* AlkPhos-231* TotBili-1.1
[**2205-5-1**] 06:30AM BLOOD PT-13.3 PTT-26.5 INR(PT)-1.1
[**2205-5-3**] 06:25AM BLOOD PT-14.9* PTT-30.2 INR(PT)-1.3*
[**2205-5-4**] 04:18PM BLOOD PT-18.2* PTT-34.0 INR(PT)-1.6*
[**2205-5-15**] 06:10AM BLOOD PT-14.2* PTT-30.1 INR(PT)-1.2*
Brief Hospital Course:
46 year old woman with Common Variable Immuno Deficiency, h/o
lymphoma s/p CHOP, granulomatous hepatitis with portal
hypertension, primary pulmonary hypertension and refractory HPV
related vulvo anal disease admitted initially for elective
operative ablation of vulvar and anal dysplastic lesions on [**4-30**],
course complicated by pseudomonas bacteremia, acute renal
failure resulting in temporary CVVH, delirium, and fluid
overload secondary to underlying cirrhosis.
.
# Acute Renal Failure:
Acute renal failure, likely secondary to ATN, had resolved by
time of discharge. ATN may have been secondary to hypotensive
episode in the OR during surgery. CVVH was initiated in the
MICU, and patient was temporarily on pressors to maintain blood
pressures with renal replacement therapy. She was transitioned
to midodrine to maintain blood pressures. Patient was
transfered to floor after CVVH was weaned off, and renal
function continued to improve. Diuretic regimen was uptitrated
slowly to 60mg lasix + 100mg spironalactone, which she tolerated
well.
# Pseudomonas Bacteremia:
Blood cultures from [**5-4**] grew pan-sensitive pseudomonas. She
was initially treated with vancomycin, cefepime, flagyl with
concern for possible polymicrobial infection, but vancomycin and
flagyl were tapered off after 5 days of persistently negative
cultures. Cefepime was transitioned to po ciprofloxacin 750mg
[**Hospital1 **] on [**2205-5-15**], and patient was discharged with plan for total
antibiotic course at least 14 days. She will follow up with
Infectious Disease specialist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] in clinic next week,
at which point he will decide how much longer to continue
antibiotic course (day #1 antibiotics [**2205-5-5**]). Day# 14
antibiotics would be [**5-19**], though total course is yet to be
determined.
.
# Delirium -
On [**5-10**], pt became increasingly agitated and emotional,
reportedly unable to sleep at all. There was concern that
perhaps this was a manic episode in the setting of taking
citalopram for depression as this medication had apparently only
been started several months back. Pt's mental status continued
to worsen over the next 24-36 hours. Psychiatry was consulted
and recommended haldol for agitation and to help w/sleep,
minimizing interruptions. Delirium work was initiated,
including Head CT, blood and urine cultures, as well as chest
Xray. Head CT showed no acute process. [**Name (NI) **] pt was agitated
and had risk of bleeding due to bleeding diathesis, decision was
made not to LP pt or do paracentesis (no fever or WBC elevation
at that time, and she was covered with cefepime for
pseudomonas). One dose Haldol had improved agitation and pt was
marginally able to partially tolerate a brain MRI but this was
relatively unrevealing showing possible enhancement of basal
ganglia often seen w/hepatic encephalopathy; however, pt's labs
had generally shown improvement since leaving the ICU she did
not have asterixis on exam. ID, Liver, Renal consults were
heavily involved. Concern for infection was high given pt's
immuno compromised state. Concern for possible medication
effects was also high as pt had past hx of medication
sensitivty. Efforts were made to minimize medications and the
following medications were stopped: voriconazole, citalopram,
sildenafil, midodrine. Pt improved in setting of getting more
sleep after haldol dose. Infectious work-up was unrevealing.
Lactulose was briefly given but stopped given pt's return to
baseline mental status, though she was continued on rifaximin.
Etiology of acute decompensation is still unclear but may have
been multifactorial.
.
# Cirrhosis ??????
Concern for mild encephalopathy. Treated with rifaximin 550mg
[**Hospital1 **] and ursodiol. Lactulose was held given anal surgery.
Hepatology continued to follow. In setting of delirium (see
above) lactulose was restarted. After delirium resolved,
lactulose was stopped. Pt remained stable w/out evidence of
acute or worsening encephalopathy. Pt was able to be titrated up
to 60mg of lasix + 100mg spironalactone to help w/diuresis and
improvement of ascites.
.
# Hypoxia: Pleural effusions improved with diuresis. NC was
weaned. Maintained sat >96%. Continued empirical antibiotics as
above with NC prn.
.
# Hypotension:
Hypotension likely multifactorial, secondary to decompensated
cirrhosis, intravascular volume depletion, sepsis. Goal SBPs >
110 to maintain renal perfusion, requiring levophed for two days
in MICU, then transitioned to midodrine, which was titrated off
on the floor. BPs continued to improve and remain stable on the
floor.
.
# Severe pulmonary hypertension:
Chronic ongoing problem which would preclude liver
transplantation. Patient's home sildenafil was held in MICU and
restarted on floor at home dose 10mg [**Hospital1 **]; however, in the
setting of delirium and ?facial swelling (which pt had had in
the past w/this medication), decision was made to stop sildenfil
(see above). Dr. [**Last Name (NamePattern1) 11031**]following.
# HPV:
Patient was admitted for elective operative ablation of vulvar
and anal dysplastic lesions on [**4-30**]. Path came back showing
vulvar cancer which Dr. [**Last Name (STitle) 107309**] discussed w/pt. Plan for f/u
with Dr. [**Last Name (STitle) 2028**] and Dr. [**Last Name (STitle) **] 2 weeks ([**Telephone/Fax (1) 107310**]) or once
pt out of hospital.
.
# Bleeding diathesis:
Patient with long standing bleeding diathesis followed by Dr.
[**Last Name (STitle) 3060**]. Temporarily on Amicar while in MICU. No evidence of
bleeding. [**Month (only) 116**] need reinstitution of Amicar if going for any
procedure with risk of bleed.
.
# CVID: long hx of infections. Pt was continued
hydroxychloroquine, valgancyclovir. Voriconazole was stopped as
above but may need to be restarted as outpt pending fungal
markers. Pt got IVIG as inpt as on [**2205-5-13**] as she was due for
her regular dose. She will continue to receive her regular IVIG
doses at home.
Prophylactic valgancyclovir dose continues at 900mg daily. Abx
as described above. Pt has planned outpt visit w/ID attending
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] for further follow-up.
.
# h/o high fungal markers: repeat beta glucan and galactomannan
markers were sent and will be followed up by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**].
Patient was initially continued on voriconazole which was later
discontinued in setting of delirium. Voriconazole may need to
be restarted by Dr. [**Last Name (STitle) 724**] as outpt pending fungal markers.
.
# depression:
Citalopram was held after episode of delirium for concern of
mania, but it will be restarted at 10mg daily on discharge, to
be uptitrated to 20mg daily after a few days.
.
Transitional issues:
- f/up fungal markers
- planned outpt visit w/ID attending Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] for further
follow-up to determine total antibiotic course for pseudomonas
bacteremia and to follow up fungal markers
- Plan for f/u with Dr. [**Last Name (STitle) 107309**] and Dr. [**Last Name (STitle) **] 2 weeks ([**Telephone/Fax (1) 107311**]) or once pt out of hospital
Medications on Admission:
MEDICATIONS (at home, confirmed with patient):
Omeprazole 20 mg PO DAILY
Acetaminophen 500 mg PO/NG Q6H:PRN pain
Creon 12 [**12-30**] CAP PO TID W/MEALS
Sildenafil 10 mg PO BID
Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **]
Citalopram 30 mg PO/NG DAILY
Ursodiol 600 mg PO DAILY
Hydroxychloroquine Sulfate 200 mg PO/NG [**Hospital1 **]
Voriconazole 200 mg PO/NG Q12H
Vitamin D 400 UNIT PO/NG DAILY
Lorazepam 0.5 mg PO/NG Q6H:PRN anxiety
ValGANCIclovir 450 mg PO EVERY OTHER DAY
Lasix 20mg daily
Spironolactone 100mg daily
.
On transfer:
Bisacodyl prn
Creon 12 [**12-30**] cap PO TID with meals
Chlorhexidine 0.12% oral rinse 15mL [**Hospital1 **]
Citalopram 30mg daily
Docusate [**Hospital1 **]
Hydroxychloroquine 200mg [**Hospital1 **]
Omeprazole 20mg daily
Senna [**Hospital1 **] prn
Sildenafil 10 mg PO BID
Ursodiol 600mg daily
Voriconazole 200mg [**Hospital1 **]
Vitamin D 400 U daily
Valgancyclovir 450mg every other day
Discharge Medications:
x
Discharge Disposition:
Home
Discharge Diagnosis:
x
Discharge Condition:
x
Discharge Instructions:
x
Followup Instructions:
x
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 4236**]
ICD9 Codes: 5845, 5119, 2762, 2761, 2767, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1355
} | Medical Text: Admission Date: [**2191-1-5**] Discharge Date: [**2191-1-6**]
Date of Birth: [**2143-3-21**] Sex: F
Service: NEUROSURGERY
Allergies:
Fioricet / ibuprofen
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
elective right pcomm aneurysm coiling
Major Surgical or Invasive Procedure:
Angiogram [**2191-1-5**]
History of Present Illness:
History of Present Illness: On her most recent hospitalization
this 47 y/o right handed woman with a history of Gastric bypass
[**2182**] (rogue-n-y), anxiety/depression, and a pacemaker for
"palpitations" who presents as an OSH transfer for Left side
body numbness.
She states that the symptoms began on [**Holiday **] eve morning when
she woke up with her left hand feeling totally numb with pins
and needles feeling. She thought she slept on it and that was
the
reason for the sensation but the sensation failed to remit or
change over the proceeding days. There was no interval
changes/evolution of the numbness/paresthesia until last night
when suddenly before going to bed she felt her whole left side
become numb with paresthesia. She called her neighbor who
suggested she go to the hospital for workup but she declined and
thought it would go away. This morning it had not resolved and
so she called the ambulance afraid she had a stroke.
She otherwise endorses weakness of the left, no bowel or bladder
incontinence, no recent fever or illness, or big weight changes.
No recent vaccinations.
Of note she has not taken her vitamin supplements in years, she
was recently prescribed eye glasses which she does not have with
her, she had a recent diagnosis of a 3rd nerve palsy but was
unsure on which side but believes it was the left with no clear
reason as to why, but does state that she also had an infection
of her eyes and had taken some eye drops for this.
Currently she presents for coiling of incidental right pcomm
aneurysm coiling that was discovered during this prior hospital
stay.
Past Medical History:
Anxiety/depression
Gastric bypass [**2182**]
HTN
Left? 3rd nerve palsy / currently right eye is dilated .5mm
compared to left
bilateral knee replacement X2 on the left
pacemaker for "palpitations"
hysterectomy
cholecystectomy
Headaches (migraine)
Social History:
trying to quite smoking, did not get pack year
history, no etoh or other drug use endorsed.
Family History:
States they are all diseased.
Physical Exam:
History of Present Illness:
The pt is a 47 y/o right handed woman with a history of
Gastric bypass [**2182**] (rogue-n-y), anxiety/depression, and a
pacemaker for "palpitations" who presents as an OSH transfer for
Left side body numbness.
She states that the symptoms began on [**Holiday **] eve morning when
she woke up with her left hand feeling totally numb with pins
and
needles feeling. She thought she slept on it and that was the
reason for the sensation but the sensation failed to remit or
change over the proceeding days. There was no interval
changes/evolution of the numbness/paresthesia until last night
when suddenly before going to bed she felt her whole left side
become numb with paresthesia. She called her neighbor who
suggested she go to the hospital for workup but she declined and
thought it would go away. This morning it had not resolved and
so
she called the ambulance afraid she had a stroke.
She otherwise endorses weakness of the left, no bowel or bladder
incontinence, no recent fever or illness, or big weight changes.
No recent vaccinations.
Of note she has not taken her vitamin supplements in years, she
was recently prescribed eye glasses which she does not have with
her, she had a recent diagnosis of a 3rd nerve palsy but was
unsure on which side but believes it was the left with no clear
reason as to why, but does state that she also had an infection
of her eyes and had taken some eye drops for this.
Past Medical History:
Anxiety/depression
Gastric bypass [**2182**]
HTN
Left 3rd nerve palsy
bilateral knee replacement X2 on the left
pacemaker for "palpitations"
hysterectomy
cholecystectomy
Headaches (migraine)
Social History:
trying to quite smoking, did not get pack year
history, no etoh or other drug use endorsed.
Family History:
States they are all diseased.
Admission Physical Examination:
Physical Exam:
General: Awake, cooperative
Neurologic:
-Mental Status: Alert, oriented to person place and time. Able
to relate history without difficulty. Attentive, able to name
DOW backward without difficulty. Language is fluent with intact
repetition and comprehension. Speech was not dysarthric. Able
to follow both midline and appendicular commands. Current
knowledge demonstrated with knowledge of current presidents name
. There
was no evidence of apraxia or neglect. Able to recall all her
medications and dosage with no problems.
-Cranial Nerves:
I: Olfaction not tested.
II: Right pupil 3mm left 2.5mm.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation decreased on the left to light touch,
minimally
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. x [**Doctor Last Name **] Tricep
minimally weak at 5-/5
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. left pronator drift, no
athetosis type movements noted.
No tremor, asterixis noted. Slow initiation of movement on the
left.
Delt Bic Tri WrE FFl FE IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**]
L 5 5 5- 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
On Discharge:
Nonfocal examination
Slight pain in R groin radiating to LE, no hematoma or edema
Pertinent Results:
CEREBRAL ANGIOGRAM [**2191-1-5**]
R PCOM aneurysm successfully coiled with no rupture of aneurysm.
Preserved flow of the R PCOM artery.
Brief Hospital Course:
Pt was admitted through the sds department for elective coiling
of Right pcomm aneurysm. She underwent the procedure without
issue. The only difficulty was that peripheral IV access was
not able to be obtained. SHe had a left femoral vein line
placed for venous access (4Fr short). She was sent to the ICU
for observation overnight.
On [**1-6**], patient remained intact. She report slight pain in the
RLE starting in her groin and radiating to the thigh, no
hematoma or edema was seen. She was started on neurontin 300mg
TID for radicular pain. She was discharged home after ambulating
and voiding appropriately.
Medications on Admission:
1. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
3. propranolol 60 mg Capsule,Extended Release 24 hr Sig: One (1)
Capsule,Extended Release 24 hr PO DAILY (Daily).
4. quetiapine 50 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
5. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
6. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. 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*
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for breakthrough pain.
Disp:*30 Tablet(s)* Refills:*0*
9. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
2. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
3. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. quetiapine 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. propranolol 60 mg Capsule,Extended Release 24 hr Sig: One (1)
Capsule,Extended Release 24 hr PO DAILY (Daily).
8. Neurontin 300 mg Capsule Sig: One (1) Capsule PO three times
a day.
Disp:*90 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
right pcomm artery aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
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:
Dr. [**First Name (STitle) **] / neurosurgery at [**Telephone/Fax (1) **] in 6 months /with MRI
MRA /Dr [**First Name (STitle) **] protocol
Completed by:[**2191-1-6**]
ICD9 Codes: 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1356
} | Medical Text: Admission Date: [**2161-4-22**] Discharge Date: [**2161-4-25**]
Date of Birth: [**2117-2-1**] Sex: M
Service: CARDIAC CARE UNIT
CHIEF COMPLAINT: Chest pain for 24 hours.
HISTORY OF PRESENT ILLNESS: A 44-year-old male with sudden
onset of substernal chest pain around 9:30 pm on [**4-21**]
while working. He reports associated shortness of breath,
nausea, but denies any lightheadedness, syncope, or back
pain. He went to the outside hospital on [**4-22**], and was
found to have a slight troponin leak, but no
electrocardiogram changes consistent with acute ischemia, and
was started on some nitroglycerin with some relief of pain.
CT scan of the chest showed ascending aortic aneurysm of 5.5
cm without any dissections seen. The patient was transferred
to [**Hospital1 69**] for further
evaluation and treatment.
In the Emergency Department, the patient was hemodynamically
stable. CT scan of the contrast films from the outside
hospital was reviewed by our in-house radiologist, and showed
no signs of dissection or aortic hematoma. Cardiothoracic
Surgery evaluated the patient and recommended aortogram,
cardiac catheterization, and transesophageal echocardiogram.
Cardiac catheterization was done showing a large ascending
aortic aneurysm, severe [**2-10**]+ aortic regurgitation, but no
aortic dissection. The patient had clean coronary arteries,
also had a pulmonary capillary wedge pressure of 29. Cardiac
output of 5.3, cardiac index of 2.3.
The transesophageal echocardiogram was done on arrival to the
Cardiac Care Unit showing bicuspid aortic valves, [**2-10**]+ aortic
insufficiency with an ejection fraction of 25-30%, borderline
dilated left ventricle, moderate left ventricular
hypertrophy, and markedly dilated ascending aorta of 5.1 cm.
Again, no aortic dissection was seen. No aortic valve
stenosis was seen. There are no vegetations on the
transesophageal echocardiogram that was seen. The patient
had 1+ mitral regurgitation.
PAST MEDICAL HISTORY: Hypertension, the patient had
previously been treated with Zestril, but had stopped two
years ago when he lost health insurance and since acquiring
health insurance again, he has not seen a physician, [**Name10 (NameIs) **] has
not been restarted on any antihypertensives.
MEDICATIONS: No medications.
SOCIAL HISTORY: No known drug history. He lives with his
long term girlfriend. Denies any alcohol history which is
confirmed with his girlfriend. [**Name (NI) **] has a 30 pack year tobacco
history. He smokes about two packs per day and is a welder.
FAMILY HISTORY: He reports a family history of coronary
artery disease in his uncle.
PHYSICAL EXAMINATION: On physical examination, the patient
was afebrile, heart rate 94, blood pressure 112/51,
respiratory rate 24, and 96% on 4 liters nasal cannula. He
is a middle aged man sedated in no acute distress. Mucous
membranes are moist, anicteric. Jugular venous pressure was
unable to be assessed. Heart was a regular, rate, and rhythm
with a 3/6 systolic ejection murmur at the left upper sternal
border with 1/6 diastolic murmur with the right upper sternal
border with a left ventricular heave. Lungs were clear to
auscultation anteriorly and laterally. Abdomen was soft,
nontender, nondistended with normoactive bowel sounds. There
is no clubbing, cyanosis, or edema in his extremities. He
had 2+ dorsalis pedis pulses bilaterally. He was alert and
oriented times three. Cranial nerves II through XII are
intact. Neurologic examination is grossly nonfocal. Left
femoral Swan-Ganz catheter was in place.
LABORATORY DATA: White count of 10.4, hematocrit of 38.0,
platelets 161. Sodium 138, potassium 4.3, chloride 103,
bicarbonate 23, BUN 17, creatinine 1.3, glucose 90, INR 1.2.
PTT 54.0. Arterial blood gas showed a pH of 7.34, CO2 of
44,medial and O2 of 110. Differential on the white count:
69% neutrophils, 21% lymphocytes, 5% monocytes, 3.6%
eosinophils, and 0.4% basophils. Troponin peaked at 1.6 and
decreased thereafter. CKs were flat ranging between 50s and
60s.
ELECTROCARDIOGRAM: Showed normal sinus rhythm at 92 beats
per minute, left atrial enlargement, normal intervals, Q in
[**Last Name (LF) 1105**], [**First Name3 (LF) **] depressions in I and V6, J-point elevation in V1
through V3 with some ST elevations, T-wave inversion in I and
L, V4 through V6, left ventricular hypertrophy by criteria.
CHEST X-RAY: Widen mediastinum with mild congestive heart
failure, small left pleural effusion.
CT scan from the outside hospital showed a 5.5 cm descending
aortic aneurysm with no dissection or hematoma.
Urine culture showed skin flora. Urinalysis was negative.
Blood cultures were negative at the time of discharge.
A transthoracic echocardiogram showed an ejection fraction of
25-30% with ascending aorta of 5.8 cm. Trivial mitral
regurgitation, 3+ aortic regurgitation, and minimal aortic
stenosis.
The patient was admitted for treatment of his congestive
heart failure as well as close monitoring of his
hemodynamics. He was started on Lasix and for diuresis, and
started on an ACE inhibitor for afterload reduction. She was
weaned off his oxygen. He had stable blood pressure.
The patient's aortic insufficiency was thought to be chronic
due to his congenital bicuspid valve. His thoracic aneurysm
was thought to be due to his uncontrolled hypertension,
however, his RPR and ESR were sent. ESR came back at 46, and
his RPR was unreactive. However, the quantitative RPR in the
treatment of treponemal antibody was sent to state laboratory
and was still pending at the time of discharge.
The patient was also started on nicotine patch for his
nicotine withdrawal symptoms. He was followed by
Cardiothoracic Surgery who felt that the patient required
surgery for valve repair and aortic aneurysm repair. He was
scheduled for surgery in 1.5 weeks. He remained stable, and
was discharged home with a diagnoses of aortic insufficiency,
congenital systolic and diastolic congestive heart failure,
hypertension, thoracic aortic aneurysm without rupture.
He was to followup with Dr. [**Last Name (STitle) 70**] in Cardiothoracic
Surgery on [**2161-4-29**], and also with his primary care
physician.
DISCHARGE MEDICATIONS:
1. Lisinopril 10 mg q day.
2. Lasix 20 mg po q day.
3. Nicotine patch.
4. Ativan prn.
DR [**Last Name (STitle) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 12.270
Dictated By:[**Name8 (MD) 6371**]
MEDQUIST36
D: [**2161-4-25**] 21:27
T: [**2161-4-30**] 09:45
JOB#: [**Job Number 48553**]
ICD9 Codes: 4019, 3051, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1357
} | Medical Text: Admission Date: [**2162-3-12**] Discharge Date: [**2162-3-17**]
Date of Birth: [**2084-8-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Dyspnea, Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is 77 yo M with a PMH of IPF on 6L O2 at home, severe
pulmonary artery hypertension, CAD s/p 4 vessel CABG [**2140**] with
PCI [**2159**], DM who was initially admitted [**2162-3-12**] from [**Hospital1 3325**] for chest pain and worsening SOB. On arrival to the
outside hospital, his O2 sats were in the low-80's on his 4L,
and he was thought to be in CHF. Troponin I at [**Hospital1 46**] was mildly
positive at 0.13, his hematocrit was 24, and his EKG showed a
RBBB. His chest pressure resolved with ASA and nitro SL. He was
started on 100%[**Hospital1 597**] and transferred to the [**Hospital1 18**] ED.
.
In our ED, he was given IV Lasix 80 mg IV x1 with 1.6 L UO. He
was subsequently transferred to the [**Hospital1 1516**] service for elevated
troponin T of 0.05 and CHF. On [**3-12**], the patient was noted
to become tachycardic with HR in 120s-140s and sats of 60% on 6L
NC-->100% on [**Name (NI) 597**] (pt was though to be mouth breathing). As
there was concern for PE given he acute nature of the event, the
patient was started on heparin and transferred to the MICU for
further care.
.
The patient at this time feels SOB but does not feels any more
SOB than he has over the past several days. He denies any
current chest pain. He does complain of some RLE cramping that
he relates to diuresis. He denies any abdominal pain. He
admits to coughing up blood-tinged sputum over the past several
months. His Plavix was stopped 2 weeks prior to admission in
the setting of this hemoptysis. He admits also to orthopnea,
PND, and DOE. In addition, the patient notes he has become more
SOB than usual starting this past [**Month (only) **]. He was diagnosed with
IPF one month ago, and prior had carried a diagnosis only of
COPD.
Past Medical History:
Pulmonary fibrosis (recently diagnosed)
Emphysemia
Hypertension
Diabetes (followed at [**Last Name (un) **])
CAD:
- MI in [**2138**]
- 4-vessel CABG in [**2140**]
- PTCA in [**2143**]
- Multiple stents placed in [**2159**] ([**Hospital3 **])
Dyslipidemia
Severe pulmonary artery hypertension
Social History:
He worked as a machinist doing fine parts. He does not know
about any toxic exposure.100 pack year history of smoking, no
current tobacco use, no ETOH use, lives with wife.
Family History:
noncontributory
Physical Exam:
Admission to Hospital:
PHYSICAL EXAMINATION:
Blood pressure was 136/66 mm Hg while seated. Pulse was 105
beats/min and regular, respiratory rate was 28 breaths/min.
Oxygen saturation was 89-99% on 100% [**Hospital3 597**].
.
Generally the patient was well developed, well nourished and
well groomed. The patient was oriented to person, place and
time. The patient's mood and affect were not inappropriate.
.
There was no xanthalesma and conjunctiva were pink with no
pallor or cyanosis of the oral mucosa. The neck was supple with
JVD to the angle of the jaw. The carotid waveform was normal.
There was no thyromegaly. The were no chest wall deformities,
scoliosis or kyphosis. The respirations were labored and there
was occasional use of accessory muscles. There were coarse
crackles at the bases and [**12-23**] the way up bilaterally.
.
Palpation of the heart revealed the PMI to be located in the 5th
intercostal space, mid clavicular line. There were no thrills,
lifts or palpable S3 or S4. The heart rate was tachycardic. The
heart sounds revealed a normal S1 and S2. There were no
appreciable rubs, murmurs, clicks or gallops.
.
The abdominal aorta was not enlarged by palpation. There was no
hepatosplenomegaly or tenderness. The abdomen was soft nontender
and nondistended. The extremities had no pallor or cyanosis.
Clubbing of the upper extremities was present. There was 1+
pitting edema to the knees bilaterally. There were no abdominal,
femoral or carotid bruits. Inspection and/or palpation of skin
and subcutaneous tissue showed no stasis dermatitis, ulcers,
scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Admission to ICU:
.
Physical Exam:
Vitals: T101.1 BP 144/67 P 119 R 22 Sat 94% on 100%[**Month/Day (4) 597**]-->ABG:
7.49/41/65
Gen: Elderly male, sitting up in bed, tachypneic, unable to
complete full sentences
HEENT: PERRL, conjunctivae anicteric/noninjected, MMM
Neck: JVP at the level of the mandible, +use of accessory
muscles
CV: tachycardia, no m/r/g, no RV heave
Lungs: dry crackles 2/3 up both lungs bilaterally
Ab: soft, NTND, NABS, no HSM
Extrem: trace pitting up to the knees bilaterally, +clubbing of
the fingernails, no cyanosis
Neuro: MAFE, A and Ox3, CN II-XII grossly intact
Guaiac negative in ED
.
Pertinent Results:
ECG [**2162-3-12**]: ECG Study Date of [**2162-3-12**] 12:10:24 PM
Sinus rhythm. Left atrial abnormality. Incomplete right
bundle-branch block pattern. Probable prior inferior wall
myocardial infarction. Compared to the previous tracing of
[**2162-2-20**] right precordial ST-T wave changes are less apparent and
the rate is faster.
CT Chest [**2162-3-13**] 2:55 PM
IMPRESSION:
1. Severe, diffuse fibrosis and emphysema throughout the lungs,
with marked interval worsening of the fibrosis compared to prior
study of [**2162-2-17**]. Findings compatible with known idiopathic
pulmonary fibrosis and emphysema.
2. Mediastinal and hilar lymphadenopathy.
3. Extensive coronary artery calcifications in a patient with
prior CABG surgery.
4. No evidence of pulmonary embolism. Findings suggestive of
pulmonary arterial hypertension.
Brief Hospital Course:
Assessment/Plan: 77 yo M with a PMH of IPF on 6L O2 at home,
severe pulmonary artery hypertension, CAD s/p 4 vessel CABG [**2140**]
with PCI [**2159**], DM, admitted for dyspnea and transferred to the
MICU for hypoxia.
.
# Hypoxic Respiratory Distress: Initial ddx includes CHF, PNA,
MI, PE and worsening pulmonary fibrosis. CTA of chest was
obtained - negative for PE but showed rapid progression of
pulmonary fibrosis. Not felt likely to be due to cardiac
ischemia, as CKMBI was negative and Tn were stable, though
mildly elevated at 0.03-0.05. Initially was treated empirically
with azithromycin and ceftriaxone for possible CAP complicating
underlying lung disease. Additionally started on high dose
steroids for IPF. Despite antibiotic treatment and steroids,
dyspnea persisted without improvement. Mr. [**Known lastname 42307**] also was
diuresed in the ED without improvement in respiratory status.
.
Respiratory distress is likely secondary to acute and rapid
worsening of IPF that is not steroid responsive. After
discussions with the Mr. [**Known lastname 42307**] and his family, he [**Known lastname 28092**] to
discontinue aggressive treatment and [**Known lastname 28092**] for hospice care at
home. Supportive care includes supplemental oxygen,
anti-tussives and morphine/codeine prn.
.
Chest Pressure: had chest pressure with coughing spasm which
resolved spontaneously. Likely musculoskeletal, though could
also be secondary to demand ischemia, as patient desturated to
75% during coughing spasm. EKG was unchanged from prior and
cardiac enzymes were unchanged x 2.
.
# ID: Pt was initially febrile and was treated empirically for
possible pneumonia. CTA was negative for PE. There was no
improvement in respiratory status with antibiotic treatment;
antibiotics were discontinued on [**3-16**] after Mr. [**Known lastname 42307**] [**Last Name (Titles) 28092**]
to transition to hospice care.
.
Mr. [**Known lastname 42307**] was discharged to home on [**2162-3-17**] with home hospice
services.
Medications on Admission:
Metformin 1000mg Daily
Glimepiride 4mg [**Hospital1 **]
Toprol XL 75mg Daily
Avandia 4mg [**Hospital1 **]
Zetia 10mg Daily
Omeprazole 40mg Daily
Atacand 16mg Daily
Lipitor 40mg Daily
Isosorbide 120mg QAM/60mg QPM
Levothyroxine 88mcg Daily
Diltiazem 120mg QAM
Aspirin 325mg Daily
Iron 65mg Daily
Discharge Medications:
1. Morphine Concentrate 20 mg/mL Solution Sig: 2-20 mg PO Q1hr.
Disp:*90 cc* Refills:*0*
2. Oxygen therapy
Please provide continuous oxygen at 15L/minute via 100%
non-rebreather. Also will need 6L continuous oxygen via nasal
canula.
3. Guaifenesin AC 10-100 mg/5 mL Liquid Sig: [**4-29**] mL PO every
4-6 hours as needed for cough.
Disp:*120 mL* Refills:*0*
4. Senna-S 50-8.6 mg Tablet Sig: 1-2 Tablets PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
5. Acetaminophen 650 mg Suppository Sig: One (1) suppository
Rectal every six (6) hours as needed for fever or pain.
Disp:*100 suppositories* Refills:*2*
6. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN
(as needed).
Disp:*50 Lozenge(s)* Refills:*2*
7. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for fever or pain.
Disp:*100 Tablet(s)* Refills:*2*
8. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed.
Disp:*30 Tablet(s)* Refills:*0*
9. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*0*
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebs
Inhalation Q6H (every 6 hours) as needed for cough.
Disp:*30 nebs* Refills:*0*
11. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for anxiety.
Disp:*60 Tablet(s)* Refills:*0*
12. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) patch
Transdermal every seventy-two (72) hours as needed for
secretions.
Disp:*10 patches* Refills:*0*
13. Levsin/SL 0.125 mg Tablet, Sublingual Sig: 0.125-0.25 mg
Sublingual every four (4) hours as needed for secretions.
Disp:*10 mL* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **]
Discharge Diagnosis:
Primary Diagnoses:
-Endstage, rapidly progressive Interstitial Pulmonary Fibrosis
-Pulmonary Artery Hypertension
Secondary Diagnoses:
-Coronary Artery Disease
-Diabetes
-Hypertension
Discharge Condition:
Stable, requiring supplement oxygen via [**Location (un) 597**] at 15L.
Discharge Instructions:
You were hospitalized at [**Hospital1 18**] for problems with your breathing
and chest pain. Your symptoms are believed to be related to
rapid worsening of your pulmonary (lung) fibrosis. You were
initially treated with antibiotics and steroids, but these did
not help with your breathing.
As you have decided with your family, you are being discharged
to home with hospice services. You will receive oxygen at home.
You will also receive other treatments, including medications
to treat your cough and pain medications. Take as prescribed.
Followup Instructions:
With hospice care providers as planned at home.
Completed by:[**2162-3-17**]
ICD9 Codes: 4280, 4019, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1358
} | Medical Text: Admission Date: [**2154-4-4**] Discharge Date: [**2154-5-1**]
Date of Birth: [**2084-2-8**] Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
" I had a stroke "
Major Surgical or Invasive Procedure:
intubation and extubation
tracheostomy
PEG placement
History of Present Illness:
Patient can currently not give a coherent history. He can
only contribute that he had a stroke and fell after feeling sick
a few days ago. The following history and PMH is obtained from
the medical records and through his wife.
.
70 y/o gentleman with past medical history significant ischemic
stroke, HTN, hyperlipidemia and diabetes presents after 2 days
of
gait instability and dizziness. Symptoms were first noted after
getting up at his usual time around 4 AM on Tuesday [**2154-4-2**]. He
was so unsteady on his feet that he stayed in bed most of that
day. On [**2154-4-3**] he fell backwards striking the back of his head
while trying to put on his shoes. Despite this he drove to work
but because he continued to feel unwell he called his son to
take
him to the hospital. There, he was hypertensive in the 170s and
head CT revealed a small frontal SAH. He was admitted to the
medical ICU for neurological monitoring. An MRI head showed a L
cerebellar ischemic stroke as well as poorly visualized
vertebral
artery concerning for dissection. Given the extent of his
infarct
he was transferred to [**Hospital1 18**] for dedicated neuroicu care.
Past Medical History:
previous CVA on [**Hospital1 107**] day [**2153**] (workup at [**Hospital1 2025**])
hyperlipidemia
HTN
DMII
total knee replacement
UTI
Social History:
Lives at home with wife. Is a former truck driver,
smokes 1 pack cigs/day, daily ETOH. Has 7 children.
Family History:
non-contributory
Physical Exam:
ADMISSION Physical Exam:
Vitals: T:37 P:50-73 BP:128-158/75-112 RR:13 SaO2:95% RA
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: regular
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
Skin: no rashes or lesions noted.
.
Neurologic:
Mental Status: Alert, oriented to self, city, situatuation
(stroke). Can't provide details regarding history. Dysnomia (can
identify a thumb and take left thumb to right ear. But
watch=telefone), perseverates (everything thereafter is a
telefone). Confuses days of the week and months of the year.
Mild
dysarthria after S+S eval.
.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. Visual fields intact to
confrontation.
III, IV, VI: EOMI, with bilateral, direction-changing,
gaze-evoked nystagmus. Left ptosis (baseline).
V: Sensation intact to LT, Temp, PP in V1-3 bilaterally
VII: no facial weakness.
IX, X: Palate elevates symmetrically. Gag weak but present.
Cough
present
XII: Tongue protrudes in midline.
.
-Motor:
[**5-11**] motor strength throughout.
.
-Sensory: Intact to LT, Temp, PP throughout. Gets confused with
vibratory/proprioception testing.
.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 3 3 3 3 - (does not relax)
R 3 3 3 3 - (does not relax)
Plantar response was extensor bilaterally.
.
Cerebellar: Left hemiataxia arm>leg.
.
.
.
.
Neuro Exam at transfer from ICU:
MSE: Awake, alert, nonverbal with minimal/no mouthing of words.
Follows simple commands occasionally, inconsistently. R gaze
preference but can cross midline to left.
CN: Left facial droop with ptosis (per family - chronic). Poor
gag.
Motor: Moves all extremities with full strength
Coordination: mild LUE ataxia.
.
.
.
.
Exam on discharge:
MSE: Awake, alert, able to speak via Passy-Muir valve. Appears
to have some comprehension deficits. Follows simple commands
although inconsistently.
CN: Pupils equal and reactive. R gaze preference but can cross
midline to left. Left facial droop with ptosis and weakness of
eye closure.
Motor: Moves all extremities with full strength.
Coordination: mild LUE ataxia
Pertinent Results:
[**2154-4-4**] 05:12AM WBC-16.7* RBC-5.24 HGB-14.0 HCT-45.7 MCV-87
MCH-26.8* MCHC-30.7* RDW-15.2
[**2154-4-4**] 05:12AM PLT COUNT-308
[**2154-4-4**] 05:12AM PT-11.3 PTT-26.3 INR(PT)-1.0
[**2154-4-4**] 05:12AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2154-4-4**] 05:12AM CK-MB-12* MB INDX-4.7 cTropnT-<0.01
[**2154-4-4**] 05:12AM ALT(SGPT)-21 AST(SGOT)-22 LD(LDH)-202
CK(CPK)-254 ALK PHOS-104 AMYLASE-20 TOT BILI-0.3
[**2154-4-4**] 05:12AM GLUCOSE-221* UREA N-13 CREAT-0.8 SODIUM-138
POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-25 ANION GAP-16
[**2154-4-4**] 12:12PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2154-4-4**] 12:12PM URINE RBC-2 WBC-7* BACTERIA-FEW YEAST-NONE
EPI-2
[**2154-4-4**] 12:12PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2154-4-17**] 01:32AM BLOOD VitB12-516
[**2154-4-5**] 03:29AM BLOOD %HbA1c-8.6* eAG-200*
[**2154-4-5**] 03:29AM BLOOD Triglyc-155* HDL-39 CHOL/HD-4.0
LDLcalc-85
[**2154-4-5**] 03:29AM BLOOD TSH-1.2
**FINAL REPORT [**2154-4-17**]**
C. difficile DNA amplification assay (Final [**2154-4-17**]):
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
NCCT [**2154-4-4**]: Atrophy, extensive SVD, bilateral hypodensities
in the cortico-subcortical [**Male First Name (un) 4746**] suggesting prior ischemic stroke
(?embolic). Left cerebellar hypodensity. No significant mass
effect on my review.
.
NCCT: [**2154-4-3**]: Small, left frontal SAH. OTW no acute pathology.
.
MRI Brain [**2154-4-3**]: Left cerebellar infarct in PICA-territory.
Several DWI-hyperintense lesions in the left frontal cortex,
consistent with SAH. Susceptibility imaging shows SAH.
MRA neck [**2154-4-3**]: Poorly visualized left vertebral artery.
Carotid arteries unremarkable.
MRA head [**2154-4-3**]: Very limited. No major pathology.
NCHCT [**2154-4-4**]
CONCLUSION:
1. Regional hypodensity of left cerebellar hemisphere is
compatible with
history of prior infarction. No evidence of intracranial
hemorrhage or mass
effect. MR may be obtained for further evaluation if not
contraindicated.
2. Subdural spaces are prominent, though determination of
chronicity is
pending review of Atrius images.
NOTE ON FURTHER REVIEW:
The prior OSH studies are scanned onto [**Hospital1 18**] PACS and available
for review on
[**2154-4-5**].
The hypodense area in the left cerebellar hemisphere is more
conspicuous
compared to the CT Head study of [**2154-4-3**]. There is mild
distortion of the
4th ventricle compared to prior, allowing for the technical
differences.
CXR [**2154-4-4**]
AP single view of the chest has been obtained with patient in
sitting semi-upright position. Comparison is made with an AP and
lateral
chest view obtained at another institution and transferred in
our image
system. The heart size is probably mildly enlarged, precise
assessment is
impossible on this portable AP chest view obtained with patient
in
semi-upright position. No typical configurational abnormality is
seen. The
pulmonary vasculature is not congested, and the lateral pleural
sinuses are
free. No pneumothorax in the apical area. No evidence of acute
infiltrates
on this portable single view chest examination. When comparison
is made with
a previous AP and lateral chest examination from the other
institution, there
is again no evidence of any acute pulmonary infiltrate or
pulmonary
congestion. Prominent breast shadows bilaterally in this adipose
patient
suggest the possibility of gynecomasty.
[**2154-4-5**] TTE
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is top
normal/borderline dilated. Overall left ventricular systolic
function is low normal (LVEF 50%). The inferior and posterior
walls appear hypokinetic but the technically suboptimal nature
of this study precludes definitive segmental wall motion
analysis. Right ventricular chamber size and free wall motion
are normal. The aortic root is mildly dilated at the sinus
level. The aortic valve is not well seen. 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. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion. Bubble study could not be
performed due to patient being unable to cooperate or to allow
completion of this examination.
[**2154-4-6**] CTA Head/Neck
FINDINGS: Again, the left cerebellar hypodense area is
redemonstrated
involving the ventral aspect of the cerebellum, vascular
territory of the left PICA, causing mild narrowing of the
inferior aspect of the fourth ventricle. Supratentorially, the
ventricles and sulci are prominent, likely age related and
involutional in nature. Areas of low attenuation are visualized
throughout the subcortical white matter, reflecting chronic
microvascular ischemic disease, additionally patchy
low-attenuation foci are visualized in the periventricular
region and basal ganglia, likely consistent with chronic lacunar
ischemic changes. Dense atherosclerotic calcifications are
visualized in the carotid siphons on both vertebral arteries.
There is no evidence of hydrocephalus or shifting of the
normally midline structures. The orbits are unremarkable, the
paranasal sinuses demonstrate mild mucosal thickening at the
ethmoidal air cells and right frontoethmoidal recess. The
mastoid air cells are clear, the patient is intubated, NG tube
and ET tubes are in place.
CTA OF THE HEAD AND NECK.
The vessels in the circle of [**Location (un) 431**] demonstrates patency of the
anterior and middle cerebral arteries as well as the posterior
cerebral arteries, the posterior communicating arteries appear
patent bilaterally with no evidence of aneurysms. The basilar
artery demonstrates segmental narrowing, more significant in the
vertebrobasilar junction, the V4 segment on the right vertebral
artery appears tortuous and with significant narrowing as
previously demonstrated on the MRA dated [**2154-4-3**].
Possible retrograde flow is producing filling the right PICA.
The left V4 segment is not identified, likely consistent with
occlusion of the left vertebral artery as previously
demonstrated by MRA.
The cervical carotid bifurcations demonstrate a combination of
soft plaque and calcified plaque, causing mild carotid artery
narrowing at the cervical bifurcations. The bony structures
demonstrate multilevel degenerative changes consistent with mild
anterior and posterior spondylosis. The thyroid gland
demonstrates a focal area of low attenuation on the left,
measuring approximately 4 x 5 mm, correlation with thyroid
ultrasound is recommended if clinically warranted (image #107,
series #3). The aortic arch demonstrates dense atherosclerotic
calcifications and dependant changes are visualized at both lung
apices and a calcified nodular lesion is noted on the left upper
lung, correlation with a dedicated CT of the chest is
recommended if
clinically warranted.
IMPRESSION:
1. Evolving left cerebellar infarction as described above.
2. Near complete occlusion of the left vertebral artery from its
origin
throughout the junction with the basilar artery with associated
extensive
atherosclerotic disease.
3. Almost complete occlusion of the V4 segment of the right
vertebral artery.
[**2154-4-8**] TTE:
Conclusions
The left atrium is mildly dilated. No definite atrial septal
defect is seen with intravenous saline injection at rest. 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 root is moderately
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets (?#) appear structurally
normal with good leaflet excursion. There is no aortic valve
stenosis. Significant aortic regurgitation is present, but
cannot be quantified. The mitral valve appears structurally
normal with trivial mitral regurgitation. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Dilated ascending aorta.
Aortic regurgitation. Mild symmetric left ventricular
hypertrophy with preserved global and regional biventricular
systolic function. If clinically indicated, a thoracic CT/MRI or
TEE is suggested to assess for a possible aortic dissection.
[**2154-4-8**] NCHCT:
IMPRESSION: Stable appearance of left PICA territory hypodensity
without
evidence of new infarct or hemorrhage. Minimal increase in
posterior fossa
mass effect with minimal displacement of the brainstem.
[**2154-4-9**] EEG:
IMPRESSION: This telemetry captured no pushbutton activations.
The
background remains slow throughout, indicating a widespread
encephalopathy. There were no prominent bursts of generalized
slowing.
There were a few minimally sharp features, but there were no
overtly
epileptiform abnormalities, and there were no electrographic
seizures.
Occasionally, the background was far more suppressed, likely
indicating
medication effect, but this reverted to earlier voltages after
an hour
or two.
[**2154-4-10**] EEG:
IMPRESSION: This telemetry captured no pushbutton activations.
It
showed a slow, encephalopathic background throughout. There were
also
several left hemisphere blunted sharp waves but without clearly
epileptiform features, rapid repetition, or evidence of
electrographic
seizures.
[**4-16**] CXR:
IMPRESSION: Since yesterday, the patient has been extubated and
has received tracheostomy which is in standard position. An
orogastric tube is seen coursing below the diaphragm into the
stomach; however, its distal course is off radiograph view. Left
subclavian line tip is at mid SVC. Bibasal opacities likely due
to combination of pleural effusion and atelectasis is new on the
right side and has minimally worsened on the left side since
yesterday. Mild mediastinal congestion is presisting. Given the
low lung volumes, presence of any minimal pulmonary vascular
congestion may be overestimated. Mild to moderately enlarged
heart is similar.
[**4-20**] CT head:
IMPRESSION: Interval evolution of left-sided cerebellar
infarction with
decreased edema as compared to the prior examination. No
evidence of new
hemorrhage or infarction.
[**4-27**] CT head:
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Evolving left posterior inferior cerebellar artery territory
infarction.
3. No fractures.
4. Bilateral mastoid opacification, unchanged since prior study.
Note is made of soft tissue swelling on the left side, preseptal
and
peri-orbital in location- correlate clinically.
[**4-27**] CT C spine:
IMPRESSION: No acute cervical spine fracture or malalignment.
Multilevel,
multifactorial degenerative changes. Correlate clinically to
decide on the need for further workup.
Brief Hospital Course:
70yoM h/o reported strokes, HTN, HL, DM2, alcoholism p/w
lightheadedness and fall with the finding of a L cerebellar
stroke.
[] Left Cerebellar Stroke - He was transferred from [**Hospital3 **] with findings of a left cerebellar infarction in the L
PICA territory. He was kept on aspirin therapy and his SBP was
kept below 180 initially. A CTA Head/Neck revealed near
occlusion of the left vertebral artery from the origin to the
junction with the basilar artery and a right V4 occlusion,
prompting the initiation of anticoagulation (heparin infusion,
goal PTT 50-70). His A1c is 8.6. His LDL is 85. He is a smoker.
A TTE was unrevealing for intracardiac shunt or thrombus,
although the study quality was poor. Given the occlusion of his
vertebral artery he was started on a heparin drip and
transitioned to coumadin. He remained clinically stable with
minimal deficits on exam other than a R gaze preference and mild
LUE ataxia. He was noted to have a left facial droop during his
admission. It was unclear whether this was new or chronic; an
MRI was recommended to assess for new stroke but his family
deferred as they did not want him to be sedated. His exam
otherwise improved gradually over the course of his stay.
On [**4-27**] he sustained an unwitnessed fall out of a chair. He
struck his head and sustained an abrasion to his left forehead.
He was asymptomatic and his neurologic exam was unchanged. CT
head was negative for bleed and CT C spine was also negative for
fracture. As his INR was supratherapeutic at the time, a second
CT head was performed the next day which was also stable.
[] Alcohol Withdrawal - Although not endorsed initially, he was
found to have a history of significant alcohol abuse (1 bottle
of liquor per day) as described by his wife and he started
showing signs of tachycardia, diaphoresis, and confusion. He was
kept on a CIWA withdrawal evaluation scale and treated with
lorazepam and clonidine. He was intubated for respiratory
protection during the time that he was receiving significant BZD
therapy. His alcohol withdrawal resolved with this regimen and
he was started on thiamine, folate, and a multivitamin for
supplementation.
[] Pulmonary / ID - On [**2154-4-8**] the patient had an episode of
oxygen desaturation to the 70s, likely after aspirating tube
feeds. He was reintubated for respiratory support. A
bronchoscopy was performed and thick secretions/tube feeds were
lavaged and removed. Cultures were sent and revealed MSSA and
E.coli in the sputum and Enterococcus in the urine. He was
treated with IV antibiotics for these infections. A second
attempt at extubation was tried but he was not able to tolerate
this and required intubation again. Subsequently, his wife was
consented for tracheostomy and he underwent this procedure on
[**2154-4-15**]. His respiratory status subsequently remained stable.
On [**4-22**] he had a single fever to 101.8 with a positive blood
culture for coag negative staph and sputum culture growing coag+
staph aureus and e. coli. His central line was discontinued; tip
culture was negative. ID was consulted and recommended treatment
with vancomycin to continue for 14 total days after line removal
([**Date range (1) 110624**]). He will need to have CBC w/diff, BUN/Cr and Vanco
trough checked at least weekly and also check vanco trough if
any renal dysfunction.
He was also started on erythromycin ointment for conjunctivitis
in his L eye.
This was initially started on [**4-21**] for 5 days. Due to continued
scleral injection and discharge, erythromycin was restarted on
[**4-28**] and should be continued until clinically improved.
[] Dysphagia - After tracheostomy, the patient was again
evaluated by our therapists and found to be aspirating all
consistencies of food. He underwent PEG placement on [**2154-4-18**]. He
had several repeat swallow evaluations during the course of his
admission but remained unsafe to take food or medications PO. He
will need to be followed closely by the speech therapy team at
rehab to monitor for recovery of his swallow function.
He initially had some difficulty with high tube feed residuals
and concerns for aspiration. KUB on [**4-24**] showed no signs of
obstruction. CT abdomen/pelvis was also unremarkable. His bowel
regimen was increased and his tolerance of his tube feeds
improved with treatment of his constipation. He had no further
issues.
[] Diabetes mellitus - During his stay, the patient had very
high blood sugars. At home he was previously on oral
medications. His HgbA1c is 8.6 indicating poor control. He was
started on NPH 30u QAM and 20u QPM as well as an insulin sliding
scale with good control of his blood glucose.
[] HTN - The patient's home medications are lisinopril 20, HCTZ
25, and norvasc 2.5. During his stay his lisinopril was
increased to 40 and norvasc to 5, resulting in improvement in
his BP control.
[] Atrioventricular nodal block - He was noted initially to have
Mobitz Type I second degree atrioventricular nodal block which
later improved to first degree AVNB. This was monitored on
telemetry but did not result in any hemodynamic changes.
TRANSITIONAL CARE ISSUES:
[] He will need to continue on coumadin for anticoagulation with
a goal INR of [**2-8**]. His INR was 1.5 upon discharge and he will be
bridged with Lovenox 100mg SC Q12hrs until his INR is
therapeutic.
[] He will need to continue Vancomycin 1500mg Q12 hours through
[**2154-5-8**]. While on this medication he will need to have CBC
w/diff, BUN/Cr and Vanco trough checked at least weekly and also
should have vanco trough checked if any renal dysfunction.
[] He will need intensive PT and OT to help regain his strength.
He will need to be followed by speech therapy for both
Passy-Muir valve trials as well as monitoring of his swallow
function. He will need to be followed by respiratory therapy for
his tracheostomy.
[] He will need to be followed by nutrition for his tube feeds.
His phosphate has been running a bit high around 5. Our
nutrition team did not recommend any adjustments at this time
but this should be followed closely with consideration of a
phosphate binder if his phos rises > 5.5.
Medications on Admission:
aspirin 81mg, glyburide 5mg QD, HCTZ 25mg QD, lisinopril 20mg
QD, norvasc 2.5mg QD, simvastatin 20mg QD
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
2. simvastatin 10 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 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): hold for loose stools .
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
hold for SBP <120
.
9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. insulin aspart 100 unit/mL Solution Sig: as directed
Subcutaneous ACHS: Per insulin sliding scale.
11. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
12. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
13. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for yeast.
15. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
16. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1)
Ophthalmic QID (4 times a day): 0.5 in LEFT EYE QID
.
17. vancomycin 500 mg Recon Soln Sig: 1500 (1500) mg Intravenous
Q 12H (Every 12 Hours) for 8 days: To be given through [**5-8**].
18. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
19. enoxaparin 100 mg/mL Syringe Sig: One (1) Subcutaneous
every twelve (12) hours.
20. NPH insulin human recomb 100 unit/mL Suspension Sig: as
directed Subcutaneous twice a day: 30u QAM, 20u QPM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital, [**Hospital1 8**]
Discharge Diagnosis:
Left cerebellar stroke
Alcohol withdrawal
Pneumonia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Neurologic: Alert, intermittently agitated, follows commands
somewhat inconsistently, able to speak via Passy-Muir valve.
Pupils equal and reactive, left facial droop. Moves all
extremities anti-gravity with full strength. Mild ataxia of left
arm.
Discharge Instructions:
Dear Mr. [**Known lastname **],
You were admitted to [**Hospital1 69**] on
[**2154-4-4**] after experiencing lightheadedness and a fall and
were found to have a stroke in your left cerebellum (back of the
brain). This is an area that controls coordination and balance.
We believe the most likely cause of your stroke is a blood clot
in an artery in your neck. You were started on blood thinners to
reduce your risk of additional strokes. You were monitored in
our neuro ICU and then transferred to the neurology floor.
You had tracheostomy and gastrostomy tubes placed while you were
in the ICU. You were also treated for a pneumonia with IV
antibiotics. You had a special IV (PICC) line placed in order to
continue to give you these antibiotics while at rehab.
We made the following changes to your medications:
Started coumadin 5mg daily
Started lovenox 100mg injection twice daily until your INR
(coumadin level) is at goal between [**2-8**]
Started vancomycin 1500mg twice daily for pneumonia (through
[**2154-5-8**])
Increased lisinopril to 20mg daily
Increased amlodipine to 5mg daily
Started erythromycin ointment for an eye infection
Started thiamine and folate supplements as well as a
multivitamin
Stopped aspirin 81mg
If you experience any of the below listed danger signs, please
call your doctor or go to the nearest Emergency Department.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
You have the following appointment scheduled with Dr. [**Last Name (STitle) **] in
our stroke clinic:
Provider: [**Name10 (NameIs) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2154-6-18**] 3:30
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
ICD9 Codes: 5070, 5990, 7907, 3051, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1359
} | Medical Text: Admission Date: [**2185-6-27**] Discharge Date: [**2185-7-2**]
Date of Birth: [**2121-1-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac cath with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 to LAD.
History of Present Illness:
Mr. [**Known lastname 4223**] is a 64yo gentleman with h/o 2 vessel CAD s/p DES
to LAD in [**3-/2185**], ESRD on HD, and DM who presented to [**Hospital1 3325**] after he awoke with acute shortness of breath. As
patient is intubated and no family present, history per chart
review.
.
Patient had 4 day history of stuttering chest pain for which he
did not seek medical care. On the day of presentation, he awoke
in the middle of the night with chest pain and shortness of
breath. He presented to [**Hospital3 **], where he was intubated
for airway protection in the setting of tachypnea and agitation.
Of note, his last HD was Saturday (2 days ago). He was noted
to have increased ST elevations in V1-V3 with trop I of 2 and
normal CK. He was not given [**Hospital3 **] or [**Hospital3 4532**]. He was started on
heparin, integrillin, and nitro gtt and given lasix 40mg IV,
lopressor 5mg IV, and levofloxacin prior to transfer.
.
In the ED at [**Hospital1 18**], his initial VS were: 100.6 171/115 106
21 97% on vent. He was given [**Hospital1 **] 600mg PR and
versed/propofol for improved sedation. He was sent to the cath
lab because of concern for STE as noted above.
.
In the cath lab, he was found to have 3 vessel disease with 50%
distal left main disease, LAD with 90% long proximal instent
restenosis and 80% D1. The LCx had 80% proximal stenosis; OM1
and ramus were noted to be patent. The RCA had 60%
proximal/ostial lesion with dampening. Left ventriculography
showed MR, EF not recorded in prelim report. Team was
undertaking POBA as bridge to CABG when he dissected his LAD; 2
cypher stents were placed with good result. Integrillin was
stopped during the procedure given his ESRD on dialysis. CT
surgery was contact[**Name (NI) **] to evaluate for possible CABG given his
anatomy and multiple comorbidities. Total contrast was 135ml.
Hemodynamics from right heart cath demonstrated elevated RA (12)
and PCW (19) pressures.
.
Unable to complete ROS as patient is intubated.
.
Cardiac review of systems not done at this time.
Past Medical History:
CAD--h/o 2 vessel disease (LAD and LCx), s/p DES to LAD in
[**3-/2185**]
ESRD on HD--secondary to diabetic nephropathy, also has h/o
dye-induced nephropathy. Started HD [**3-/2185**] and currently being
evaluated for transplant.
Chronic mild systolic heart failure with EF 40%
Dyslipidemia
Hypertension
PVD s/p bilateral lower extremity revascularization in [**2181**]
Diabetes mellitus c/b neuropathy, nephropathy and
retinopathy--A1C not available
Hypothyroidism
Hemorrhoids
Heard of Hearing
Social History:
Social history is significant for the absence of current tobacco
use; he smoked for 35-40 years but quit over 15 years ago.
There is no history of alcohol abuse. He works as a carpet
salesman and runs 3 miles a day. He is divorced with 4 adult
children.
Family History:
Mother DM, died at age 63 from colon cancer
Brother CAD age 55
Father CAD, died of MI at age 62
Physical Exam:
VS: T 97.6, BP 141/93, HR 80, RR 19, O2 100% on AC 100% 550/12
PEEP 10
Gen: Elderly gentleman, intubated and sedated. Moves arm and
leg to light touch but does not follow commands. Breathing
comfortably on vent.
HEENT: Intubated. NCAT. Sclera anicteric. PERRL, EOMI.
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with JVP of cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: L chest with HD catheter, site looks clean. No chest wall
deformities, scoliosis or kyphosis. Resp were unlabored, no
accessory muscle use. No crackles, wheeze, rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits. Right groin has access sheath
in place, no bleeding or hematoma, no bruit.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
[**2185-6-27**] 07:40AM BLOOD CK-MB-5 cTropnT-1.57*
[**2185-6-27**] 02:37PM BLOOD CK-MB-NotDone cTropnT-1.89*
[**2185-6-27**] 10:44PM BLOOD CK-MB-NotDone cTropnT-2.33*
[**2185-6-28**] 05:41AM BLOOD CK-MB-NotDone cTropnT-3.13*
[**2185-6-27**] 07:40AM BLOOD CK(CPK)-122
[**2185-6-27**] 02:37PM BLOOD CK(CPK)-82
[**2185-6-27**] 10:44PM BLOOD CK(CPK)-69
[**2185-6-28**] 05:41AM BLOOD CK(CPK)-78
.
[**2185-6-27**] 07:40AM BLOOD WBC-12.9* RBC-4.67 Hgb-12.9* Hct-40.1
MCV-86 MCH-27.7 MCHC-32.2 RDW-16.5* Plt Ct-335
[**2185-7-2**] 07:48AM BLOOD WBC-7.1 RBC-3.92* Hgb-10.9* Hct-33.9*
MCV-86 MCH-27.8 MCHC-32.2 RDW-15.8* Plt Ct-399
[**2185-7-2**] 07:48AM BLOOD PT-20.3* PTT-74.2* INR(PT)-1.9*
[**2185-6-27**] 07:40AM BLOOD Glucose-246* UreaN-37* Creat-5.3* Na-138
K-3.7 Cl-95* HCO3-25 AnGap-22*
[**2185-7-2**] 07:48AM BLOOD Glucose-196* UreaN-48* Creat-7.3* Na-138
K-3.5 Cl-98 HCO3-24 AnGap-20
[**2185-7-2**] 07:48AM BLOOD Calcium-9.7 Phos-6.1* Mg-1.9
[**2185-7-1**] 07:10AM BLOOD ALT-8 AST-13
.
Echo [**2185-6-27**]:
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is mildly
dilated with extensive regional dysfunction including near
akinesis of the septum and anterior walls, distal inferior and
lateral walls, and apex There is an apical left ventricular
aneurysm. A left ventricular mass/thrombus cannot be excluded
(clip [**Clip Number (Radiology) **]). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size is normal with focal hypokinesis of the apical free
wall. 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 left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. The pulmonary
artery systolic pressure could not be estimated.There is no
pericardial effusion.
.
ECG [**2185-6-27**]:
Sinus tachycardia. Old anteroseptal myocardial infarction. Right
bundle-branch block. Left anterior fascicular block.
.
Cardiac cath [**2185-6-27**]:
1. Three vessel coronary artery disease.
2. In-stent restenosis of proximal LAD stent.
3. Elevated biventricular filling pressures.
4. Successful angioplasty and stenting of the proximal LAD using
two
overlaping 2.5x28 and 2.5x8 mm Cypher (DES) stents.
5. Continue [**Month/Day/Year **]
Brief Hospital Course:
64yo gentleman with h/o CAD, DM, and ESRD being evaluated for
transplant admitted with chest pain, ST elevations, and
respiratory distress requiring intubation, found to have 3
vessel disease on cath, s/p LAD dissection and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 to LAD.
The patient ruled in with troponins.
.
# CAD/Ischemia:
Noted to have 3 vessel disease on cath. Attempt was made at
balloon angioplasty of LAD, with plan to then go to CABG;
however, this was complicated by dissection of his LAD. Two DES
were placed in the LAD after dissection in the cath lab, and
patient was started on [**Last Name (Prefixes) **], [**Last Name (Prefixes) 4532**], beta blocker, statin, imdur.
No ACE was started as the patient has a history of hyperkalemia
on these medications. He was also started on anticoagulation
(heparin and coumadin) for an apical aneurysm on echo. His INR
was 1.9 at discharge with a goal INR of 1.8-2.5. As patient was
complaining of increased shortness of breath several days before
he presented to the hospital with markedly elevated troponins
(above that expected with ESRD) despite normal CKs as well as
EKGs with rate-related anterior ST elevations, he most likely
had a missed STEMI prior to admission. As pt is on [**Last Name (Prefixes) 4532**] s/p
stenting, he will be medically managed for now and will follow
up with cardiothoracic surgery for CABG evaluation in a month.
.
# LV systolic dysfunction:
Echo [**6-27**] showed depressed systolic function (EF <20% compared
to EF of 40% in [**2-19**]), extensive LV regional dysfunction
including near akinesis of the septum and anterior walls, distal
inferior and lateral walls, and apex, and apical LV aneurysm.
Evidence of mild volume overload on right heart cath and
pulmonary edema on CXR. Pt was treated with hydralazine and
imdur for afterload reduction. No ACE or [**Last Name (un) **] was started as the
patient has a history of hyperkalemia on these medications.
.
# Respiratory failure:
Likely due to pulmonary edema in the setting of acute systolic
and diastolic heart failure. Extubated on day 2 and gradually
weaned off oxygen, continuing to maintain good oxygen saturation
levels.
.
# ESRD on HD, being evaluated for renal transplant:
Followed by renal. The patient was dialyzed while in the
hospital with a regular dialysis schedule of Tuesdays,
Thursdays, and Saturdays. The patient was placed on Sevelamer as
a phos binder. The No ACE or [**Last Name (un) **] was started as the patient has
a history of hyperkalemia on these medications.
.
# Temp to 100.6 in ED:
Had a temperature of 100.6 in ED, but has been afebrile since,
with no systemic signs of infection. Elevated WBC at [**Hospital1 46**] now
resolved. UA, urine culture, chest x-ray, and blood cultures
were checked.
.
# HTN:
Received metoprolol, hydralazine, imdur, and amlodipine.
.
# DM:
Initially was maintained on insulin drip. Transitioned to home
insulin pump on hospital day 3. [**Last Name (un) **] followed patient and the
patient used his insulin pump for the remainder of the
admission.
.
# Hypothyroidism:
The patient was continued on his levothyroxine
Medications on Admission:
confirmed with pharmacy (CVS in [**Location (un) 3320**] ([**Telephone/Fax (1) 40408**]):
Ambien 10mg QHS PRN
Synthroid 200mcg daily
Protonix 40mg daily
Norvasc 10mg daily
Hydralazine 25mg QID
Isosorbide 30mg daily
Lopressor 50mg TID
Proventil
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Hydralazine 25 mg PO Q6H
4. Isosorbide Mononitrate 30 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Amlodipine 5 mg PO DAILY
7. Warfarin 2 mg PO Once Daily
8. Pantoprazole 40 mg Tablet PO Daily
9. Outpatient Lab Work
Please draw pt's INR on Tuesday at dialysis. The results should
be called to Dr. [**Last Name (STitle) 3321**] at [**Telephone/Fax (1) 5315**].
10. Humalog, Please continue to take according to sliding scale.
11. Levothyroxine 175 mcg PO once daily
12. Metoprolol Succinate 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
ST elevation myocardial infarction
.
Secondary:
Acute systolic congestive heart failure
Coronary artery disease
End-stage renal disease on hemodialysis
Diabetes mellitus type 1 with complication of nephropathy
Discharge Condition:
good. stable vital signs. tolerating routine hemodialysis.
Discharge Instructions:
You were admitted with severe shortness of breath and were found
to have had a heart attack. The heart attack was caused by a
blockage in one of the coronary (heart) arteries. The blockage
was opened with angioplasty and stenting. As there were more
blockages, you should be evaluated for heart bypass surgery.
.
Please take your medications as prescribed.
New medications include:
[**Telephone/Fax (1) **]
Coumadin
Metoprolol changed to 50 mg extended release (once daily)
.
It is very important that you take your [**Telephone/Fax (1) 4532**] every day. Do
not stop taking [**Telephone/Fax (1) 4532**] unless you are instructed to do so by a
physician.
.
Also, while you are taking coumadin, your blood needs to be
checked regularly to help adjust the dose. The INR (which is a
measure of how thin your blood is) needs to be between 2 and 3.
If it is too high, you are at risk for bleeding. If you develop
bloody or very dark, tarry stools, come to the hospital right
away.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5L
.
If you develop any new or concerning symptoms such as chest
pain, shortness of breath, sudden loss of consciousness, or
bleeding; please seek medical attention immediately.
Followup Instructions:
1. You have an appointment with the cardiac surgeon, Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **], on Wednesday [**7-27**] at 1:30pm. The location is the
[**Last Name (un) 2577**] Building at [**Last Name (NamePattern1) **], [**Hospital Unit Name **]. Call ([**Telephone/Fax (1) 40409**] with any questions.
2. You need to schedule an appointment with Dr. [**Last Name (STitle) 3321**] in
the next 2-3 weeks. Please call [**Telephone/Fax (1) 5315**] to schedule an
appointment.
Please keep your previously scheduled appointments.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2185-8-30**] 2:00
Provider: [**Last Name (NamePattern5) 7224**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2185-9-27**]
10:30
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2185-11-14**] 1:00
Completed by:[**2185-7-6**]
ICD9 Codes: 5856, 4280, 2720, 2449, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1360
} | Medical Text: Admission Date: [**2110-9-20**] Discharge Date: [**2110-9-28**]
Date of Birth: [**2110-9-20**] Sex: F
Service: NEONATOLOGY
HISTORY OF THE PRESENT ILLNESS: Baby girl [**Known lastname 1256**]
is a 33 5/7 weeks gestation female infant, 1,975 grams at
birth admitted to the NICU because of prematurity. The
mother is a 41-year-old G2, P0 to 1. Her medical history is
remarkable for a history of depression. The pregnancy was
achieved with the assistance of IVF. Prenatal screens of O
positive, antibody negative, RPR nonreactive, rubella immune,
PPD negative, GBS unknown. The pregnancy was complicated by
cervical shortening at 30 weeks gestation treated with bed
rest and a course of betamethasone. The mother developed
vaginal bleeding at 3:30 on the morning of admission and
rupture of membranes at 5:30 in the morning. She was treated
with IV ampicillin prior to delivery. No maternal fever
noted.
A normal spontaneous vaginal delivery, Apgar scores eight and
nine. The baby was treated with bulb suctioning and blow-by
02 in the Delivery Room.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature
99.1, heart rate 168, respiratory rate 40s-80s, blood
pressure 65/24, mean of 35, 02 saturations 98%. General:
Alert, centrally pink, AGA preterm female infant. Weight:
1,975 grams, 50th percentile. Length: 45 cm, 50th
percentile. Head circumference: 30.5 cm, 50th percentile.
HEENT: Anterior fontanelle soft and flat. The pupils were
equal, round, and reactive to light. Normal red reflex
bilaterally. Palate intact. Facies normal. Ears externally
appear normal. Respiratory: Breath sounds clear and equal,
no retractions intermittently, mildly tachypneic.
Cardiovascular: S1 and S2 normal in intensity. No murmur.
Pulses normal. Abdomen: Soft with normal bowel sounds. No
organomegaly. GU: Normal female external genitalia,
somewhat prominent labia minora and clitoris but within
normal limits for gestational age. The anus was normally
placed. Neurologic: Good tone and symmetric movement of the
upper and lower extremities.
HOSPITAL COURSE: 1. RESPIRATORY: The patient was stable in
room air throughout admission, maintaining normal oxygen
saturations.
2. CARDIOVASCULAR: The patient was cardiovascularly stable
throughout admission with normal blood pressures, no murmur.
3. FLUIDS, ELECTROLYTES, AND NUTRITION: The patient was
initially n.p.o. and on IV fluids. The patient was started
on enteral feedings on day of life number one and advanced on
enteral feedings without difficulty. Reached full feedings
on day of life number four of PE20 and breast milk. The
patient required taking most feeds p.o., although required
some gavage feeds. Currently on 150 cc per kilogram per day
of breast milk 24 or and PE24. Took all feeds in the 48
hours prior to discharge. Glucoses have been monitored and
remained within normal limits. The patient was started on Fer-
In-[**Male First Name (un) **] and Poly-Vi-[**Male First Name (un) **].
4. BILIRUBIN: The bilirubin levels were monitored. The
bilirubin peaked at 10.3/0.2 on day of life number three and
the patient was started on single phototherapy. Bilirubin
8.2/0.2 on day of life number five and phototherapy was
discontinued. The rebound bilirubin on [**2110-9-26**] was 8.9/0.3.
5. HEMATOLOGY: The patient's hematocrit on admission was 55.0.
The patient did not require any blood products.
6. INFECTIOUS DISEASE: CBC and blood cultures sent on
admission. White count 15.3, with 29 polys, 2 bands,
platelet count 297,000. The patient was started on
ampicillin and gentamicin. The blood cultures were with no
growth at 48 hours and antibiotics were discontinued.
7. PSYCHOSOCIAL: [**Hospital1 18**] social work was involved with the
family. The contact social worker is [**Name (NI) 4457**] [**Name (NI) 36244**] and she
can reached at [**Telephone/Fax (1) 8717**].
PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) 4468**] [**Last Name (NamePattern1) 18412**], [**Location (un) **].
DISCHARGE DIAGNOSES:
Prematurity
Sepsis, ruled out
[**First Name11 (Name Pattern1) 37693**] [**Last Name (NamePattern4) 37927**], M.D. [**MD Number(1) 37928**]
Dictated By:[**Last Name (NamePattern1) 50027**]
MEDQUIST36
D: [**2110-9-26**] 06:03
T: [**2110-9-26**] 18:44
JOB#: [**Job Number 50462**]
ICD9 Codes: 7742, V053, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1361
} | Medical Text: Admission Date: [**2171-9-9**] Discharge Date: [**2171-9-17**]
Date of Birth: [**2107-5-31**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Gold Salts / Penicillins / Remicade / Erythromycin Base
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back and leg pain
Major Surgical or Invasive Procedure:
Posterior lumbar laminectomy and fusion
History of Present Illness:
Ms. [**Known lastname **] has a long history of back and leg pain. She has
attempted conservative therapy but has failed. She now presents
for surgical intervention.
Past Medical History:
Rheumatoid arthritis
Osteoarthritis
Depression
Cataracts
Cerebral aneurysm
s/p R THR
s/p L shoulder arthroplasty
s/p cerical facet injection
Social History:
non-contributory
Family History:
non-contributory
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
Pertinent Results:
[**2171-9-16**] 04:55AM BLOOD WBC-6.3 RBC-2.85* Hgb-8.8* Hct-25.3*
MCV-89 MCH-30.9 MCHC-34.7 RDW-16.2* Plt Ct-240
[**2171-9-14**] 04:00PM BLOOD Hct-23.0*
[**2171-9-14**] 05:25AM BLOOD WBC-9.7 RBC-1.98* Hgb-6.3* Hct-18.4*
MCV-93 MCH-31.6 MCHC-33.9 RDW-15.2 Plt Ct-234
[**2171-9-14**] 03:46AM BLOOD WBC-9.3 RBC-1.93*# Hgb-6.4*# Hct-18.5*#
MCV-93 MCH-32.5* MCHC-35.0 RDW-15.2 Plt Ct-224
[**2171-9-13**] 03:16AM BLOOD WBC-13.5*# RBC-3.08* Hgb-9.9* Hct-28.8*
MCV-94 MCH-32.3* MCHC-34.4 RDW-16.0* Plt Ct-284
[**2171-9-9**] 08:10PM BLOOD WBC-5.7 RBC-3.96* Hgb-12.8 Hct-37.9
MCV-96# MCH-32.3*# MCHC-33.8 RDW-15.2 Plt Ct-397
[**2171-9-16**] 04:55AM BLOOD Calcium-8.0* Phos-3.0 Mg-2.1
[**2171-9-14**] 04:00PM BLOOD Calcium-8.0* Phos-3.3 Mg-1.7
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2171-9-9**] and taken to the Operating Room for a L3-L5
laminectomies, L2-S1 fusion. Initial postop pain was controlled
with a PCA. Please refer to the dictated operative note for
further details. A dural tear was sustained and she was kept
flat for 48 hours. She was transfered to the SICU for
hemodynamic monitoring due to acute post-op blood loss.
Postoperative HCT was low and she was transfused multiple PRBCs.
She was kept NPO until bowel function returned then diet was
advanced as tolerated. The patient was transitioned to oral pain
medication when tolerating PO diet. Foley was left in place and
will be managed at rehab. She was fitted with a lumbar
warm-n-form brace for comfort. Physical therapy was consulted
for mobilization OOB to ambulate. Hospital course was otherwise
unremarkable. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet.
Medications on Admission:
Naprosyn, Prilosec, methotrexate, leucovorin, prednisone,
Humira, Celexa, BuSpar, Wellbutrin, and Premarin , neurontin,
HCTZ, methocarbamol
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever, pain.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. abatacept Intravenous
4. prednisone 1 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily).
5. bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
6. gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
7. escitalopram 10 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily).
8. nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
9. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. hydrochlorothiazide 12.5 mg Capsule Sig: 0.5 Capsule PO
DAILY (Daily).
11. alendronate 70 mg Tablet Sig: One (1) Tablet PO QWEEK ().
12. methocarbamol 500 mg Tablet Sig: 1.5 Tablets PO TID (3 times
a day).
13. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
14. buspirone 10 mg Tablet Sig: 4.5 Tablets PO QAM (once a day
(in the morning)).
15. buspirone 5 mg Tablet Sig: Three (3) Tablet PO NOON (At
Noon).
16. buspirone 5 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
17. sodium chloride 0.65 % Aerosol, Spray Sig: [**11-24**] Sprays Nasal
QID (4 times a day) as needed for nasal dryness.
18. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for Antifungal .
19. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
20. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] at [**Location (un) 620**]
Discharge Diagnosis:
Lumbar stenosis and spondylosis
Dural tear
Post-op acute blood loss anemia
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: POSTERIOR Lumbar
Decompression With Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Ambulate tid
Brace for ambulation; may be out of bed to chair without.
Treatments Frequency:
Please continue to change the dressing daily
Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days
Completed by:[**2171-9-17**]
ICD9 Codes: 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1362
} | Medical Text: Admission Date: [**2110-1-6**] Discharge Date: [**2110-1-6**]
Date of Birth: [**2033-5-27**] Sex: F
Service: CT [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: This is a 75-year-old white
female with a past medical history significant for coronary
artery disease status post acute inferior wall myocardial
infarction and subsequent post infarct ventricular septal
defect, insulin-dependent diabetes mellitus, obesity,
hypertension, and hypercholesterolemia who presented to the
Cardiac Catheterization Lab [**2110-1-6**] for an acute inferior
ST elevation MI.
Cardiac catheterization revealed two-vessel coronary artery
disease with moderate systolic ventricular dysfunction as
well as a moderate left-to-right intracardiac shunt at the
ventricular level and an acute inferior myocardial infarction
managed by acute percutaneous transluminal coronary
angioplasty of the right coronary artery vessel.
HOSPITAL COURSE: The patient was emergently brought to the
Operating Room that same day, [**2110-1-6**], for an emergent
ventricular septal defect closure and coronary artery bypass
grafting times one with a saphenous vein graft to the left
anterior descending artery.
In the Operating Room the patient became progressively more
hemodynamically unstable with profound tachycardia and a
falling blood pressure. She was intubated and emergently
prepped and draped. She was found to have a very large
ventricular septal defect. A patch was sewn over the VSD and
the VSD was debrided of the necrotic tissue as much as
possible. When complete, a second patch was placed over the
right ventricle, after which BioGlue was applied to the whole
area to assure hemostasis, at which point the saphenous vein
graft was placed to the left anterior descending artery.
Upon removal of the cross clamp the patient's heart was
allowed to resuscitate for 40 minutes, and the patient was
subsequently weaned off bypass, and Protamine was begun on
the patient.
Upon removal of the cannula from the patient's heart, the
suture line tore are the inferior aspect of the patch
closure, and the patient's chest filled with blood. She was
crashed back on bypass with an attempt to repair the suture
line with more BioGlue and sutures, however, with
unsatisfactory results. She weaned off of her bypass with
the inability to achieve hemostasis at that time, and the
patient expired at 8:45 p.m. [**2110-1-6**].
DISCHARGE DIAGNOSES:
1. Post infarct ventricular septal defect.
2. Coronary artery disease.
Because of the emergent nature of this patient's condition,
an adequate medical history was not obtained with no outside
medical records available for consultation.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Doctor Last Name 2011**]
MEDQUIST36
D: [**2110-2-7**] 11:34
T: [**2110-2-7**] 15:41
JOB#: [**Job Number 53888**]
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1363
} | Medical Text: Admission Date: [**2201-1-7**] Discharge Date: [**2201-1-23**]
Date of Birth: [**2115-1-13**] Sex: M
Service: MEDICINE
Allergies:
Indomethacin
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
SOB, obtundation
Major Surgical or Invasive Procedure:
Balloon valvuloplasty
History of Present Illness:
85 y.o. Male with a past medical history of medically-managed
CAD s/p MI x 2 in [**2179**], CVA, severe aortic stenosis seen on
cath [**7-22**] presenting to the ED with marked respiratory
distress. Per ED report and EMS sheet they were called for
someone in respiratory distress.. When EMS arrived on scene he
was noted to be in profound respiratory distress but was able to
talk to the paramedics. His BP was noted to be in the 220s and
he became obtunded enroute to the ED. He was intubated
emergently in the field and given nitropaste for his
hypertension.
.
In the [**Name (NI) **] pt's initial VS were noted to be HR 65, BP 133/62, RR
30, Sat 97%. His CXR showed ET and NG tubes positioned
appropriately. Diffuse pulmonary opacities raise concern for
pulmonary edema though a superimposed pneumonia cannot be
entirely excluded. Initial ABG was noted to be show
resp/metabolic acidosis. pH 6.84, pCO2 105, pO2 170, HCO3 20,
lactate 7.4. He was given propofol for intubation, IV Nitro gtt
as well as Furosemide 20mg x 1. His vent was changed to FiO2
100%, Rate 30, TV 450, PEEP 10 with a resulting pH of 7.08, pCO2
59, pO2 141, HCO3 19. Repeat lactate trended down to 6.6. His
BP then dropped to SBPs in the 70s, sedation switched to
fent/versed, and patient started on dopamine gtt given severe
AS. Nitropaste was taken off and patient bolused 500 cc NS.
His CBC was notable for a leukocytosis 12.5, Hct 35.1. CT Head
showed no acute process. ABG prior to transfer showed pH 7.29
pCO2 42 pO2 105 HCO3 21 with lactate now 1.1.
.
Of note, he was apparently scheduled to see Dr. [**Last Name (STitle) 10121**] in the AM
for AVR for his history of Aortic stenosis.
.
Review of systems unobtainable as patient intubated.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
CAd s/p 2 MIs
- CABG:
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
- CVA [**2195**] without residual deficits
- Gastric Ca s/p Bilroth II ([**2177**])
- Recurrent hyperplastic polyps w/ high grade dysplasia
- HTN
- BPH
Social History:
Per prior d/c summary. No alcohol, or illicit drug use. Smoked
cigarettes for 40 yrs, quit 20 yrs ago. Moved from [**Country 10363**] to US
>25 years ago and speaks both Romanian and Russian fluently.
Lives with wife and has a daughter/son in law in the area.
Family History:
Non contributory
Physical Exam:
GENERAL: Intubated, sedated.
HEENT: Conjunctiva were pink, no pallor or cyanosis of the oral
mucosa. No xanthalesma.
NECK: Supple with JVP of 10 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: Diffuse ronchi and wheeze bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Warm, no edema.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
ADMISSION LABS:
.
[**2201-1-7**] 07:10PM BLOOD WBC-12.5* RBC-3.63* Hgb-10.7* Hct-35.1*
MCV-97 MCH-29.4 MCHC-30.4* RDW-21.6* Plt Ct-193
[**2201-1-7**] 07:10PM BLOOD PT-13.9* PTT-29.3 INR(PT)-1.2*
[**2201-1-8**] 02:00AM BLOOD Glucose-157* UreaN-43* Creat-1.4* Na-143
K-4.7 Cl-111* HCO3-22 AnGap-15
.
ECHO [**2201-1-8**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
unusually small. Overall left ventricular systolic function is
normal (LVEF 75%). Right ventricular chamber size and free wall
motion are normal. There are focal calcifications in the aortic
arch. The aortic valve leaflets are severely thickened/deformed.
There is severe aortic valve stenosis. 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 left ventricular inflow pattern
suggests impaired relaxation. There is no pericardial effusion.
.
ECHO [**2201-1-10**]:
Technically suboptimal study.
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. The aortic valve leaflets are severely
thickened/deformed. There is moderate aortic valve stenosis
(valve area 1.0-1.2cm2). Mild to moderate ([**12-14**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mitral regurgitation is seen. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
.
CXR [**2201-1-15**]:
IMPRESSION: Decreased bilateral pulmonary edema with resultant
right greater than left small pleural effusions and bibasilar
opacities likely reflective of compressive atelectasis.
.
VIDEO SWALLOW STUDY [**2201-1-15**]:
IMPRESSION:
Aspiration and penetration with puree and nectar-thickened
liquids.
.
VIDEO SWALLOW STUDY [**2201-1-20**]:
IMPRESSION: Aspiration with all consistencies of barium despite
head
maneuvers. Please see speech and swallow note for details.
.
MICRO:
BLOOD CX [**2201-1-7**]: NO GROWTH
BLOOD CX [**2201-1-8**]: NO GROWTH
BLOOD CX [**2201-1-12**]: NO GROWTH
.
SPUTUM CX [**2201-1-8**]: MODERATE GROWTH Commensal Respiratory Flora.
.
URINE CX [**2201-1-7**]: NO GROWTH
URINE CX [**2201-1-12**]: NO GROWTH
URINE CX [**2201-1-17**]: NO GROWTH
Brief Hospital Course:
HOSPITAL COURSE:
85 y.o. Male with a past medical history of medically-managed
CAD s/p MI x 2 in [**2179**], CVA, hypertension, hyperlipidemia,
severe/critical aortic stenosis presenting with hypertensive
emergency, respiratory distress s/p intubation, pulmonary edema.
Course complicated by delirium, and swallowing difficulty
post-intubation, requiring open j-tube.
.
ACTIVE ISSUES:
#. Aortic stenosis: Patient with critical-severe aortic stenosis
noted in [**Month (only) 216**]. On admission, patient was started on and
required additional pressure support with neo. He went into
AFib with RVR, started on amiodarone gtt, then taken off when he
spontaneously converted to sinus brady. He continued to be
dependent on pressors, and balloon valvuloplasty was done with a
goal to bridge to valve replacement once acute status improves.
He improved and was able to come off pressors and was eventually
extubated. He was evaluated by cardiac surgery, who felt he did
not require AVR at this time. ACEI was held initially given
hypotension. Plan for this to be restarted, but given BP
well-controlled without, this was not restarted during this
admission. His home Imdur was held given preload dependence.
.
# CAD: Pt has history of CAD with prior cath in [**7-/2200**] showing
2 vessel disease, he was managed medically. On aspirin, plavix;
held beta blocker initially, isosorbide while on pressors.
Plavix was discontinued on admission, as it was not thought to
be clinically indicated and pt had recent GIB. He was continued
on ASA 325mg daily. Imdur continued to be dc'd given critical AS
as above. He was started on captopril on HD 5. Captopril was
uptitrated, and then switched to Lisinopril 40mg daily
initially. However, after pt made npo as discussed below, this
was held, and not restarted at discharge. This may need to be
readdressed as an outpt.
He was started on IV metoprolol briefly given agitation and need
for more tight BP management. This was switched to po metoprolol
to continue on discharge.
.
# Respiratory Failure: Patient intubated in the field for
altered mental status. Respiratory distress likely secondary to
flash pulmonary edema. Evetually able to be extubated once
clinical status improved. He had intermittent hypoxia, thought
to be related to flash pulmonary edema when pt became
hypertensive with agitation.
.
# Afib with RVR: In setting of flash pulmonary edema. He was
treated with beta blockade and kept on ASA 325mg. However, given
recent GIB and history of gastric CA, he was not anticoagulated.
Pt and family understood the risks of holding anticoagulation.
.
# Delirium: The patient was noted to be confused, and difficult
to orient on admission. Likely multifactorial [**1-14**] hypoxia,
sundownwing, ICU delirium. He was initially started on seroquel
qHS, but this did not effective and was started on Haldol with
frequent re-orientation. Daily ECG's were checked for prolonged
QT, and were normal. Geriatrics was consulted, and helped to
dose Haldol. His delirium resolved somewhat and he is
intermittantly alert and oriented. He has had no further
agitation. Given that delerium waxes and wanes, would recommend
low dose Haldol PO if needed for agitation.
.
# HTN: His BP was difficult to control when he became agitated,
requiring nitro gtt initially. He was then transitioned to
captopril with uptitration and hydral. His BP improved as his
delirium and agitation improved. ACEI then later held as above.
He was started on metoprolol 5mg IV q6hrs. He was discharged on
po metoprolol.
.
# Hypernatremia: [**1-14**] hypovolemia and no po intake. As noted
below, pt had to be NPO for several days. He was treated with
free water, and his Na improved. His Na improved after pt was
able to have TPN. His Na was 142 on discharge.
.
# Aspiration, failed swallow eval: Pt's voice was hoarse after
extubation, and he repeatedly failed swallow evals, and eventual
video swallow on [**1-15**]. ENT was consulted, and recommended that
would like improve with time, with NTD acutely. TPN was briefly
started. He failed a second video swallow, and ACS was consulted
for j-tube placement. Given his anatomy, he had an open j-tube
placed, and tube feeds were started.
He will follow-up with ENT as an outpatient for further
evaluation.
.
#. History of Gastric cancer/GIB/Anemia: Patient with
transfusion of units during stay with inappropriate increase
after transfusion. Initial source was thought to be RP bleed
from valvuloplasty or GI as he has a history of gastrict cancer.
Hcts remained stable after transfusions, however, CT scan was
negative for RP bleed, but showed splenic infarct. Hct remained
stable.
He was discharged on his Lansoprazole (switched from aciphex),
Lipase-Protease-Amylase, and Hyoscyamine Sulfate per prior
regimen.
.
# Thrombocytopenia: Suspicion for HIT while on heparin subq.
PF4 antbodies and iptic density density sent. Patient started on
argatroban for DVT prophylaxis briefly. PF4 Ab's resulted as
negative. Heparin SC was restarted for PPx. Plts uptrended and
remained stable on discharge.
.
# Anemia: Hct was 35 on admission, and dropped to 25, without
s/s bleeding. He was transfused 2 units PRBC's on [**1-10**], with
appropriate increase. His Hct remained stable for the duration
of the admission. He had slight drop after surgery, but was
without other s/s bleeding.
.
# Acute renal failure: Likely pre-renal/poor forward flow in
setting of critical AS. Cr improved quickly s/p valvuloplasty.
.
.
INACTIVE ISSUES:
# BPH: Finasteride was held during admission, and restarted on
discharge. Started on Flomax on discharge.
.
# HLD: Continued on Atorvastatin 40mg daily.
.
# Gout: Allopurinol held during admission given changing renal
function. Restarted on discharge.
.
TRANSITIONAL CARE:
1. FOLLOW-UP: Dr. [**Last Name (STitle) **] (Cardiology), and ENT
2. Studies pending: none
3. CODE: FULL
Medications on Admission:
1. Atorvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
2. Lipase-Protease-Amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) [**Last Name (STitle) **]: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
3. Allopurinol 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
4. Finasteride 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
[**Last Name (STitle) **]: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual [**Last Name (STitle) **]: One (1)
Tablet, Sublingual Sublingual 1 tab prn ().
7. Clopidogrel 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Aciphex 20 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
11. Lasix 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
12. Ambien CR 12.5 mg Tablet, Multiphasic Release [**Last Name (STitle) **]: One (1)
Tablet, Multiphasic Release PO at bedtime as needed for
insomnia.
13. Ferrous Sulfate
14. Simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet,
Chewable PO q 4h prn () as needed for gas.
15. Loratidine
Discharge Medications:
1. atorvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
2. insulin lispro 100 unit/mL Solution [**Last Name (STitle) **]: 0-12 units
Subcutaneous every six (6) hours: see attached Humalog sliding
scale.
3. docusate sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) ml PO BID (2
times a day).
4. senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
5. aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
6. heparin (porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
injection Injection TID (3 times a day).
7. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) vial Inhalation Q6H (every 6 hours) as
needed for SOB, wheezing.
9. multivitamin, stress formula Tablet [**Last Name (STitle) **]: One (1) Tablet
PO DAILY (Daily).
10. oxycodone 5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
11. acetaminophen 500 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO TID (3
times a day) as needed for pain/fever.
12. 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.
13. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) [**Last Name (STitle) **]: One (1) Cap PO every eight (8) hours:
Please remove from capsule and dissolve completely. .
14. metoprolol tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
twice a day.
15. allopurinol 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
16. finasteride 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
17. Flomax 0.4 mg Capsule, Ext Release 24 hr [**Last Name (STitle) **]: One (1)
Capsule, Ext Release 24 hr PO at bedtime.
18. hyoscyamine sulfate 0.125 mg Tablet, Sublingual [**Last Name (STitle) **]: One (1)
tablet Sublingual four times a day as needed for gastric spasm.
19. simethicone 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO four times a
day as needed for indigestion.
20. Outpatient Lab Work
Please check chem-7, CBC on sunday [**1-25**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Critical Aortic Stenosis s/p Valvuloplasty
Hypertension
Coronary Artery disease
Hypernatremia
Delerium
Aspiration
Atrial Fibrillation
Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - sometimes.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You had severe aortic stenosis and required a valvuloplasty to
open the stiffened artery. This worked well and the aortic
stenosis is better. You required a breathing [**Last Name (un) **] to help you
throught the acute breathing problems. We adjusted your
medicines to treat your fluid overload and help your heart work
better. You became delerious during your hospital stay and
required some medicine to help your sleep. We found that your
swallowing is very weak and you are aspirating food and fluid
into your lungs. We started intravenous feeding and placed a J
tube to use for tube feedings and medicines. You will be
re-evaluated by a speech therapist at the rehab and will
hopefully be able to eat and drink again in the next month. You
were not empyting your bladder and a foley catheter was placed.
The foley should be left in for 2 weeks, then attempt to d/c
again.
.
We made the following changes to your medicines:
1. Start Humalog sliding scale to treat high blood sugars while
getting intravenous nutrition
2. Start colace and senna to prevent constipation
3. Start Tamulosin to help your prostate shrink and help you
urinate. Please take this for 2 weeks, then the foley catheter
will be discontinued.
4. Start heparin injections to prevent a blood clot
5. Start a multivitamin with the tube feedings
6. Start oxycodone and tylenol as needed for pain
7. Stop taking Loratidine, ambien, Aciphex, Imdur, Plavix,
Lisinopril, Ferrous sulfate, and lasix.
Followup Instructions:
Otolaryngology:
Phone: [**Telephone/Fax (1) 2349**]
Address:
[**Location (un) **] (east bound side of Rt 9) [**Apartment Address(1) **]
[**Location (un) 55**], MA Dr. [**Last Name (STitle) 106472**] [**Name (STitle) **]
Date/Time: [**2-10**] at 11:00am
.
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Specialty: Cardiology
Address: [**Street Address(2) 2687**],STE 7C, [**Location (un) **],[**Numeric Identifier 822**]
Phone: [**Telephone/Fax (1) 5768**]
Appointment: Tuesday [**1-27**] at 11:30AM
ICD9 Codes: 2930, 2760, 5849, 2762, 4241, 4280, 412, 2724, 2875, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1364
} | Medical Text: Admission Date: [**2169-4-18**] Discharge Date: [**2169-4-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Dyspnea, AAA
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname 15674**] is an 85 year old male with hypothyroidism, COPD,
former smoker, who presents with chest/abdominal pain and
dyspnea. He was in his usual state of health until 2 days ago
when he developed mild dyspnea, worse on exertion. He also
complained of mild cough at that time. This was accompanied by
intermittent chest and back pain of unknown duration, with assoc
nausea, but no radiation of the pain, HA, or true abd pain. He
denies any fever/[**Last Name (LF) **], [**First Name3 (LF) **], leg pain, swelling orthopnea. He
endorses normal Bms, urination, and appetite. He otherwise
denies dizziness, focal numbness or weakness. At [**Hospital1 **] [**Location (un) 620**]
patient he was mildly hypertensive and diaphoretic, and had an
EKG which was unremarkable for ischemia. He underwent CT Abd
which demonstrated a 4.2-4.5 cm infrarenal AAA with thrombus.
No evidence of dissection or bleed. Lungs with emphysematous
changes, no evidence of infection, PE, or edema. He was
transferred here for further evaluation.
In the ED, T97.6, BP 121/76, HR 79, RR 17, 99%RA. The patient
was maintained on nitro gtt with BP mostly in the 150s-160s
systolic range. The patient was given ASA 81mg, Lopressor 50mg
PO x1, zofran x2, as well as nebulizers with good effect.
Cardiac enzymes were negative.
ROS: As per above, otherwise negative
Past Medical History:
COPD
Hypothyroidism
h/o colon CA s/p colectomy (unsure which side)
Prostatectomy
Hemmorhoid surgery
s/p cataract surgery
Social History:
Former smoker 1ppd x35yrs. Quit 10yrs ago. Seldom EtOH. No
recreational drug use. Works part time at Stop & Shop
Family History:
Non-contributory
Physical Exam:
VS: T 97.2, HR 61, BP 163/92, RR 12, 98% 2L
Gen: lying in bed, comfortable, NAD
HEENT: EOMI, anicteric sclera, MM dry, OP clear, right-sided
ptosis
Neck: supple, no carotid bruits
Heart: distant heart sounds, no m/r/g
Lungs: Decreased breath sounds throughout with poor air
movement. Diffuse expiratory wheeze
Abd: obese with midline surgical scar. + BS no rebound or
guarding. No bruits appreciated
Ext: warm well perfused
Skin: no rash
Neuro: CN II-XII intact
Pertinent Results:
Admission Labs:
[**2169-4-18**] 10:48AM BLOOD WBC-17.2* RBC-4.17* Hgb-12.6* Hct-37.8*
MCV-91 MCH-30.1 MCHC-33.2 RDW-14.0 Plt Ct-307
[**2169-4-18**] 10:48AM BLOOD Neuts-90.3* Lymphs-5.1* Monos-3.3 Eos-1.0
Baso-0.2
[**2169-4-18**] 10:48AM BLOOD PT-13.8* PTT-26.9 INR(PT)-1.2*
[**2169-4-18**] 10:48AM BLOOD Glucose-132* UreaN-17 Creat-1.2 Na-142
K-4.1 Cl-107 HCO3-27
[**2169-4-18**] 10:48AM BLOOD ALT-15 AST-19 CK(CPK)-121 AlkPhos-73
TotBili-0.4
[**2169-4-18**] 10:48AM BLOOD Lipase-32
[**2169-4-18**] 10:48AM BLOOD CK-MB-5
[**2169-4-18**] 10:48AM BLOOD cTropnT-<0.01
[**2169-4-18**] 10:48AM BLOOD Albumin-3.9 Calcium-8.4 Phos-2.4* Mg-2.1
[**2169-4-18**] 11:12AM BLOOD Glucose-129* Lactate-2.0 Na-144 K-4.4
Cl-103 calHCO3-28
[**2169-4-19**] 03:53AM BLOOD Triglyc-113 HDL-32 CHOL/HD-4.7 LDLcalc-96
[**2169-4-18**] 12:05PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.015
[**2169-4-18**] 12:05PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2169-4-18**] 12:05PM URINE RBC-[**6-14**]* WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0
Studies:
[**2169-4-18**] ECG - Baseline artifact. Sinus rhythm. Premature atrial
contraction. No previous tracing available for comparison.
[**2169-4-18**] ECG - Sinus rhythm. Compared to tracing #1 the premature
atrial contraction and artifact are both absent.
[**2169-4-18**] Portable CXR - FINDINGS: No definite focal consolidation
is noted. There is diffuse fine reticular interstitial pattern
of unknown chronicity. This, however, is not consistent with an
edema-like picture. There is marked tortuosity of the thoracic
aorta. The cardiac silhouette is otherwise normal in size. There
is discoid atelectasis in both lung bases, particularly the
right. No definite effusion or pneumothorax is noted. The
visualized osseous structures are unremarkable.
IMPRESSION: No definite acute pulmonary process.
Brief Hospital Course:
Mr. [**Known lastname 15674**] is a 85 year old male with COPD, hypothyroidism, and
a former smoker, who presented with dyspnea and chest/back pain,
and found to have an infrarenal AAA with thrombus.
# Dyspnea/Chest Pain/COPD: The patient's symptoms were
associated with exertion. He has a history of COPD and his exam
was notable for poor air flow and wheezing. EKG and enzymes were
unremarkable for cardiac ischemia. Chest x-ray was without
evidence of infection or edema. CT at [**Hospital1 **] [**Location (un) 620**] showed
emphysema and no obvious PE. Ultimately, it was felt that his
symptoms were related to a mild COPD exacerbation and he was
started on albuterol and ipratropium nebs as well as advair.
Given his hemodynamic stability, he was transfered from the MICU
to the medical floor. There he was started on a short steroid
burst with azithromycin as he was noted to desat to 85% on room
air with walking. The patient's PCP's office was called an no
records of his baseline oxygen sats could be obtained. The
following day, the patient's wheezing was still present, though
improved, and his oxygen level only dropped to 93% with
ambulation. He was discharge with instructions to complete a
short course of steroids and azithromycin to prevent return of
his symptoms. He was instructed to continue to use advair and
albuterol inhaler as needed. Home VNA was arranged to check on
the patient and to ensure that he was using his inhalers
properly as he had difficulty with them initially in the
hospital.
# Infrarenal abdominal aortic aneurysm: The patient remained
clinically asymptomatic and without any signs of rupture.
Vascular surgery was consulted and recommended blood pressure
control to SBP < 140 (the patient was hypertensive and requiring
a nitro drip initially on arrival), aspirin, and statin. As the
patient's LDL was less than 100, statin therapy was deferred for
consideration as an outpatient. Follow-up with Dr. [**Last Name (STitle) **]
was scheduled for 6 months following discharge.
# Hypertension: The patient was transitioned from a nitro gtt to
lisinopril. His SBP remained predominantly in the 120s-130s.
He was instructed regarding the importance of taking this
medication, checking his blood pressure, and that the dose may
need to be titrated up by his PCP.
# Hypothyroidism: The patient was continued on his home
levothyroxine dose.
Medications on Admission:
Levothyroxine 75mcg daily
Proair hfa inhaler 2 puffs prn
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Albuterol 90 mcg/Actuation Aerosol Sig: [**1-6**] Inhalation every
four (4) hours as needed for shortness of breath or wheezing.
4. 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*
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
6. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
7. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary Diagnoses:
1. Chronic obstructive pulmonary disease exacerbation
2. Abdominal aortic aneurysm
Discharge Condition:
Vital signs stable. Afebrile. Ambulatory O2 sat 93% on room
air.
Discharge Instructions:
You were admitted to the hospital for evaluation of shortness of
breath, chest pain, and back pain. You likely had a COPD
exacerbation and are being treated with a short course of
steroids, antibiotics, and inhalers. It is important that you
take these medications as prescribed to prevent recurrence of
symptoms.
You were also found to have an enlarged aorta. You blood
pressure was also mildly elevated and you were started on a new
medication, Lisinopril, to decrease your blood pressure and help
prevent further enlargement of your aorta. You should also take
a baby aspirin. It is important that you follow-up with your
primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3142**], regarding this.
The following changes have been made to your medications.
1. Start taking Lisinopril 5 mg daily for your blood pressure.
2. Start taking Aspirin 81 mg daily for your heart and blood
vessels.
3. Use the advair diskus inhaler twice a day for your lungs; you
may continue to use your Proair (albuterol) inhaler as needed
for shortness of breath.
4. Take prednisone 40 mg daily through [**4-23**] for your lungs.
5. Take azithromycin 250 mg daily through [**4-23**] for your lungs.
Please call Dr. [**Last Name (STitle) 3142**] or return to the hospital if you have
worsening shortness of breath, fevers, worsening back or chest
pain, or other concerning symptoms.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 3142**] within the next two weeks.
His office phone number is [**Telephone/Fax (1) 19980**].
You have a follow-up appointment with the Vascular Surgeon Dr.
[**Last Name (STitle) **] regarding your aortic aneurysm on [**2169-10-19**] at 10:00
am. His office phone number is [**Telephone/Fax (1) 1237**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1365
} | Medical Text: Admission Date: [**2144-1-9**] Discharge Date: [**2144-1-9**]
Date of Birth: [**2144-1-9**] Sex: M
Service: NB
HISTORY: Baby [**Name (NI) **] [**Known lastname 65136**] is the 3.325-kilogram product of
a 38-week gestation born to a 27-year-old G1, P0 now 1
mother.
PRENATAL SCREENS: O-positive, antibody negative, hepatitis
surface antigen negative, RPR nonreactive, rubella immune,
GC/chlamydia negative, HIV negative, GBS positive.
Mother received intrapartum antibiotics. Pregnancy notable
for prenatal diagnosis of bladder exstrophy, bilateral
hydroceles with undescended testes. Amniocentesis revealed
normal XY karyotype.
Infant was delivered by C-section due to failed induction. He
emerged vigorous with good cry. In the delivery room, sterile
tie and sterile Tegaderm dressing was placed over the exposed
bladder.
PHYSICAL EXAM ON ADMISSION: Weight 3.325 kilograms, head
circumference 36 cm, length 51.5 cm. Anterior fontanel: Open
and flat. Bilateral red reflex. Palate and clavicles: Intact.
Clear breath sounds with good aeration. Regular rate and
rhythm, no murmur. Good femoral pulses. Abdomen: Soft,
nondistended. Bladder exstrophy present and moist. Normal
male with question right testis palpable in canal. Patent
anteriorly placed anus.
HISTORY OF HOSPITAL COURSE BY SYSTEMS: Respiratory: Has been
stable on room air since admission to the newborn intensive
care unit.
Cardiovascular: No issues.
Fluid and electrolytes: Birth weight was 3.325 kilograms.
Infant was started on 80 cc per kilogram per day of D10W.
Mother plans to breastfeed and has not yet done so. D-sticks
have been 48 and 74.
GI/GU: Dr. [**Last Name (STitle) 45267**] is the urologist from [**Hospital3 1810**]
who has been following this patient prenatally.
Hematology: Hematocrit on admission was 50.4. Has not
required any blood transfusions.
Infectious disease: CBC and blood culture obtained on
admission. After consultation with urology resident, decision
was made not to start postpartum antibiotics.
Neuro: Appropriate for gestational age.
Sensory: Hearing screen was not yet performed, but should be
done prior to discharge.
Psychosocial: Parents are here from [**State 531**] state. Father of
baby does not have the 2nd tag. Mother of baby and maternal
grandmother both have ID tags. The father of baby is somewhat
involved. Has been in to see the infant.
CONDITION AT DISCHARGE: Stable.
DISCHARGE DISPOSITION: [**Hospital3 1810**] [**Location (un) 86**] for repair of
exstrophy of bladder.
CARE AND RECOMMENDATIONS: Continue IV fluids at 80 cc per
kilogram per day.
MEDICATIONS: Not applicable.
DISCHARGE DIAGNOSES: Bladder exstrophy,
rule out sepsis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2144-1-9**] 07:26:04
T: [**2144-1-9**] 07:49:39
Job#: [**Job Number 65137**]
ICD9 Codes: V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1366
} | Medical Text: Admission Date: [**2126-4-4**] Discharge Date: [**2126-4-13**]
Date of Birth: [**2064-8-9**] Sex: M
Service: cardiac surgery
HISTORY OF PRESENT ILLNESS: The patient is a 61 year-old
gentleman with a past medical history of coronary artery
disease status post cardiac catheterization and stenting in
[**2123**] who presents with substernal chest pain on exertion.
His symptoms began the evening of presentation when he was
walking. He described the chest pressure as 7 on a scale of 1
to 10. He reportedly lightheadedness with chest pressure.
The pain continued despite rest and he was brought to the ED
where his symptoms resolved with sublingual nitroglycerin
times two. He denied any radiation, shortness of breath,
diaphoresis, nausea or vomiting with this exertional angina.
He reports that his exertional angina began a few weeks ago
but normally is relieved by rest.
He underwent exercise test on [**6-5**] which was negative to
[**Doctor First Name **] 83 without symptoms or EKG changes and with a MIBI that
was completely normal, no longer revealing mild inferior
re-perfusing defect that was present on his prior study.
PAST MEDICAL HISTORY:
1. Sleep apnea.
2. GERD.
3. Hypercholesterolemia.
4. Coronary artery disease status post cath and stenting.
MEDICATIONS:
1. Lopressor 50 milligrams po bid.
2. Aspirin 325 milligrams po q day.
3. Lipitor 10 milligrams po q day.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: Negative except for HPI.
SOCIAL HISTORY: A 30 pack year history of tobacco use. A
history of alcoholism but absent for the past six years.
PHYSICAL EXAMINATION: He is afebrile. Pulse of 92. Blood
pressure 168/94, respiratory rate 15, saturation 97% on four
liters. Generally he is alert and oriented times 3 in no
acute distress. HEENT - pupils are equal, round and reactive
to light. Extraocular muscles are intact. Moist mucous
membranes. No LED. Supple neck, no JVD. Cardiovascular - S1,
S2 regular rate and rhythm. Pulmonary - mild bibasilar
crackles. Abdomen - nontender, nondistended, soft, obese,
reducible umbilical hernia. Extremities - 1+ pedal edema
bilaterally. Neuro - cranial nerves II through XII are
intact. Groin - no bruits bilaterally.
LABORATORY DATA: EKG shows normal sinus rhythm with an axis
of -30 degrees, normal interval except for prolonged PR
interval, left atrial enlargement.
Labs - white count 8.2, crit 39, platelet count 228,000. Chem
7 140, 3.6, 103, 26, 20, 1.1 and 107.
HOSPITAL COURSE: The patient was admitted on [**2126-4-4**] and
underwent cardiac catheterization which showed significant
distal left main coronary artery stenosis extending into the
proximal LAD and a very high grade mid LAD stenosis. The
patient was placed on a Heparin drip and aspirin.
The cardiothoracic surgery service was consulted on [**4-5**]
regarding surgical correction of these lesions. The patient
was scheduled for Monday, [**4-8**]. The patient underwent a
three vessel CABG on [**2126-4-8**] with saphenous vein graft to
the distal LAD, LIMA to mid LAD and radial artery to RM 1.
The patient did well postoperatively and was transferred to
the CSRU.
The patient was placed on Imdur on postoperative day one. The
patient's mediastinal tubes were removed on postoperative day
one. The patient was transferred to the floor on the evening
of postoperative day one.
On postoperative day two the patient continued to do well and
his pleural chest tubes were removed. On postoperative day
three the patient had his wires removed. The patient's
Lopressor was increased to 25 milligrams po bid.
On postoperative day four the patient continued to do well
and was ambulating at a level V with physical therapy. The
patient was discharged to home on postoperative day five in
good condition on the following medications:
DISCHARGE MEDICATIONS:
1. Lopressor 50 milligrams po bid.
2. Lasix 20 milligrams po bid times seven days.
3. Lipitor 10 milligrams po q day.
4. Isosorbide Mononitrate 60 milligrams po q day.
5. Prilosec 20 milligrams po q day.
6. Percocet 5/325 one to two tablets four to six hours prn.
7. Aspirin 325 milligrams po q day.
8. KCL 20 milliequivalents po bid times seven days.
9. Colace 100 milligrams po bid.
DISCHARGE DIAGNOSIS:
1. Status post CABG times three vessels with LIMA, Radical
artery and saphenous vein on [**2126-4-8**].
DISCHARGE STATUS: Good condition.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 6067**]
MEDQUIST36
D: [**2126-4-12**] 13:11
T: [**2126-4-12**] 13:36
JOB#: [**Job Number 13958**]
ICD9 Codes: 4111, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1367
} | Medical Text: Admission Date: [**2152-2-25**] Discharge Date: [**2152-3-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2605**]
Chief Complaint:
SOB
Sepsis
Cellulitis
Major Surgical or Invasive Procedure:
Placement of subclavian central venous catheter
Placement of PICC line
Removal of subclavian central venous catheter
History of Present Illness:
The patient is a [**Age over 90 **] year old non-diabetic female who presented
to the E.D. with history of 1 day of increasing confusion, left
leg pain, nausea/emesis, and loose stools without associated
fevers/rigors/chills. Patient's stools were noted to be
non-bloody and patient was without abdominal pain. On initial
admission, the patient was noted to have a SpO2 of 86% but rose
to 96% on RA in ED. A CXR at this time suggested pulmonary edema
for which the patient received 10mg IV lasix with subsequent
development of hypotension to 77/20 although the patient was
reported to be asymptomatic. In the E.D. the patient was started
on dopamine 5mcg/min for her hypotension.
Given the patient had leukocytosis with WBC of 16 with 35%
bands, the patient was given ceftriaxone and Vancomycin. Given
LLE erythema, clinical impression was that the patient had a
likely cellulitis as source of infection.
.
On transfer to the MICU, a central line was placed and the
patient was transitioned to levophed briefly. Patient's labs on
transfer were noteable for a mild transaminitis, leukocytosis
and a lactate of 6. The patient's antibiotics regimen was
changed to Vanc and Zosyn, then again to Vanc, Cefepime and
Flagyl. The patient was reported to have received approximately
5 liters of fluid prior to transfer to the MICU. Given
moderately elevated blood sugars on admission the patient was
initally placed on an insulin gtt as well which was
transitioned rapidly to SC Insulin. The patient had a mildly
elevated troponin on admission that remained relatively flat
throughout her MICU course, likely elevated secondary to fluid
overload and possible demand ischemia in the setting of sinus
tachycardia with heart rate in the 130's. The patient had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**]
stim test that did not demonstrate adrenal insufficiency but was
remarkable for an elevated baseline cortisol of 46.
.
Since [**2152-2-26**] the patient has been weaned off pressors and fluid
support. The patient was to be called out of the MICU on [**2152-2-27**]
but her course was complicated at this time by tachypnea and
tachycardia with decreased O2 sats thought likely to represent
flash edema. The patient was diuresed with 20mg IV lasix with
good effect. Since this time, the patient's BP has been stable
if not mildly hypertensive and she has since been restarted on a
BB for her hypertension and tachycardia. The patient remains
mildly tachycardic with O2 requirement on transfer. The patient
had LENIs performed which were negative, making PE less likely
(although not completely ruled out) with her current vitals
thought to represent ongoing fluid overload for which the
patient is being diuresed. The patient has a goal balance on
transfer of 1L negative, currently -600cc. On transfer the
patient is currently receiving Vancomycin and Unasyn for broad
spectrum cutaneous coverage with plan for placement of PICC line
for extended course of IV abx given persistent leg erythema and
leukocytosis.
.
Allergies: Unknown, NKDA
Past Medical History:
CHF - EF 40%, Mod RV dysfunction, Mod Pulm HTN
s/p MVR
Osteoporosis
GERD
Chronic leg edema
Anemia
HTN
Dementia
Prior rectal bleeding
No documented CAD although fixed wall motion abnormalities seen
on echo
.
PSH:
- s/p MVR with bioprosthetic valve, year unknown
Social History:
SH: Patient lives with husband. She has poor short term memory
with some confusion progressing over last year, likely with
early dementia. Patient uses a walker at baseline. She denies
tobacco, ETOH, or drug use.
Family History:
Non-contributory
Physical Exam:
On presentation to E.D:
Tm 98.9 hr 107-120 NSR, rr 20, bp 105-115/40-50, map 63-72
CVP 3 SpO2 98% on 2 L nc
.
Gen: nontoxic
heent: neck vein flat, mouth dry
lungs: crackles 50% up posterior field. no wheeze, good
aeration.
cv: tachy regular, s1/s2. mumur not apprec.
abd: soft, nttp
ext: L>R edema, more erythmatous with blanching on left. tender
to palpation. no fluctuance or crepitus though skin has brawny
induration. sensation intact.
.
.
On transfer from ICU:
Tc: 98.5___ Tmx: 99.4 ___ BP: 139/55___ HR: 97
RR: 31 (19-31) ___ Os Sat: 98% on 3L NC
I/O: 1604/2200 (-600)___ LOS: +1337 in MICU (plus 4-5L in E.D.)
.
Gen: Patient is an elderly female, sitting in bed, appears
relatively comfortable in NAD. A+O x 2, does not know year
HEENT: NCAT, EOMI. COnjunctiva on right mildly injected. OP:
Mildy dry plaques on roof of mouth. No other lesions
Neck: Supple, no LAD.
Chest: Thin, + well healed sternotomy scar. Lungs noteable for
fine crackles anterior on left. + fine crackles present
bilaterally 3/4 up lung zones bilaterally L > R
Cor: Mildly tachycardic, generally regular with some ectopic
beats +I/VI systolic murmur at LLSB. No rubs/gallops
Abd: Healed vertical surgical scar. Soft, NT, ND. +NABS
Ext: LLE noteable for significant 3+ pitting edema to knee, with
significant blanching erythema and superficial scaling of skin.
Mildly tender to palpation.
RLE: [**12-13**]+ pitting edema also with some associated chronic skin
changes and mild erythema although less than left leg
Access: Left CVL, foley
Pertinent Results:
Admission Labs:
.
[**2152-2-25**] 09:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2152-2-25**] 09:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2152-2-25**] 09:30PM PT-12.2 PTT-20.0* INR(PT)-1.0
[**2152-2-25**] 09:30PM PLT SMR-NORMAL PLT COUNT-241
[**2152-2-25**] 09:30PM HYPOCHROM-OCCASIONAL ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2152-2-25**] 09:30PM NEUTS-49* BANDS-35* LYMPHS-6* MONOS-4 EOS-0
BASOS-0 ATYPS-1* METAS-5* MYELOS-0
[**2152-2-25**] 09:30PM WBC-13.3* RBC-3.68* HGB-11.8* HCT-35.6*
MCV-97 MCH-32.1* MCHC-33.2 RDW-14.1
[**2152-2-25**] 09:30PM DIGOXIN-0.6*
[**2152-2-25**] 09:30PM ALBUMIN-3.6 CALCIUM-9.5 PHOSPHATE-3.1
MAGNESIUM-1.9
[**2152-2-25**] 09:30PM CK-MB-2
[**2152-2-25**] 09:30PM cTropnT-0.05*
[**2152-2-25**] 09:30PM AST(SGOT)-153* CK(CPK)-77 ALK PHOS-150*
AMYLASE-30 TOT BILI-0.5
[**2152-2-25**] 09:30PM GLUCOSE-132* UREA N-26* CREAT-1.2* SODIUM-135
POTASSIUM-5.5* CHLORIDE-97 TOTAL CO2-22 ANION GAP-22*
[**2152-2-25**] 10:03PM LACTATE-6.6*
.
Pertinent Labs/Studies:
.
[**Last Name (un) **] stim test ([**2152-2-26**]): 46.1 -> 58.5 -> 60.9
.
Iron binding studies ([**2152-2-26**]) calTIBC-315 VitB12-1059*
Folate-15.4 Ferritn-62 TRF-242
.
%HbA1c ([**2152-2-28**]) - 6.2
Digoxin ([**2152-2-25**]) - 0.6
.
CK: 26 -> 33 -> 48 -> 52 -> 56 -> 52
CM-MB: ND -> ND -> 2 -> ND -> ND -> 2
Troponin: .02 -> .03 -> .03 -> -.04 -> .06 -> .06 -> .05
.
Lactate: 6.6 -> 5.2 -> 3.2 -> 2.6 -> 1.6
.
Microbiology:
Blood cultures:
[**2152-2-25**] - NGTD
[**2152-2-26**] - NGTD
[**2152-2-29**] - NGTD
.
Urine cultures
[**2152-2-25**] - NGTD
[**2152-2-29**] - NGTD
[**2152-3-2**] - Pending, NGTD
.
Stool:
[**2152-3-1**] - C. Diff - Negative
.
Imaging Studies:
.
[**2152-2-25**]: Portable Chest - Diffuse interstitial opacity,
cardiomegaly, pulmonary hilar fullness indicate cardiac failure.
Probable left pleural effusion. Right costophrenic angle also
not well identified. S/P sternotomy and MVR
IMPRESSION: Cardiac failure with interstitial edema and left
pleural
effusion.
.
[**2152-2-25**]: LLE LENI - Normal compressibility, color flow, and
Doppler waveforms are seen in the deep venous system from the
common femoral vein to the popliteal. No evidence of DVT.
IMPRESSION: No evidence of DVT in the left lower extremity.
Findings were relayed to the ED dashboard at time of image
interpretation.
.
[**2152-2-26**] - Portable Chest - The patient is rotated to the left.
The heart size is top normal. The patient is status post median
sternotomy, CABG and mitral valve replacement. Bilateral
perihilar opacity is seen which is also involved the whole lung
and represent congestive heart failure. The finding seems to be
worsening in comparison to the previous film from yesterday.
Bilateral small-to-moderate amount or pleural effusion is
present. Left subclavian catheter is inserted with its tip
projecting over the area or right atrium below the cavoatrial
junction. No evidence of pneumothorax or other complication of
the central venous line insertion are present.
IMPRESSION:
1. Congestive heart failure.
2. No evidence of pneumothorax after insertion of the left
subclavian venous catheter. The tip of the catheter is projected
over the area of right atrium.
.
[**2152-2-26**]: Echocardiogram:
Left Atrium - Long Axis Dimension: *5.1 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.4 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.7 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.4 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.0 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 40% (nl >=55%)
Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.7 cm (nl <= 3.4 cm)
Aorta - Arch: 3.0 cm (nl <= 3.0 cm)
Aortic Valve - Peak Velocity: 1.8 m/sec (nl <= 2.0 m/sec)
Mitral Valve - Mean Gradient: 8 mm Hg
Mitral Valve - Pressure Half Time: 77 ms
Mitral Valve - E Wave: 1.9 m/sec
Mitral Valve - A Wave: 2.1 m/sec
Mitral Valve - E/A Ratio: 0.90
Mitral Valve - E Wave Deceleration Time: 352 msec
TR Gradient (+ RA = PASP): *37 mm Hg (nl <= 25 mm Hg)
.
The left atrium is moderately dilated. There is mild symmetric
left
ventricular hypertrophy. The left ventricular cavity size is
normal. LV systolic function appears moderately depressed.
Tissue velocity imaging E/e' is elevated (>15) suggesting
increased left ventricular filling pressure (PCWP>18mmHg).
Resting regional wall motion abnormalities include inferolateral
akinesis and basal inferior hypokinesis with mild to moderate
hypokinesis elsewhere. The right ventricular cavity is
moderately dilated. Right ventricular systolic function is
borderline normal. [Intrinsic right ventricular systolic
function is likely more depressed given the severity of
tricuspid regurgitation.] The aortic valve leaflets are mildly
thickened. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. A bioprosthetic mitral valve prosthesis
is present. The gradients are mildly elevated for this
prosthesis. No mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion. Compared with the report of the prior
study (images unavailable for review) of [**2147-7-28**], the mean
mitral gradient is similar. Left ventricular systolic function
may be similar or slightly improved.
.
[**2152-2-28**]: Portable Chest - The tip of the left PICC catheter
overlies the SVC/right atrial junction. The patient is status
post median sternotomy, CABG, mitral valve replacement.
Bilateral perihilar opacity suggests mild CHF, but has improved
slightly from [**2-26**]. Small right pleural effusion is
unchanged.
.
[**2152-3-1**]: Chest Pa/Lat - Sternotomy and mitral valve replacement
are again noted. The heart is upper limits of normal in size
for technique, and the aorta is unfolded. Lung volumes are much
improved since the previous exam, and bilateral pleural
effusions have diminished. Mild CHF persists. Compression
deformities within the lumbar spine are difficult to accurately
compare to the [**2146**] exam, but grossly the configuration is
unchanged.
.
IMPRESSION: Mild CHF and small bilateral effusions, markedly
improved since the previous exam. No evidence of pneumonia.
Discharge Labs: [**2152-3-3**]
.
[**2152-3-3**] 06:29AM BLOOD WBC-13.7* RBC-3.23* Hgb-10.1* Hct-31.1*
MCV-96 MCH-31.3 MCHC-32.5 RDW-14.6 Plt Ct-334
[**2152-3-3**] 06:29AM BLOOD Neuts-79.8* Lymphs-14.7* Monos-2.6
Eos-2.1 Baso-0.8
[**2152-3-3**] 06:29AM BLOOD Glucose-97 UreaN-34* Creat-1.1 Na-140
K-3.3 Cl-104 HCO3-23 AnGap-16
[**2152-3-3**] 06:29AM BLOOD Mg-2.0
Brief Hospital Course:
Assessment/Plan: Patient is a [**Age over 90 **] year old female with history
of systolic heart failure presents to MICU with sepsis thought
likely to be secondary to lower extremity cellulitis.
.
#. Sepsis - As detailed in admission note, the patient was
transferred to the MICU from the E.D with hypotension, fever,
elevated white count and elevated lactate indicative of sepsis.
Of note, the patient received fluid support as appropriate.
However, given history of CHF with depressed EF and patient's
code status as DNR/DNI, overly aggressive volume resuscitation
was avoided given concern for volume overload. The patient was
initially placed on a dopamine gtt in the E.D. which was
transitioned to levophed upon transfer to the MICU, but
ultimately weaned relatively rapidly. The patient was initially
given ceftriaxone and Vancomycin in the E.D. with transition of
abx regimen initially to Vanc and Zosyn. This was then changed
to Vanc, Cefepime and Flagyl and then ultimately Vanc and Unsayn
upon transfer to the floor. Of note, the patient's lactate was
6.0 at time of admission to the MICU with WBC of 13 but 35%
bands, peak WBC of 23.4. Patient continues to have an elevated
white count although this continues to improve with current
antibiotic regimen since admission without bandemia now. Upon
initial transfer to the MICU the patient is reported to have
received approximately 5L NS. The patient had an O2 requirement
of 3L NC (none as outpatient) as well as chest imaging revealing
fluid overload. Once the patient's pressures were stabilized,
she was diuresed with approximately 2-3L output over 3 days.
Further workup for etiology of infection has been relatively un
revealing. On admission the patient had chest film performed
that did not demonstrate a PNA and UA/UCx did not provide
evidence for a UTI. To date all blood cultures are without
growth. Of note, the day after discharge from the MICU the
patient had a temp spike to 101. Repeat chest film was performed
which revealed no infiltrate or consolidation, although it did
reveal marked improvement of the patient's pulmonary edema.
Although admission UA/Ucx was negative, a repeat UA revealed
RBCs and Leuks (see results) with no bacteria. Given these
findings the patient's foley catheter was removed with
subsequent UA post-foley removal revealing again leukocytes,
RBCs as well as yeast. Although it was not clinically suspected
that the patient was having a systemic fungal infection, she
received Fluconazole 150mg po x1. Given the patient's cellulitis
over her left leg, it is suspected clinically to be the
patient's ongoing source of infection. The patient's leg remains
swollen with erythema but has been progressively improving since
her admission. The patient has generally been slowly improving
with her current regimen and supportive care. She should
continue her current regimen of Vancomycin and Unasyn as
instructed although total duration of therapy will have to be
reassessed at the end of treatment. If the patient's white count
remains elevated or she has ongoing evidence for cellulitis she
should likely have her treatment course extended. Should the
patient spike a temperature or have a rising white count again,
ongoing concern would be for inadequate treatment of the
patient's cellulitis. Given her apparent response to Zosyn
and/or cefepime initially, the patient should be transitioned to
a regimen of Vanc/Zosyn or Vanc/Cefepime.
.
#. CHF - As above the patient has a known history of systolic
CHF with depressed EF. On presentation to the E.D. the patient
was with pulmonary edema for which she received lasix with
subsequent development of hypotension and treatment as above for
sepsis. On admission to the MICU ECG did not reveal changes
consistent with acute infarction and cardiac markers revealed
mildly elevated troponin's although they remained relatively
flat. These mildly elevated troponins were thought likely to be
secondary to CHF as well as possibly mild demand ischemia as the
patient was with tachycardia with rates in the 120s to 130s. A
repeat echocardiogram was performed that revealed a moderately
depressed EF of 40% (stable to mildly improved since [**2146**]),
resting wall motion abnormalities including inferolateral
hypokinesis/akinesis (improved since [**2144**], suspicious for
previous infarct although patient does not carry this
diagnosis), RV dilation with borderline normal function (also
improved from previous), and evidence for moderate pulmonary
artery hypertension. With stabilization of pressures the
patient's CHF medications were slowly reintroduced. As an
outpatient the patient was admitted with a regimen including:
Atenolol 25 po qd, Captopril 12.5 [**Hospital1 **], Digoxin 125 po qd, and
Lasix 40 qd prn. The patient was diuresed as above and first
given back metoprolol 12.5mg po bid given mild tachycardia which
has since been increased to 25mg po bid, well tolerated. She
will be discharged with transition to qd dosing qith Toprol XL
given her history of heart failure. After diuresis, low dose
captopril was reintroduced as well at a dose of 6.25mg po tid.
The patient again tolerated this well with regards to her BP but
was noted to have a small, but expected, bump in her creatinine
from 0.8 to 1.2. On day of discharge her creatinine is now 1.1
and should have ongoing monitoring at least twice weekly. The
patient should have her creatinine rechecked approximately three
days after admission to extended care facility. If her
creatinine remains relatively stable, her captopril should be
increased back to her outpatient regimen of 12.5mg po bid with
ongoing monitoring of her creatinine as instructed. The patient
was maintained on a low sodium, cardiac healthy diet with fluid
restriction < 1500cc.
.
#. Psych - The patient was admitted from the ICU in good
spirits, pleasant, but noted to have findings consistent with
dementia including poor memory incorporation. On the day prior
to discharge the patient appeared mildly upset and reported to
the staff that she was tired of being old and sick and endorsed
suicidal ideation. This was discussed with the patient at
length. She reported to the team that she was tired of being in
the hospital and wanted to go home. When asked about intention
to hurt herself, the patient denied any plan to harm herself and
also denied any thoughts about how she might ever hurt herself.
She contracted for safety and reported to the team that should
she ever have feelings she would hurt herself she would notify a
member of the medical staff. The patient was deemed to be safe
and does not require a 1:1 sitter. The patient was seen by
psychiatry who also agreed that the patient does not require a
1:1 sitter. It seems the patient's symptoms are most likely a
situational mood disorder that will improve with her leaving the
hospital. On the a.m. of discharge the patient was very
pleasant, denied any SI and actually did not recall any of the
events of the preceding day. She is very excited about the idea
of leaving the hospital, getting therapy and rehab, and then
heading back home. The psychiatry team agrees that the patient
is not depressed and no further treatment is required at this
time.
.
#. HTN - As above the patient was hypotensive on admission to
the MICU. After diuresis for volume overload the patient was
restarted on low dose metoprolol as well as low dose captopril
as above which will require ongoing titration back to outpatient
doses as tolerated. The patient is currently hemodynamically
stable with SBP range from 110-130.
.
#. Hyperglycemia - The patient was with moderately elevated
sugars on admission to the MICU with initiation of insulin gtt
for tight glycemic control. As the patient's BS were easily
controlled she was rapidly transitioned to SC insulin with
sliding scale and was maintained on a sliding scale without
large requirements. The patient had a HgA1C performed with value
of 6.1% revealing some degree of glucose intolerance but not
enough to warrant initiation of outpatient medical management
currently. She will be continued on an insulin sliding scale on
transfer to extended care facility but likely will not require
insulin or oral hypoglycemics on discharge.
.
#. CKD/ARF - The patient was admitted with an elevated
creatinine of 1.2 on admission thought initially to be secondary
to sepsis. With improvement in hemodynamics as well as volume
status the patient's creatinine decreased to 0.8 which is within
the patient's normal baseline range. As above, with re
initiation of an ACE inhibitor, the patient experienced a bump
in her creatinine to 1.2, today 1.1. This will need ongoing
monitoring with possible titration of ACE as above. Medications
were renally dosed as appropriate and nephrotoxins avoided as
possible.
.
# Anemia - Patient is known to have a chronic anemia with
Hematocrit range over last few years of 30-35. On admission the
patient was noted to have a Hct of 35.6 which has remained
relatively stable accepting for volume shifts. Iron binding
studies/anemia work up revealed a low iron level with normal
ferritin and transferrin, possibly suggestive for mild iron
deficiency. The patient was started on PO iron supplementation
with appropriate bowel regimen. Vitamin B12 levels were noted to
be WNL. The etiology of the patient's iron deficiency is unknown
and ongoing workup should be evaluated as appropriate by the
patient's PCP as an outpatient.
.
#. FEN: The patient was maintained on a low salt cardiac healthy
diet, fluid restriction < 1500cc
.
#. Ppx: The patient was given SC Heparin, a PPI, and bowel
regimen. The patient received one tap water enema with
successful large BM x1.
.
#. Code: DNR/DNI. This was reviewed with the patient's husband
upon transfer to the MICU. At this time, it was agreed that
transfer to the MICU was acceptable as was pressors but the
patient was not to be intubated or resuscitated in the case of a
code. This directive should be continued upon transfer to the
extended care facility. The patient's husband should be
contact[**Name (NI) **] with any acute change in clinical status: [**Telephone/Fax (1) 100831**]
Medications on Admission:
Atenolol 25 po qd
Ativan 0.5mg prn
Captopril 12.5 [**Hospital1 **]
Lanoxin 125 po qd
Lasix 40 qd prn
Mvi
Mylanta prn
Tums 1500 qd
Zantac 75 75mg [**Hospital1 **] prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
5. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day): please continue until
discharge.
7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram
Intravenous Q 24H (Every 24 Hours) for 9 days.
10. Ampicillin-Sulbactam [**1-12**] g Recon Soln Sig: Three (3) grams
Injection Q8H (every 8 hours) for 9 days.
11. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
12. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit
Injection ASDIR (AS DIRECTED): please continue insulin sliding
scale as provided.
13. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2732**] & Retirement Home - [**Location (un) 55**]
Discharge Diagnosis:
Primary:
Sepsis
Cellulitis
CHF
.
Secondary:
CHF - EF 40%, Mod RV dysfunction, Mod Pulm HTN
s/p MVR
Osteoporosis
GERD
Chronic leg edema
Anemia
HTN
Dementia
History of rectal bleeding
Discharge Condition:
Good. Patient is afebrile, hemodynamically stable with O2 sats >
90% on room air. Patient's cellulitis improving.
Discharge Instructions:
1. Please take all medications as prescribed
.
2. Please keep all outpatient appointments
.
3. Please continue care as provided by the healthcare providers
at your extended care facility
.
4. Please weigh yourself daily after discharge from your
extended care facility. If your weight increases by more than 3
pounds, please call your physician to ask about how you should
adjust your lasix doses.
Followup Instructions:
1. Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 712**]
[**Name (STitle) 713**] on discharge from your extended care facility. You have
an appointment with Dr. [**Last Name (STitle) 713**] on Thursday, [**3-23**] at
12:00p.m.
Please call her office at [**Telephone/Fax (1) 719**] with any questions or
scheduling needs.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2608**] MD, [**MD Number(3) 2609**]
ICD9 Codes: 0389, 5849, 4280, 4240, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1368
} | Medical Text: Admission Date: [**2151-3-2**] Discharge Date: [**2151-3-5**]
Date of Birth: [**2092-5-31**] Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Left sided headaches
Major Surgical or Invasive Procedure:
[**2151-3-2**]: Left Craniotomy for SDH
History of Present Illness:
Ms. [**Known lastname 59190**] is a 58-year-old female who presented with bilateral
subdural hematoma after a fall. She subsequently had bilateral
burr holes on [**2151-1-24**]. Following this, she has improved but
still continues to have left-sided headaches and the ;eft
collection never fully resolved and she opted to procede for
surgery.
Past Medical History:
depression, anxiety,
hyperlipidemia, and hypertension.
Social History:
Widowed, works in medical records, smokes [**2-15**] ppd. drinks three
beers a night to help her to sleep. denies illicit drug uses
Family History:
non contributory
Physical Exam:
At discharge:
Alert and oriented x3, PERRL, speech clear, follows commands,
MAE [**6-19**], incision C/D/I with sutures
Pertinent Results:
[**2151-3-2**] 02:37PM PT-10.8 PTT-32.5 INR(PT)-1.0
CT head [**2151-3-2**]:
IMPRESSION:
Interval left craniotomy with expected pneumocephalus and
decrease in size of the subdural hematoma layering over the left
cerebral convexity. No evidence of re-accumulation.
Brief Hospital Course:
Ms. [**Known lastname 59190**] was admitted to [**Hospital1 18**] under the care of DR. [**First Name (STitle) **].
She proceded to the OR and underwent a left craniotomy for SDH
for evacuation. She was extubated and taken to PACU. CT head
showed some residaul hematoma but she was neurologically stable
and remained in the ICU overnight. She was on CIWA precautions
to follow for possible ETOH withdraw. Her exam remained stable
and she was transferred to the floor on [**3-3**]. She remained
stable. On [**3-4**], she was observed by PT and acute PT was not
recommended. Outpatient PT was given as an option for endurance
training if the patient wanted.
She was discharged home with her daughter on [**3-5**]. She was
discharged on Keppra and with a outpatient PT order in case she
decides to go ahead with PT.
Medications on Admission:
Citalopram 30mg daily, Pravastatin 40mg daily, Diltiazem 30mg
QID, Lisinopril 40mg daily, Percocet 5/325mg prn, Trazodone 50mg
QHS, Keppra 750mg [**Hospital1 **], famotadine 20mg [**Hospital1 **]
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*QS Patch 24 hr(s)* Refills:*0*
3. diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
4. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
8. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
9. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for headache.
Disp:*60 Tablet(s)* Refills:*0*
11. Keppra 750 mg Tablet Sig: One (1) Tablet PO twice a day:
Continue until seen by Dr [**First Name (STitle) **].
Disp:*60 Tablet(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Subdural hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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 > 10 lbs,
straining, or excessive bending.
?????? You may wash your hair only after sutures have been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury, you may
safely resume taking this when cleared by your neurosurgeon.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
Followup Instructions:
??????Please return to the office in 10 days (from your date of
surgery) for removal of your sutures. This appointment can be
made by calling [**Telephone/Fax (1) 4296**]. If you live quite a distance from
our office, please make arrangements for the same, with your
PCP.
??????Please call ([**Telephone/Fax (1) 2102**] 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:[**2151-3-5**]
ICD9 Codes: 2724, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1369
} | Medical Text: Admission Date: [**2184-4-23**] Discharge Date: [**2184-5-3**]
Date of Birth: [**2123-2-22**] Sex: M
Service: Cardiothoracic surgery.
HISTORY OF PRESENT ILLNESS: Briefly, this is a 61 year old
gentleman with no significant past medical history. He
presented to an outside hospital with shortness of breath and
substernal chest pain, times six days. He was transferred to
[**Hospital1 69**] for coronary artery
bypass graft and also for respiratory failure. He had
undergone a cardiac catheterization at the outside hospital,
which showed 70% right coronary artery lesion, 100% left
anterior descending lesion and 95% circumflex lesion. He was
originally admitted to the CCU on the medical service and was
started on an IVP as well as multiple pressors. He required
intubation for respiratory difficulty.
PAST MEDICAL HISTORY: Only significant for a family history
of coronary artery disease and history of tobacco.
ALLERGIES: No known drug allergies.
MEDICATIONS: He took no medications. He did, however, smoke
one pack per day with occasional alcohol.
PHYSICAL EXAMINATION: Upon admission here, he was afebrile.
His heart rate was 73. Blood pressure was 88/50;
respiratory rate of 11; saturating 97%. He was intubated and
sedated. His cardiovascular is regular rate and rhythm with
a 2/6 systolic murmur at the apex. He had bilateral diffuse
crackles. His abdomen was soft, nontender, nondistended.
Extremities had no edema. Dopplerable dorsalis pedis and
posterior tibial pulses. He had a right and left groin
sheath in.
LABORATORY DATA: On admission, his white count was 9.2;
hematocrit was 39.7; platelet count of 302. Chemistries:
137; 4.5; 101; 27; BUN of 11; creatinine of 0.9. Blood sugar
of 115. CK was 175. MB was 4.3. Troponin of 1.8.
The patient was admitted to the medical service on [**2184-4-23**]
for evaluation and management. As stated previously, he
underwent a repeat cardiac catheterization here at [**Hospital1 1444**] that reconfirmed the presence
of three vessel disease and a repeat echo which again showed
similar results.
Cardiothoracic surgery was consulted at that time for
evaluation for emergent coronary artery bypass graft. The
patient went to the operating room on [**2184-4-27**] where he
underwent a coronary artery bypass graft times three and a
mitral valve repair. Please see the operative report for
further details. The patient was transferred to the CSIU
postoperatively. His ejection fraction postoperatively was
45%. He was slowly weaned from his ventilator and ultimately
able to be extubated. He required pressors postoperatively
for blood pressure support. He was fully weaned from his
Levophed and he was also given Amiodarone. He was taken off
of his Levophed and started on Milrinone for blood pressure
support. He was weaned off of his Amiodarone drip. He was
also given a course of Levofloxacin for a positive urinary
tract infection. He continued to improve and was extubated
on postoperative day number one. He was kept in the CSIU.
Physical therapy was consulted while he was in the CSIU and
they continued to follow him throughout his hospital course.
He was ultimately deemed capable of going home and being
improved from a physical therapy standpoint. He was weaned
off of all pressors by postoperative day number three. He
continued do well. His laboratory values were all within
normal limits. He made excellent urine and was started on
Lasix for diuresis. He was started on Captopril, Lopressor,
Plavix and Lasix for his cardiac medications. His wires and
chest tubes were removed on postoperative day number four and
the patient was transferred out to the floor on postoperative
day number five. His Foley catheter was also removed after
arriving on the floor. He remained in sinus rhythm throughout
his hospital stay and continued to do well.
On [**2184-5-3**], the patient was cleared by physical therapy,
tolerating a regular diet and was discharged to home with VNA
services.
DISCHARGE MEDICATIONS:
1. Lopressor 50 mg p.o. twice a day.
2. Lasix 20 mg p.o. twice a day.
3. Colace 100 mg p.o. twice a day.
4. Aspirin 325 mg p.o. q. day.
5. Percocet one to two tablets p.o. every four hours prn for
pain.
6. Plavix 75 mg p.o. q. day.
7. Lipitor 80 mg p.o. q. day.
8. Potassium 20 meq p.o. twice a day.
FOLLOW-UP: The patient was instructed to follow-up with his
primary care physician in one to two weeks.
Follow-up with cardiologist in three weeks.
Follow-up with the cardiothoracic service at [**Hospital3 1280**] in
four weeks.
DISPOSITION: He was discharged to home in stable condition.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Status post myocardial infarction.
3. Status post cardiac catheterization.
4. Status post IBP.
5. Now status post coronary artery bypass graft times three.
6. Mitral valve regurgitation.
7. Now status post mitral valve repair.
SECONDARY DIAGNOSES:
1. Urinary tract infection.
2. Hypokalemia.
3. Hypomagnesemia.
The patient is discharged to home in stable condition.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern4) **]
MEDQUIST36
D: [**2184-5-4**] 08:15
T: [**2184-5-4**] 08:22
JOB#: [**Job Number 55626**]
ICD9 Codes: 4280, 5990, 2768, 4240, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1370
} | Medical Text: Admission Date: [**2187-3-17**] Discharge Date: [**2187-3-23**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8747**]
Chief Complaint:
left sided weakness
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
This is a 81 yo woman with a large suprasellar
mass/meningioma (patient refused surgical removal in recent
past)
causing panhypopituitaryism, who was admitted yesterday from the
ED with sepsis to the [**Hospital Unit Name 153**]. I am now being called for left
sided
weakness since about 4:30am (it is now 10AM).
She was found unresponsive in bed at [**Location (un) 15383**] Home where
she lives, incontinent, fever to 104. No seizure activity
noted.
+N/V for several days beforehand. In our ED she was 104.8
degrees F and hypotensive to the 80's. Her BP picked up with
IVF, she was given CTX/Vanco/Flagyl in the ED (now on CTX/Vanco
in [**Hospital Unit Name 153**]), and steroids were increased to stress dose (from 20mg
hydrocort a day to 50 IV q6). She had an LP yesterday that was
unremarkable. No OP withdrawn, 4 cc obtained in the ED.
In the [**Hospital Unit Name 153**] she was noted to have left sided weakness at around
4:30am, team was notified at 7:30am, and neurology was called
around 9:45am. Patient seen immediately. Please see my exam
below. She is confused, slumps to the right (left neglect),
left
hemiparesis (arm is plegic) but sensation intact.
ROS: no arrhythmias overnight. She was hypotensive to 91/30 and
given fluid bolus overnight. Patient currently has no
complaints
but is confused.
Past Medical History:
1. Tuberculum sellae meningioma with suprasellar extension and
superior and posterior displacement of the optic chiasm, 4.1 x
3.4 x 2.1 cm in transverse x anterior posterior x superior
inferior dimensions. dx'd ~5yrs ago per pt at BU. Patient was
admitted in [**10-21**] and underwent extensive evaluation of this
mass by onc/neurosurg/xrt. She was admitted for an unresponsive
episode that was thought to be secondary to adrenal
insufficiency. Patient refused surgery on her mass. She is on
replacement thyroid, steroids.
2. Seizure disorder: Details unclear--pt first reported being on
dilantin for ~1 year, then reported being on it only 6 weeks.
She is unable to provide details of the seizures.
3. Hypertension
4. COPD
5. Hypothyroidism
6. Cataracts and ?glaucoma left eye. Pt unsure if has had
surgery on it.
7. Severely decreased vision L eye, etiology uncertain but
likely
due to mass
8. Likely has dementia per Dr. [**Last Name (STitle) 4253**].
ALL: NKDA
Social History:
lives at [**Location (un) **] Home for past 5 years or so.
+Tobacco for at least 20 yrs, reports [**12-18**] ppd for 5yrs.
Previously drank ~1pint/day, none for [**4-25**] yrs. Used to work as
maid at Colonnade Hotel until ~5 yrs ago.
Family History:
Unknown
Physical Exam:
PHYSICAL EXAM:
VITALS: T 100.2 current, 89, 109/34, 21, 98% RA. FS 129
GEN: elderly woman slumping to the right in bed, not intubated,
in [**Hospital Unit Name 62876**]: no rash
HEENT: NC/AT, anicteric sclera, mmm
NECK: supple, no carotid bruits
CHEST: normal respiratory pattern, CTA bilat
CV: regular rate and rhythm without murmurs
ABD: soft, nontender, nondistended, +BS
EXTREM: no edema
NEURO:
Mental status:
Patient is alert, awake but falls asleep in middle of exam. She
is confused, unable to tell me why she's here or any story. She
is oriented to self, "06", but not location, "I'm here." She
names her right thumb and her nose, but when asked to name her
left thumb she gives nonsense answer. Language is fluent with
fair comprehension (follows simple commands), no dysarthria.
Unable to perform further testing as she falls asleep.
Cranial Nerves:
I: deferred
II: Visual acuity: not tested today. Visual fields: no blink
to threat on the left. Fundoscopic exam: unable, small pupils.
Pupils: 1 mm and fixed.
III, IV, VI: Looks to the right well, does not cross the
midline, but does dolls laterally appropriately (when sleepy).
No nystagmus or ptosis.
V: + corneals.
VII: left lower facial weakness
VIII: unable
IX, X: gag reflex present bilaterally.
[**Doctor First Name 81**]: unable
XII: unable
Sensory: withdrawls vigorously on the right, winces and cries on
the left to painful stim with minimal withdrawl of the left leg
proximally. Left arm plegic.
Motor:
Normal tone. Left hemiparesis with left arm plegia.
Reflexes:
[**Hospital1 **] BR Tri Pat Ach Toes
RT: 2 2 2 tr 0 down
LEFT: 2 2 2 tr 0 mute
Coordination:
unable
Gait:
unable
Pertinent Results:
[**2187-3-17**] 08:45PM GLUCOSE-86 UREA N-20 CREAT-1.0 SODIUM-143
POTASSIUM-4.6 CHLORIDE-118* TOTAL CO2-14* ANION GAP-16
[**2187-3-17**] 08:45PM CK(CPK)-141*
[**2187-3-17**] 08:45PM CK-MB-3 cTropnT-<0.01
[**2187-3-17**] 08:45PM CALCIUM-6.1* PHOSPHATE-3.1 MAGNESIUM-1.5*
[**2187-3-17**] 08:45PM WBC-7.7 RBC-4.51 HGB-13.2 HCT-41.6 MCV-92
MCH-29.3 MCHC-31.7 RDW-15.5
[**2187-3-17**] 08:45PM NEUTS-89.1* BANDS-0 LYMPHS-7.0* MONOS-3.1
EOS-0.6 BASOS-0.2
[**2187-3-17**] 08:45PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2187-3-17**] 08:45PM PLT SMR-NORMAL PLT COUNT-190
[**2187-3-17**] 08:45PM PT-13.4* PTT-29.5 INR(PT)-1.2*
[**2187-3-17**] 06:26PM GLUCOSE-93 UREA N-20 CREAT-1.0 SODIUM-142
POTASSIUM-4.6 CHLORIDE-117* TOTAL CO2-12* ANION GAP-18
[**2187-3-17**] 06:26PM CK(CPK)-138
[**2187-3-17**] 06:26PM CALCIUM-6.5* PHOSPHATE-2.8 MAGNESIUM-1.6
[**2187-3-17**] 06:26PM WBC-8.8# RBC-4.74 HGB-13.8 HCT-43.9 MCV-93
MCH-29.0 MCHC-31.3 RDW-15.5
[**2187-3-17**] 06:26PM NEUTS-70 BANDS-22* LYMPHS-5* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2187-3-17**] 06:26PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2187-3-17**] 06:26PM PLT SMR-NORMAL PLT COUNT-209
[**2187-3-17**] 06:26PM PT-26.5* INR(PT)-2.7*
[**2187-3-17**] 05:02PM TYPE-ART PO2-71* PCO2-34* PH-7.30* TOTAL
CO2-17* BASE XS--8 INTUBATED-NOT INTUBA
[**2187-3-17**] 05:02PM LACTATE-0.9
[**2187-3-17**] 01:50PM CEREBROSPINAL FLUID (CSF) PROTEIN-110*
GLUCOSE-73
[**2187-3-17**] 01:50PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-1* POLYS-0
LYMPHS-92 MONOS-8
[**2187-3-17**] 12:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2187-3-17**] 12:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2187-3-17**] 11:19AM LACTATE-2.0
[**2187-3-17**] 11:10AM GLUCOSE-106* UREA N-25* CREAT-1.6* SODIUM-144
POTASSIUM-3.8 CHLORIDE-112* TOTAL CO2-21* ANION GAP-15
[**2187-3-17**] 11:10AM ALT(SGPT)-24 AST(SGOT)-27 CK(CPK)-64 ALK
PHOS-102 AMYLASE-149* TOT BILI-0.2
[**2187-3-17**] 11:10AM cTropnT-<0.01
[**2187-3-17**] 11:10AM CK-MB-NotDone
[**2187-3-17**] 11:10AM TOT PROT-6.6 ALBUMIN-4.1 GLOBULIN-2.5
CALCIUM-8.6 MAGNESIUM-1.8
[**2187-3-17**] 11:10AM TSH-0.18*
[**2187-3-17**] 11:10AM CORTISOL-9.3
[**2187-3-17**] 11:10AM PHENYTOIN-19.4
[**2187-3-17**] 11:10AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2187-3-17**] 11:10AM WBC-5.2 RBC-4.50 HGB-13.4 HCT-40.9 MCV-91
MCH-29.7 MCHC-32.7 RDW-15.2
[**2187-3-17**] 11:10AM NEUTS-78* BANDS-11* LYMPHS-10* MONOS-1* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2187-3-17**] 11:10AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2187-3-17**] 11:10AM PLT SMR-NORMAL PLT COUNT-247
[**2187-3-17**] 11:10AM PT-13.1 PTT-22.6 INR(PT)-1.1
TRANSTHORACIC ECHO:
Cardiology Report ECHO Study Date of [**2187-3-19**]
PATIENT/TEST INFORMATION:
Indication: Cerebrovascular event/TIA. Left ventricular
function.
Height: (in) 62
Weight (lb): 162
BSA (m2): 1.75 m2
BP (mm Hg): 156/59
HR (bpm): 75
Status: Inpatient
Date/Time: [**2187-3-19**] at 12:52
Test: Portable TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006E006-0:36
Test Location: East MICU
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.9 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 4.6 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.3 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 1.1 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.1 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 2.6 cm
Left Ventricle - Fractional Shortening: 0.37 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 60% to 65% (nl >=55%)
Aorta - Valve Level: 2.6 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.9 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.5 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 1.1 m/sec
Mitral Valve - E/A Ratio: 0.73
Mitral Valve - E Wave Deceleration Time: 263 msec
TR Gradient (+ RA = PASP): *38 to 48 mm Hg (nl <= 25 mm Hg)
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Mildly dilated
RA.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Normal
regional LV systolic function. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber
size. Normal RV systolic function.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Trivial MR.
TRICUSPID VALVE: Mild [1+] TR. Moderate PA systolic
hypertension.
PERICARDIUM: No pericardial effusion. There is an anterior space
which most likely represents a fat pad, though a loculated
anterior pericardial effusion cannot be excluded.
GENERAL COMMENTS: Suboptimal image quality.
Conclusions:
1.The left atrium is mildly dilated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%).
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No aortic regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
6.There is moderate pulmonary artery systolic hypertension.
7.There is no pericardial effusion. There is an anterior space
which most
likely represents a fat pad, though a loculated anterior
pericardial effusion cannot be excluded.
Compared with the findings of the prior study (images reviewed)
of [**2186-10-20**], no change.
IMPRESSION:
No cardiac source of embolism seen.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD on [**2187-3-19**]
17:29.
HEAD CT AT PRESENTATION [**3-17**]:
NON-CONTRAST HEAD CT: Comparison with [**2186-10-20**] CT scan
and [**2186-10-21**] MRI. The suprasellar mass exerting mild
mass effect on the left inferior frontal lobe is again
identified, measuring 34 x 32 mm, not significantly changed in
size or appearance. There is no hydrocephalus. There is no shift
of normally midline structures, intra- or extra-axial
hemorrhage, or acute major vascular territorial infarct. The
[**Doctor Last Name 352**]-white differentiation appears preserved. There is scattered
opacification of mastoid air cells, but the remainder of the
imaged sinuses appear clear.
IMPRESSION: Stable appearance of large suprasellar meningioma.
No other acute intracranial hemorrhage or mass effect.
MRI:
This study is compared with similar examination performed on
[**2186-10-21**].
FINDINGS:
MRI of the brain without contrast was performed. There is no MR
evidence of hemorrhage, edema, midline shift or hydrocephalus.
Diffusion-weighted images demonstrate a focal area of restricted
diffusion in the right frontal and parietal regions and also on
the left side in the similar region and appears to be along the
watershed zone between the anterior and middle cerebral artery
distributions.
MR angiography is severely limited by motion. Faint flow is
noted in the middle cerebral arteries bilaterally, right greater
than the left.
Again noted is a sellar meningioma, which appears to be
unchanged in size and extension since the prior examination.
IMPRESSION:
Acute infarct noted in the watershed zone within the anterior
and middle cerebral artery distribution on the right and also on
the left.
MR [**First Name (Titles) 4058**] [**Last Name (Titles) 4059**] absent flow in the right internal
carotid artery, suggesting right internal carotid artery
occlusion. Faint flow is noted in the right middle cerebral
artery and appears to be via the anterior communicating artery
from the left side.
These findings were immediately discussed with Dr. [**Last Name (STitle) 7673**] from
neurology at the time of interpretation.
[**3-19**] head CT:
COMPARISON: [**2187-3-17**].
TECHNIQUE: Noncontrast head CT scan.
FINDINGS: Compared to yesterday's study, multiple new cortical
hypodensities are seen within the right frontal and
frontoparietal regions. There is no evidence of acute
intracranial hemorrhage. There is no shift of normally midline
structures. The ventricles appear unchanged compared to prior
study. Again seen is a large suprasellar mass in the left
inferior frontal region, not significantly changed in size or
appearance compared to yesterday's study. Mild mucosal
thickening is seen within the ethmoid air spaces. There is
evidence of a left-sided mucous retention cyst in the left
maxillary sinus. Scattered opacification of the mastoid air
cells appears unchanged.
IMPRESSION:
1. Multiple new cortical hypodensities seen within the right
frontal and frontoparietal regions, consistent with MCA infarct.
2. No acute intracranial hemorrhage or shift of normally midline
structures.
3. Unchanged appearance of large suprasellar mass seen in the
left inferior frontal region.
Findings discussed with Dr. [**Last Name (STitle) 7673**] at 10:30 a.m. on [**2187-3-18**].
[**3-19**] CTA:
TECHNIQUE: Non-contrast head CT was first performed and then, a
CTA was performed with IV contrast.
FINDINGS: There are no prior comparison examinations.
Correlation is obtained with the prior MRI of [**2187-3-18**].
The non-contrast head CT [**Year (4 digits) 4059**] multiple hypodensities
within the territory of the right middle cerebral artery
territory brain cortex, consistent with early subacute infarcts.
There is no evidence of intracranial hemorrhage or shift of the
normally midline structures. A large suprasellar mass slightly
eccentric to the left is again identified, reportedly
characteristic of a meningioma from prior MRIs.
CTA [**Year (4 digits) 4059**] the left common carotid artery has mild areas
of narrowing from its origin at the arch due to atherosclerotic
plaques. At the bifurcations of both internal carotid arteries,
there is a large amount of atherosclerotic plaque. On the left,
the internal carotid artery is severely narrowed at its origin.
On the right, only a few mm of the proximal internal carotid
artery are identified. There is no flow just distal to this
point. The right internal carotid artery then reconstitutes at
its petrous segment and flow is present in its cavernous and
supraclinoid portions, although with atherosclerotic plaque some
of which is calcified.
The left internal carotid artery just distal to its internal
carotid artery origin has flow with calcified atherosclerotic
plaque at its cavernous segment. The supraclinoid left internal
carotid artery then is encased by the presumed meningioma with
significant narrowing of its normal caliber. Once the vessel
leaves the suprasellar mass, the normal caliber is restored and
there is flow within the middle cerebral artery and minimal flow
within a hypoplastic segment of the left A1 anterior cerebral
artery.
Flow is seen within the right middle cerebral artery as well as
within both anterior cerebral arteries.
The right vertebral artery is noted to be very thin and
irregular from its origin on the aortic arch. The left vertebral
artery appears to be dominant. The basilar artery appears
normal. There may be a small segment of stenosis at the proximal
right posterior cerebral artery. The remainder of the posterior
cerebral arteries enhance normally.
IMPRESSION: Non-visualization of the right internal carotid
artery from its origin to the petrous segment. At the petrous
segment, the right internal carotid artery is reconstituted and
courses normally to its bifurcation into the anterior and middle
cerebral arteries. The left internal carotid artery has stenosis
at its origin due to atherosclerotic plaque. It then courses
superiorly and is encased by the suprasellar mass at its
supraclinoid portion. In this region, the lumen of the left
internal carotid artery appears significantly narrowed. Once the
left internal carotid artery exits the mass, a more normal
caliber is restored and there is opacification of the anterior
and middle cerebral arteries.
The right vertebral artery appears small throughout its entire
course and slightly irregular, likely due to atherosclerotic
disease.
EKG AT PRESENTATION"
Sinus tachycardia. Low limb lead voltage. Compared to the
previous tracing
of [**2186-10-25**] the rate has increased. Otherwise, no diagnostic
interim change.
Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**]
Intervals Axes
Rate PR QRS QT/QTc P QRS T
111 112 74 322/387.71 65 77 64
Brief Hospital Course:
81 yo RH woman with hx HTN, COPD, sz d/o and a large suprasellar
mass/meningioma for which she had apparently refused surgical
removal and w/u currently considering xrt, mass causing
panhypopituitarism, on outpatient hydrocortisone, initially
admitted to the [**Hospital Unit Name 153**] on [**2187-3-18**] with fever and hypotension after
being found unresponsive in bed at [**Location (un) 45045**] NH. She had
apparently
been found unresponsive in bed at [**Location (un) 15383**] Home where she
lives, incontinent of urine, with fever to 104. No seizure
activity had been noted by staff; of note, according to hx
obtained by her PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], she had had viral illness with
nausea and vomiting for days before she came in, and many other
NH residents were also sick with an apparent viral illness. She
was taken to [**Hospital1 18**] ED where temp was 104.8 and SBP was in the
80s
- it transiently increased with IVF then required many boluses
IVF; patient was treated with vanco and flagyl, 4L IVF, LP was
negative with neg cx (though no OP recorded, and only 4cc fluid
sent) and she was transferred to the [**Hospital Unit Name 153**]/[**Hospital Ward Name 516**] for
further
workup of what was thought at the time to be sepsis. Initial
head ct had been negative for new changes or infarcts but showed
stable size of meningioma.
The following morning, she was noted to have L-sided weakness
and the
neurology team was called at 7:30 AM. She was felt to be
confused, slumping to the right, neglecting the left, and with
left sided hemiplegia; sensation reported as intact. Further
workup of septic source for fever/hypotension was negative,
including negative blood cultures, negative TTE, and negative
chest xray/UA. She was intubated for airway protection with
change in MS, later extubated without event on [**3-21**]. CT of the
brain had suggested bilateral watershed infarcts; MRI was
consistent with this finding, though images reviewed by the
stroke consult team suggested right watershed infarcts and tight
RCA, with ?L embolic infarct. Blood pressure has been stable for
24 hours, and she is ready for transfer to the neurology
service.
The patient has no complaints except not being able to move her
left side. Visual loss is also a complaint, but this is chronic
and related to the sellar mass according to her primary care
doctor. He reports that her baseline is "oriented times one,"
with very poor memory, but able to ambulate independently
without
a cane. She apparently has a bed reserved at [**Last Name (un) **] NH when she
has stabilized.
Sepsis workup was negative, including cx and TTE, and imaging
was
found to have R>L infarcts on head ct thought watershed from low
bp, versus embolic on one side. She had imaging with L ICA
occlusion/severe stenosis that was not present on MRI in [**2185**].
She was initially started on Aggrenox and switched to Plavix;
she
is now on plavix, aspirin, a statin, and on an ACE-I as her BP
is
more stable with stress-dose steroids. One possible mechanism
for her stroke (also suggested by PCP) was viral illness with
poor endogenous steroid response related to panhypopit and
resulting functional adrenal crisis. On hydrocortisone she has
done much better and endocrine is following her. She was
continued on
continue current meds from [**Hospital Unit Name 153**]; lytes and dilantin level were
monitored and were within goal range (dilantin level 16.4 on
[**3-23**]), stroke workup was completed including Hba1c of 5.9, FLP
pending.
With dementia and comorbidities, she was felt to be a poor
candidate for surgical correction of carotid stenosis; stent is
one possibility, but as the other carotid is completely
occluded, it might be a risky procedure. She was also felt to
be a he will be a poor coumadin candidate secondary to poor
vision and now a fall risk due to hemiplegia. She was continued
on aspirin and plavix.
PT and OT felt that she might benefit from rehab stay; she was
transferred to rehab at [**Hospital3 537**], where her NP and HCP
[**Name (NI) 11320**] [**Name (NI) 16528**] could continue to follow her.
Medications on Admission:
MEDICATIONS IN HOUSE
Magnesium Sulfate 3 gm / 250 ml D5W IV ONCE Duration: 1 Doses
Phenytoin 100 mg IV Q12H [**3-17**] @ 2054 View
Calcium Gluconate 2 gm / 100 ml D5W IV ONCE Duration: 1 Doses
Insulin SC (per Insulin Flowsheet)
Sliding Scale 04/01 @ 1826 View
Levothyroxine Sodium 37.5 mcg IV DAILY [**3-17**] @ 1826 View
Ipratropium Bromide Neb 1 NEB IH Q6H [**3-17**] @ 1826 View
Albuterol
0.083% Neb Soln 1 NEB IH Q6H [**3-17**] @ 1826 View
Hydrocortisone Na Succ. 50 mg IV Q6H [**3-17**] @ 1826 View
Ceftriaxone 1 gm IV Q24H Start: In am [**3-17**] @ 1826 View
Vancomycin HCl 1000 mg IV Q48H Start: In am
Heparin 5000 UNIT SC TID [**3-17**] @ 1826 View
Pantoprazole 40 mg IV Q24H [**3-17**] @ 1826 View
Aspirin 81 mg PO DAILY [**3-17**] @ 1826 View
Discharge Medications:
1. Hydrocortisone 10 mg Tablet Sig: see below Tablet PO see
below: Taper Hydrocortisone as follows:
-Take 25 mg po q6h (5 tabs) x 2 days, then
-Take 25 mg po q8h (5 tabs) x 2 days, then
-Take 25 mg po bid (5 tabs) x 2 days, then
-Home dose of 20 mg (4 tabs) qAM and 10 mg (2 tabs) qPM
thereafter. Call Endocrinologist if any questions.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
11. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Phenytoin 50 mg Tablet, Chewable Sig: see below Tablet,
Chewable PO twice a day: take 2 tablets (100 mg) qam and 1
tablet (50 mg) qpm for total of 150 mg daily.
13. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous
once a day for 1 days: please give dose on [**3-24**] then D/C
peripheral IV.
14. Rocephin in Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1) Intravenous Q24H (every 24 hours) for 1 days: please give
one dose 4/8 then d/c peripheral IV.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Watershed cerebral infarctions
Hypotension
Fever
Adrenal insufficiency related to panhypopituitarism
Discharge Condition:
Left-sided hemiplegia, right-sided weakness, visual acuity poor
with likely visual field cuts, left-sided hemineglect and
hemisensory changes (diminished pinprick and light touch).
Memory poor (baseline dementia). Stable blood pressure.
Discharge Instructions:
Please [**Name8 (MD) 138**] MD or return to ED if new changes in mental status,
worsened weakness, or any other signs of stroke. If she becomes
hypotensive or sick, consider also calling her endocrinologist
Dr. [**Last Name (STitle) 10759**], as this might indicate an episode of adrenal
insufficiency.
Followup Instructions:
Primary care: Dr. [**Last Name (STitle) **] - please call for appointment once
rehab stay completed.
Neurology: please call office of Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 7394**] for
appointment in 4 weeks.
Endocrinology: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12647**] [**Name (STitle) **]
Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2187-4-24**] 4:00
Completed by:[**2187-3-23**]
ICD9 Codes: 5849, 496, 4019, 4589 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1371
} | Medical Text: Admission Date: [**2147-3-22**] Discharge Date: [**2147-3-24**]
Date of Birth: [**2069-10-4**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 6807**]
Chief Complaint:
Carotid Stenosis
Major Surgical or Invasive Procedure:
Right carotid artery balloon and stenting
History of Present Illness:
Mr. [**Known lastname 6164**] is a 70 yo male with a history of DM2, PVD, HLD, s/p
CVA [**2136**] with residual left-sided weakness, multifactorial gait
disorder, chronic left ICA total stenosis, who presented for
carotid stenting for critical stenosis (>80%) of the right ICA,
enrolled in the CREATE study. There was some discrepancy between
CTA and carotid dupplex regarding severity of stenosis but both
studies referred to it as "high grade". Carotid stenting was
originally planned for yest but canceled due to patient anxiety.
Stenting was done successfully today and pt is coming to the CCU
for hemodynamic monitoring s/p CEA as surgery immediately next
to carotid sinus and concern that might be temporarily affected
post-op.
.
Currently, pt says he feels tired. He states he is just coming
to after his surgery and still isn't completely clear what all
has happened although he knows his carotid was fixed. Pt denies
any current dizziness, lightheadedness, change in vision,
nausea, chest pain, shortness of breath, neck pain, abdominal
pain, lower extremity numbness tingling or pain.
.
On review of systems, s/he denies any prior history bleeding at
the time of surgery, hemoptysis, or red stools. He does report
last bowel movement was yesterday and was black in color. He
denies black stools prior to that and states he has never had an
EGD and has no history of GI bleeding (pt is also on oral iron).
S/he denies recent fevers, chills or rigors. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, -
Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- CVA [**11/2136**] at [**Hospital1 2025**] with mild residual left sided weakness and
STM deficits
- Chronic gait disturbance pre CVA, now worse ? related to
diabetic
neuropathy versus alcohol peripheral neuropathy. Uses walker and
not allowed to navigate stairs.
- Alcohol related peripheral neuropathy
- Prior alcohol abuse with abnormal liver function tests -> had
been off statins as a result
- Current tobacco use
- Depression - flat affect. Not currently on meds
- PVD
- Type 2 Diabetes - managed with diet and oral agents
- Chronic left ICA occlusion
- Hypertrigylceridemia
- Chronic skin ulcer
- Phalanx fracture
- Esophagitis - on Bx. Started on prilosec [**2143-2-14**]
- Hyperplastic Colon polyps - last [**Last Name (un) **] [**2143-2-14**] with 4
hyperplastic polyps with next [**Last Name (un) **] rec [**2148**]
- Anemia (Iron deficient with low transferrin sat 10.2%)
- Mild peripheral edema (thought [**2-8**] to venous insufficiency)
Social History:
He lives a [**Hospital1 **] House [**Hospital3 400**] in [**Hospital1 8**]. He has
never been married and does not have any children. His lawyer is
his health care proxy and is presently out of state. Patient is
able to consent for himself. He uses a walker for his chronic
gait disturbance. His case manager is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6330**] (cell)
[**Telephone/Fax (1) 89497**]; she will accompany him to the procedure. The house
manager is [**Doctor First Name **] [**Telephone/Fax (1) 89498**]. He does have some short term
memory deficits. He has had falls in the past andreports last
fall approximately 6 months ago.
ETOH: none at present. Prior alcohol abuse stopped after his CVA
Tobacco: Current use of [**1-8**] PPD with 10 pack yr hx
HCP: Mr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 89499**] [**Telephone/Fax (1) 89500**]
Contact upon discharge: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6330**]
[**Last Name (NamePattern1) **] Care Services: none
Family History:
Unknown
Physical Exam:
Admission:
VS: T=99.2 BP= 122/61 non-invasive and 123/56 on A-line (outside
baseline 110-120s/60s) HR=83 RR=[**12-24**] O2 sat= 96-98% on 2L NC
GENERAL: elderly male in NAD. Some difficulty with orientation
but answering questions appropriately and mood, affect
appropriate.
HEENT: Tongue midline, pupils equal and reactive, Sclera
anicteric. EOMI but lateral nystagmus. Conjunctiva were pink.
NECK: Supple with JVD barely visible above clavicle.
CARDIAC: RRR, normal S1, S2. [**2-12**] early systolic peaking murmur
best heart at RUSB. No thrills, lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB in
anterior and lateral fields, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, mildly distended. No HSM or tenderness.
EXTREMITIES: A-line in place on L wrist. Small surrounding
bleeding from placement. No c/c/e. Cath site in L groint with
small surrounding bleeding from palcement but no palpable
hematoma and no femoral bruit. Intact sensation bilateral lower
ext. No pain to palp
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 1+
Left: DP 2+ PT 1+
Discharge Exam:
t: 98.4, P: 86, BP: 132/58, RR: 19, 98% on RA
GENERAL: elderly male in NAD. answering questions appropriately
and mood, affect appropriate.
HEENT: Tongue midline, pupils equal and reactive. EOMI but
lateral nystagmus.
NECK: Supple with JVD barely visible above clavicle.
CARDIAC: RRR, normal S1, S2. [**2-12**] early systolic peaking murmur
best heart at RUSB. No thrills, lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB
ant/lat fields
ABDOMEN: Soft, mildly distended. No HSM or tenderness.
Normoactive BS
EXTREMITIES: A-line in place on L wrist. Small surrounding
bleeding from placement. No c/c/e. Cath site in L groint with
small surrounding bleeding from palcement but no palpable
hematoma and no femoral bruit.
PULSES:
Right: DP 2+ PT 1+
Left: DP 2+ PT 1+
Pertinent Results:
Admission Labs ([**2147-3-23**]):
Hct-33.8*
Glucose-156* UreaN-30* Creat-0.9 Na-140 K-4.1 Cl-107
Glucose-135* Lactate-2.4* Na-140 K-3.4* Cl-108
freeCa-1.04*
.
Hct Trend:
[**2147-3-23**] 07:05AM BLOOD Hct-33.8*
[**2147-3-23**] 08:18PM BLOOD Hct-27.7*
[**2147-3-24**] 01:02AM BLOOD Hct-27.1*
[**2147-3-24**] 05:15AM BLOOD WBC-6.3 RBC-2.80* Hgb-9.3* Hct-27.1*
MCV-97 MCH-33.3* MCHC-34.5 RDW-13.5 Plt Ct-219
.
Operative Report:
- Pending
.
Discharge Labs ([**2147-3-24**]):
[**2147-3-24**] 05:15AM BLOOD WBC-6.3 RBC-2.80* Hgb-9.3* Hct-27.1*
MCV-97 MCH-33.3* MCHC-34.5 RDW-13.5 Plt Ct-219
[**2147-3-24**] 05:15AM BLOOD PT-12.3 PTT-24.9 INR(PT)-1.0
[**2147-3-24**] 05:15AM BLOOD Glucose-149* UreaN-21* Creat-0.7 Na-138
K-3.9 Cl-107 HCO3-24 AnGap-11
[**2147-3-24**] 05:15AM BLOOD CK(CPK)-22*
[**2147-3-24**] 05:15AM BLOOD Calcium-8.2* Phos-3.4 Mg-2.1
Brief Hospital Course:
77 yr/o M with DM, PVD, past CVA, and bad carotid disease now
S/p R CEA today being transfered to CCU for hemodynamic
monitoring after surgery near carotid sinus currently with vital
signs stable.
CCU Course:
# Carotid Stenting:
Pt was transfered to the CCU after being extubated post-op from
carotid stenting earlier in the day. Due to fact that R carotid
stent was placed near the carotid body, there was concern that
pt might have labile BP post-op and he was admitted to CCU for
close monitoring and possible nitro or dobutamine drips. At time
of arrival to unit, BP in 110-120s without aid of medications.
Pt not reporting any symptoms and with good peripheral pulses
and good post-angioseal groin exam. Pt monitored on tele
overnight with Q4hr neuro checks. He was continued on ASA/plavix
as well as other home medications. Neurochecks were normal and
mental status stable.
# Hct drop:
Pt with vague report of one dark stool day prior to admission
while on ASA/Plavix. Pt also on oral iron and with no Hx of GI
bleed, no bright red blood, and no past EGD so black stool most
likely [**2-8**] to iron supplements. Baseline Hct in Atrius records
form [**3-17**] showed Hct 38, down to 33 on day of admission and 27
the following afternoon. Hct trended for 24hrs and stayed stable
around 27. Pt should have follow-up Hct check a few days after
discharge.
# Diabetes:
Pt with A1C well controlled at 4.9 on [**Hospital1 **] metformin as outpt.
Metforming held while in hospital in 48hrs post-proceedure. Pt
should restart this medication on Saturday either in hospital if
still here or at [**Hospital1 **] if already discharged.
# Tobacco Use:
Pt still smoking a few cigarettes each day at home, but with no
symptoms or signs of nicotine withdrawal so no nicotine patch
initiated as pt did not think he neeeded this.
Medications on Admission:
clopidogrel [Plavix] 75 mg daily (had been on aggrenox until
recently)
colestipol 5 gram daily
metformin 500 mg [**Hospital1 **] (stopped [**3-21**])
omeprazole 20mg EC daily
aspirin 325 mg daily
iron 325 mg [**Hospital1 **]
colestipol 5gm packets
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. colestipol 5 gram Packet Sig: One (1) PO once a day.
3. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day:
Please restart on [**3-25**].
4. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. iron 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice
a day.
7. Outpatient Lab Work
Please check CBC on [**2147-3-27**]. Please fax results to Dr. [**Last Name (STitle) 60967**] at
[**Telephone/Fax (1) 6808**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
-Bilateral Carotid Artery Stenosis
Secondary:
-Diabetes Mellitus
-Peripheral Vascular 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:
Dear Mr. [**Known lastname 6164**],
It was a pleasure taking part in your care. You were admitted to
the hospital for placement of a stent in your right carotid
artery. You were monitored in the cardiac intensive care unit
after the procedure for close monitoring and you had no
complications.
No changes were made to your medications. It is very important
that you continue take all medications as prescribed,
particularly your aspirin and Plavix to prevent re-stenosis of
the carotid artery.
Followup Instructions:
You will need to follow-up with your cardiologist Dr. [**Last Name (STitle) 33746**]. We
have scheduled the following appointment for you:
[**2147-4-18**]
Carotid ultrasound at 9:30 am
Appointment with Dr. [**Last Name (STitle) 33746**] at 11:30 am
Phone: [**Telephone/Fax (1) 2258**]
[**Location (un) **] Center Office
[**Location (un) 2129**]
[**Location (un) 86**], MA
ICD9 Codes: 4439, 2724, 4019, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1372
} | Medical Text: Admission Date: [**2117-3-21**] Discharge Date: [**2117-4-27**]
Date of Birth: [**2045-2-18**] Sex: M
Service: MEDICINE
Allergies:
Iodine / IV Dye, Iodine Containing Contrast Media
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
radiation to left femur
Femur fracture repair
History of Present Illness:
72 yo M living at nursing facility p/w decline in mental status
during past 8 days, per family, w/ acute worsening between
yesterday and today.
.
Pt was admitted to [**Hospital3 **] on [**2117-3-11**], after 1-2 weeks'
complaint of L sided flank pain, which the patient thought was
secondary to a kidney stone. He was found in the ED to have a
GI bleed, which was thought to be secondary to NSAID use for the
flank pain. Found to have gastroduodenitis w/out ulcer via EGD
there, per report. He required no transfusions. He had a CT
scan that demonstrated moderate to severe central stenosis at
L3-L4, L4-L5,
L5-S1 and mottled appearance of bone, worrisome for MM vs. mets
vs. osteopenia. ? of a multiple myeloma suspicion years ago, per
daughter. Discharged to rehab on [**3-13**]. Patient has been making
non-sensical conversations and today was noted not to recognize
daughter. Apparently patient became unarousable today at rehab
and was rushed to the [**Hospital1 18**] emergency department for further
evaluation.
.
In the ED inital vitals were, 97 82 115/101 18 96%RA.
Labs notable for hypercalcemia and acute kidney injury. Being
treated with IV fluids (NS). Mental status improving. CT head
(negative per ED resident). CT torso (not read yet). Vital signs
on transfer: 138/64 77 15 100%/2L. EEG ordered in ED but not
done yet. Access is 18 and 20.
.
On arrival to the ICU, vitals were: 98.5 82 163/82 13 96%RA.
Patient is alert and oriented x2 (person and month/year). Knew
was in hospital but thought was in [**Hospital1 392**]. Patient with halting
speech. Children around patient and very supportive. Pt denies
urinary incontinence/retention, bowel incontinence, saddle
paresthesia. No fevers, chills per family. No chest pains.
Past Medical History:
-GI bleed: recent admission to [**Hospital1 **]
-Coronary artery disease: per mention of d/c summary. No
history of catheterization or echo in the chart. Apparently MI
3 years ago.
-Vascular insufficiency w/ multiple leg ulcers
-? Multiple myeloma: daughter notes that had a mention of MM
disgnosis [**5-31**] yrs ago, but was not confirmed when pt and
-Hypertension
-Hyperlipidemia
-COPD
-OSH -- on BIPAP at home
-Obesiety
-Diverticulitis
-CHF
-Spinal stenosis
Social History:
Prior to hospitalization, pt used a walker to get around. Able
to do all ADLs including cooking, feeding, cleaning.
- Tobacco: quit smoking 10 yrs ago; 140 pack-year hx
- Alcohol: quit EtOH 23 yrs ago
Pt worked as a substance abuse counselor
Family History:
non-contributory
Physical Exam:
ADMISSION EXAM:
VITALS: 98.5 82 163/82 13 96%RA
General: alert, oriented to person, month and year, states is in
"[**Hospital6 10353**]"
HEENT: Sclera anicteric, MM mildly dry w/ mucous in back of
throat
Neck: supple, JVP not elevated, no LAD, FROM of neck, no
meningismus
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur heard best in RU sternal border
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Back: no midline spinal tenderness
GU: foley in place
Ext: no pedal edema b/l, significant bilateral lower extremity
skin changes consistent with chronic venous insufficiency
Neuro: AOx2, CN II-XII w/out focal abnormality, patient
purposefully moving all four extremities, with 5-/5 strength in
lower extremities.
.
DISCHARGE EXAM:
.
Pertinent Results:
admission labs:
[**2117-3-21**] 06:00PM BLOOD WBC-7.1 RBC-2.92* Hgb-10.0* Hct-29.3*
MCV-100* MCH-34.2* MCHC-34.1 RDW-14.7 Plt Ct-274
[**2117-3-21**] 06:00PM BLOOD Neuts-67.1 Lymphs-24.3 Monos-6.5 Eos-1.7
Baso-0.6
[**2117-3-21**] 06:00PM BLOOD PT-12.2 PTT-28.4 INR(PT)-1.1
[**2117-3-21**] 06:00PM BLOOD Glucose-90 UreaN-69* Creat-3.7* Na-136
K-4.2 Cl-96 HCO3-29 AnGap-15
[**2117-3-21**] 06:00PM BLOOD ALT-9 AST-23 AlkPhos-62 TotBili-0.3
[**2117-3-21**] 06:00PM BLOOD Lipase-61*
[**2117-3-21**] 06:00PM BLOOD CK-MB-5
[**2117-3-21**] 06:00PM BLOOD cTropnT-0.19*
[**2117-3-21**] 11:36PM BLOOD CK-MB-5 cTropnT-0.18*
[**2117-3-21**] 06:00PM BLOOD Albumin-3.6 Calcium-13.3* Phos-7.0*
Mg-2.9*
[**2117-3-21**] 06:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
other pertient labs:
[**2117-3-23**] 02:49AM BLOOD VitB12-218* Folate-5.7
[**2117-4-6**] 09:15PM BLOOD %HbA1c-5.7 eAG-117
[**2117-4-7**] 05:45AM BLOOD Triglyc-144 HDL-35 CHOL/HD-3.8 LDLcalc-68
[**2117-4-6**] 09:15PM BLOOD Ammonia-34
[**2117-3-21**] 06:00PM BLOOD TSH-5.2*
[**2117-3-22**] 03:59AM BLOOD T4-5.1 T3-86 Free T4-1.1
[**2117-3-22**] 02:26AM BLOOD PTH-22
[**2117-3-22**] 02:26AM BLOOD 25VitD-50
[**2117-4-2**] 03:20PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM
HBc-NEGATIVE
[**2117-3-22**] 02:26AM BLOOD PEP-ABNORMAL B IgG-[**2037**]* IgA-27* IgM-6*
IFE-MONOCLONAL
[**2117-4-1**] 05:30AM BLOOD PEP-ABNORMAL B IgG-[**2110**]* IgA-44* IgM-16*
[**2117-3-23**] 02:49AM BLOOD IgG-3481* IgA-48* IgM-12*
[**2117-3-23**] 05:19PM BLOOD b2micro-4.0*
.
FREE KAPPA AND LAMBDA, WITH K/L RATIO
Test Result Reference
Range/Units
FREE KAPPA, SERUM 3290.0 H 3.3-19.4 mg/L
FREE LAMBDA, SERUM 7.1 5.7-26.3 mg/L
FREE KAPPA/LAMBDA RATIO 463.38 H 0.26-1.65
.
PARATHYROID HORMONE RELATED PROTEIN
Test Result Reference
Range/Units
PTH-RP 15 14-27 pg/mL
.
VITAMIN D [**2-17**] DIHYDROXY
Test Result Reference
Range/Units
VITAMIN D, 1,25 (OH)2, TOTAL 24 18-72 pg/mL
VITAMIN D3, 1,25 (OH)2 15
VITAMIN D2, 1,25 (OH)2 9
.
CSF
[**2117-3-31**] 04:16PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-0 Polys-0
Lymphs-74 Monos-26
[**2117-3-31**] 04:16PM CEREBROSPINAL FLUID (CSF) TotProt-38 Glucose-96
LD(LDH)-15
[**2117-3-31**] 04:16PM CEREBROSPINAL FLUID (CSF) CSF-PEP-NO OLIGOCL
NO OLIGOCLONAL BANDING SEEN
STRONG MONOCLONAL BAND IS SEEN IN GAMMA REGION
SAME BAND IS ALSO SEEN IN SERUM PEP
ALTHOUGH THIS IS LIKELY TO REPRESENT NONSPECIFIC
LEAKAGE OF SERUM MONOCLONAL PROTEIN INTO THE CSF
WE CANNOT EXCLUDE THAT THIS REPRESENTS INTRATHECAL SYNTHESIS
[**2117-3-31**] 04:16PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-negative
.
discharge labs:
.....
.
micro:
all blood cultures during admission with no growth
urine cultures x4 with no growth
[**2117-3-31**] 4:16 pm CSF;SPINAL FLUID Source: LP TUBE#3.
GRAM STAIN (Final [**2117-3-31**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2117-4-4**]): NO GROWTH.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
Cdifficile negative x2
.
studies
admission
Normal sinus rhythm. Possible left atrial abnormality.
Non-specific
ST-T wave abnormalities. No previous tracing available for
comparison
.
admission CXR: Cardiomegaly, but no definite acute
cardiopulmonary process.
.
CT head [**3-21**]
No definite acute intracranial process. Lytic lesions throughout
the skull compatible with multiple myeloma.
.
CT torso [**3-21**]
1. Ground-glass opacities in the bilateral lung zones may
reflect
atelectasis, though a developing infectious process, possibly
aspiration,
cannot be excluded.
2. Cardiomegaly.
3. 2.2 cm rounded hypodensity in the lower pole of left kidney
may represent hemorrhagic cyst, however cannot exclude
malignancy. No lymphadenopathy evident. Could be further
evaluated with ultrasound.
3. Extensive rounded peripancreatic calcifications of unclear
etiology may
represent combination of calcified cysts, and adjacent
diverticula or
aneurysms.
4. Diverticulosis without diverticulitis.
5. Lytic lesions throughout the axial skeleton, as well as large
femoral neck luceny, consistent with reported history of
multiple myeloma. Large femoral neck lytic lesion increases risk
of pathologic fracture.
6. 8 mm heavily calcified outpouching of the aortic arch likely
represents
stable pseudoaneurysm.
.
ECHO [**3-22**]
The left atrium is moderately dilated. 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. Left
ventricular systolic function is hyperdynamic (EF>75%). There is
no ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is severe
mitral annular calcification. Trivial mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. The
pulmonary artery systolic pressure could not be determined. The
pulmonic valve leaflets are thickened. There is no pericardial
effusion.
.
Femur AP and lateral
1) High suspicion for a new femoral neck fracture, new since
[**2117-3-21**] torso CT. This is likely a pathologic fx through the
lytic lesion in the proximal femoral neck seen on that torso CT.
2) Large lytic lesion in proximal femoral diaphysis, with
endosteal
scalloping, at increased risk for fx.
.
Hip Xray
Essentially a single view of the left hip was obtained. Detail
is
considerably limited by overlying soft tissues. There is
accentuated varus
angulation of the intertrochanteric proximal left femur,
consistent with a
left basicervical fracture. This is new compared with a torso CT
obtained on [**2117-3-21**].
.
MRI head without contrast
Motion limited study. No definite acute infarct identified.
Brain atrophy and small vessel disease seen. Chronic infarcts in
the
brainstem and right thalamus are identified.
.
routine EEG [**3-30**]
This is an abnormal EEG because of mild to moderate diffuse
background slowing and focal epileptiform discharges in the
right
temporal region. These findings are indicative of a mild to
moderate
diffuse encephalopathy with focal area of epileptogenic
potential in the
right temporal region.
.
CT head without contrast [**4-6**]
No CT evidence for acute intracranial process, though MR would
be
more sensitive for acute infact, particularly given the
extensive background abnormality.
.
CXR [**4-6**]
As compared to the previous radiograph, the esophageal catheter
has
been removed. There is a minimal left pleural effusion.
Unchanged low lung
volumes with persistent mild pulmonary edema. The signs
suggesting previous interstitial edema have improved. There is
no evidence of current pneumonia.
.
ECHO [**4-7**]
The left atrium is elongated. No atrial septal defect (ASD) or
patent foramen ovale (PFO) is seen by 2D, color Doppler or
saline contrast with maneuvers. The estimated right atrial
pressure is 0-5 mmHg. There is mild symmetric left ventricular
hypertrophy (LVH) with normal cavity size. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The left ventricular inflow pattern suggests
impaired relaxation. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Overall, normal
biventricular systolic function. However, due to technical
difficulties, a focal wall motion abnormality cannot be fully
excluded. Mild LVH. Mildly dilated ascending aorta. No ASD or
PFO seen by 2D, color Doppler or saline contrast with maneuvers.
No significant valvular stenosis or regurgitation. Borderline
pulmonary hypertension.
.
CXR [**4-8**]
Mild-to-moderate pulmonary edema is new, and basal opacification
is first
attributable to dependent edema before considering concurrent
pneumonia.
Heart size top normal, unchanged. Small pleural effusions are
presumed. No
pneumothorax. A vascular line ends in the left axilla before
entering the
chest.
.
24 hour EEG [**4-9**]
This telemetry captured no pushbutton activations. The
background was mildly slow throughout suggesting an
encephalopathy.
There was minimal left temporal slowing. There were no clearly
epileptiform features or electrographic seizures.
.
LUE ultrasound [**4-10**]
Thrombosis along the venous catheter within the left cephalic
vein. No thrombosis within the deep veins of the left upper
extremity.
.
-------------
[**2117-4-18**] 07:20AM BLOOD WBC-5.3# RBC-3.07* Hgb-9.6* Hct-30.9*
MCV-101* MCH-31.3 MCHC-31.1 RDW-18.1* Plt Ct-243
[**2117-4-19**] 08:50AM BLOOD WBC-5.3 RBC-3.15* Hgb-10.1* Hct-32.3*
MCV-103* MCH-32.2* MCHC-31.4 RDW-18.4* Plt Ct-256
[**2117-4-20**] 05:50AM BLOOD WBC-6.3 RBC-2.98* Hgb-9.5* Hct-31.0*
MCV-104* MCH-31.9 MCHC-30.6* RDW-18.7* Plt Ct-217
[**2117-4-21**] 06:20AM BLOOD WBC-5.4 RBC-2.83* Hgb-9.0* Hct-29.8*
MCV-105* MCH-31.9 MCHC-30.3* RDW-18.8* Plt Ct-172
[**2117-4-21**] 04:57PM BLOOD WBC-10.8# RBC-2.50* Hgb-8.3* Hct-25.8*
MCV-103* MCH-33.4* MCHC-32.4 RDW-18.7* Plt Ct-183
[**2117-4-21**] 08:45PM BLOOD WBC-11.7* RBC-2.57* Hgb-8.3* Hct-26.7*
MCV-104* MCH-32.2* MCHC-31.0 RDW-18.8* Plt Ct-171
[**2117-4-22**] 06:30AM BLOOD WBC-7.5 RBC-2.32* Hgb-7.7* Hct-23.9*
MCV-103* MCH-33.2* MCHC-32.2 RDW-19.1* Plt Ct-135*
[**2117-4-23**] 07:10AM BLOOD WBC-5.4 RBC-2.34* Hgb-7.7* Hct-24.0*
MCV-102* MCH-32.7* MCHC-32.0 RDW-19.9* Plt Ct-120*
[**2117-4-23**] 08:10PM BLOOD Hct-27.2*
[**2117-4-24**] 08:37AM BLOOD WBC-6.8 RBC-2.83* Hgb-9.5* Hct-27.8*
MCV-99* MCH-33.5* MCHC-34.0 RDW-20.0* Plt Ct-133*
[**2117-4-24**] 05:45PM BLOOD Hct-28.9*
[**2117-4-24**] 05:45PM BLOOD Hct-28.9*
[**2117-4-25**] 07:35AM BLOOD WBC-6.5 RBC-3.13* Hgb-10.0* Hct-31.2*
MCV-100* MCH-32.0 MCHC-32.0 RDW-19.4* Plt Ct-154
[**2117-4-26**] 07:00AM BLOOD WBC-6.5 RBC-3.04* Hgb-9.8* Hct-30.7*
MCV-101* MCH-32.3* MCHC-32.0 RDW-19.0* Plt Ct-191
[**2117-4-22**] 06:30AM BLOOD Glucose-90 UreaN-31* Creat-0.9 Na-137
K-4.5 Cl-105 HCO3-25 AnGap-12
[**2117-4-23**] 07:10AM BLOOD Glucose-90 UreaN-32* Creat-0.9 Na-140
K-4.4 Cl-108 HCO3-26 AnGap-10
[**2117-4-24**] 08:37AM BLOOD Glucose-88 UreaN-24* Creat-0.7 Na-140
K-4.2 Cl-107 HCO3-26 AnGap-11
[**2117-4-25**] 07:35AM BLOOD Glucose-91 UreaN-20 Creat-0.7 Na-141
K-4.5 Cl-107 HCO3-28 AnGap-11
[**2117-4-26**] 07:00AM BLOOD Glucose-80 UreaN-20 Creat-0.8 Na-141
K-5.1 Cl-107 HCO3-27 AnGap-12
[**2117-4-25**] 07:35AM BLOOD ALT-23 AST-13 LD(LDH)-173 AlkPhos-80
TotBili-0.5
[**2117-3-23**] 02:49AM BLOOD VitB12-218* Folate-5.7
[**2117-4-6**] 09:15PM BLOOD %HbA1c-5.7 eAG-117
[**2117-4-7**] 05:45AM BLOOD Triglyc-144 HDL-35 CHOL/HD-3.8 LDLcalc-68
[**2117-3-21**] 06:00PM BLOOD TSH-5.2*
[**2117-3-22**] 03:59AM BLOOD T4-5.1 T3-86 Free T4-1.1
[**2117-3-22**] 02:26AM BLOOD PEP-ABNORMAL B IgG-[**2037**]* IgA-27* IgM-6*
IFE-MONOCLONAL
[**2117-3-23**] 02:49AM BLOOD IgG-3481* IgA-48* IgM-12*
[**2117-4-1**] 05:30AM BLOOD PEP-ABNORMAL B IgG-[**2110**]* IgA-44* IgM-16*
[**2117-4-20**] 05:50AM BLOOD PEP-ABNORMAL B
[**2117-3-23**] 02:49AM BLOOD FREE KAPPA AND LAMBDA, WITH K/L
RATIO-Test
[**2117-4-20**] 05:50AM BLOOD FREE KAPPA AND LAMBDA, WITH K/L
RATIO-Test
Brief Hospital Course:
BRIEF HOSPITAL COURSE: Patient is a 72M with a PMH significant
for coronary artery disease, peripheral vascular disease, HTN,
hyperlipidemia with question of prior MGUS or smoldering myeloma
diagnosis who now presented with altered mental status found to
have severe hypercalcemia of malignancy, diffuse lytic lesions
on imaging and monoclonal immunoglobulin spike on protein
electrophoresis in the setting of acute renal insufficiency
concerning for multiple myeloma. His mental status gradually
improved with treatment of hypercalcemia in the ICU and he was
tranferred to the floor. His course of the floor was complicated
by an episode of acute altered mental status thought to be due
to seizure and he was started on keppra. He started treatment
for his multiple myeloma with good response in his SPEP and IgG
Kappa labs and ultimately decided to undergo surgery to
stabilize his femur fracture on [**4-21**] which was complicated only
by some mild post-operative anemia requiring 4 units of pRBCs
over 3 days. At discharge, his HCT was stable. He is due for
his second cycle of chemotherapy on [**4-30**] of
velcaide/dexamethasone.
# HYPERCALCEMIA OF MALIGNANCY, [**2-25**] MULTIPLE MYELOMA ?????? Patient's
calcium on admission in the 13 range, which downtrended to
normal. Appeared intravascularly depleted on admission and
sustained aggressive volume resuscitation with improvement in
metabolic derangements. Diagnosis most consistent with
hypercalcemia in the setting of myeloma given lytic lesions,
monoclonal Ig spike and renal insufficiency. Responded well to
ECV repletion with IV fluids, IV bisphosphonate therapy and
calcitonin SC. Calcitonin was discontinued and calcium remained
within normal range up to discharge.
# ALTERED MENTAL STATUS ?????? Likely multifactorial toxic or
metabolic encephalopathy based on exam and clinical appearance
on admission. Attempted IV naloxone infusion given opioid use
and renal insufficiency which provided a quick response
initially but did not clear the delirium. Infectious work-up was
negative. TSH and TFTs reassuring. CT head without acute
intracranial process, only skull lytic lesions. MRI also did not
show acute process and LP did not show signs of infection.
Overall mental status improved with hydration and improvement in
electrolyte imbalances. On [**4-6**] patient had episode of acute
altered mental status. Code stroke was called. CT head without
contrast did not show evidence of bleed. Patient declined repeat
MRI. Episode thought to be most likely [**2-25**] to seizure. 24 hr EEG
did not show any epileptiform featurs or electrographic
seizures, however per neuro the decision was made to continue to
treat with keppra 750 mg by mouth [**Hospital1 **]. He was also continued on
ASA and statin. He has plans to follow up with neurology after
discharge.
# Multiple myeloma: Patient started treatment with velcaid on
[**4-9**] and dexamethasone was added on [**4-13**]. Heme path reviewed CSF
which had no evidence of plasma cells. Patient underwent
palliative XRT of lytic lesion in femur on [**4-12**]. Tolerated
cycle 1 well without complication. IgG Kappa and SPEP showed
good response to chemotherapy. Due for second cycle of
velcaide/dex [**4-30**]. Outpatient oncologist will be Dr [**First Name8 (NamePattern2) 85290**]
[**Last Name (NamePattern1) **].
# Left Femoral fracture: Patient found to have pathologic left
femur fracture. Initially the decision was made to hold off on
surgery given altered mental status. However, patient clinically
improved. He underwent palliative XRT of a lytic lesion in his
femur. He then underwent orthopedic surgery on [**4-21**] for repair
and tolerated this well, only complicated by mild anemia
post-operatively requiring 4 units pRBC over 3 days. He will
require extensive physical therapy both for his femur repair as
well as his overall deconditioning (bedbound for ~34 days). He
will follow up with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4223**] of orthopedics.
# ACUTE RENAL INSUFFICIENCY ?????? Creatinine on presentation in the
3.7 range with response to hydration. Secondary to hypovolemia.
Creatinine returned to baseline and remained stable through
duration of admission.
# Fever - patient spiked fever to 101.7 on [**4-8**]. pancultured.
started vanc and zosyn for concern of possible aspiration
pneumonia however CXR concerning for volume overload. UA
negative. Stage 1 decub without evidence of infection. Had RUE
ultrasound which showed clot around the midline in left cephalic
vein which may have caused fever. Line was removed. Abx dc'd on
[**4-12**] and patient continued to remain afebrile.
# CORONARY ARTERY DISEASE, CHF HISTORY ?????? Presented with severe
volume depletion, but no evidence of coronary ischemia. Cardiac
biomarkers elevated slightly in the setting of renal
insufficiency with flat CK-MB. No prior catheterization reports
available. 2D-Echo this admission showing hyperynamic LVEF with
only severe MV annular calcification and no significant valvular
disease. EKG reassuring on admission. ACE/[**Last Name (un) **] held in the
setting of initial renal insufficiency. He was continued on beta
blocker, statin, aspirin, and imdur.
# COPD ?????? Stable. Continued nebs prn.
# OSA - Continued home bipap.
[**Date range (1) 92436**] ICU course:
Patient was admitted with respiratory distress. He was placed on
CPAP and suctioned with removal of large mucous plugs. He was
taken off of narcotics and given IV tylenol. He had good oxygen
saturations on room air at time of discharge from the ICU.
Transitional Issues
- if platelets drop below 50 with active bleeding, or if
platelets drop below 30 without bleeding, please discontinue
lovenox and aspirin
- last day lovenox [**5-12**] for dvt ppx after orthopedic procedure
- follow-up with new providers: [**Doctor Last Name **] for Heme/onc,
[**Location (un) 4223**] for orthopedics, [**Doctor Last Name 1206**]/[**Doctor Last Name **] Haerents for neurology.
- cycle 2 of chemotherapy on [**4-30**]:
Chemotherapy Regimen
?????? Bortezomib 2.9 mg IV Days 1, 4, 8 and 11. (1.3 mg/m2)
Supportive Hydration
?????? Dexamethasone 20 mg PO ASDIR Please give the day before and
day after velcade. Specifically days 1,2,4,5,8,9,11,12
?????? If this patient has central venous access, flush per hospital
policy.
PLEASE SPEAK WITH DR [**Last Name (STitle) **] AT ([**Telephone/Fax (1) 3936**] PRIOR TO
ADMINISTRATION
Medications on Admission:
Metoprolol XL 50 mg PO OD
Imdur 60 mg PO OD
Zocor 40 mg PO OD
MVI 1 tab PO OD
Protonix PO 40 mg [**Hospital1 **]
Flexeril 10 mg TID PRN Muscle spasm (d/c [**3-15**])
Oxycodone 5 mg PO Q 4 hr PRN PAin (recent d/c)
tylenol 650 mg PO q 4 hr PRN fever
Furosemide 40 mg PO OD
spiriva
proair
Discharge Medications:
1. acetaminophen 500 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO TID (3
times a day).
2. docusate sodium 100 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO BID (2
times a day).
3. aspirin 81 mg Tablet, Chewable [**Month/Year (2) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
4. sulfamethoxazole-trimethoprim 400-80 mg Tablet [**Month/Year (2) **]: One (1)
Tablet PO DAILY (Daily).
5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Month/Year (2) **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
6. Toprol XL 50 mg Tablet Extended Release 24 hr [**Month/Year (2) **]: One (1)
Tablet Extended Release 24 hr PO once a day.
7. levetiracetam 750 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2
times a day).
8. simvastatin 40 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
9. cholecalciferol (vitamin D3) 400 unit Tablet [**Month/Year (2) **]: Two (2)
Tablet PO DAILY (Daily).
10. acyclovir 400 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q8H (every 8
hours).
11. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
12. Imdur 60 mg Tablet Extended Release 24 hr [**Last Name (STitle) **]: One (1)
Tablet Extended Release 24 hr PO once a day.
13. enoxaparin 30 mg/0.3 mL Syringe [**Last Name (STitle) **]: One (1) syringe
Subcutaneous Q12H (every 12 hours) for 3 weeks: last day [**5-12**].
14. multivitamin Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY
(Daily).
15. senna 8.6 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
16. oxycodone 5 mg Tablet [**Month/Year (2) **]: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
17. pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] hospital for continuing medical care [**Hospital1 **]
Discharge Diagnosis:
Toxic metabolic encephalopathy
Hypercalcemia
Multiple myeloma
Pathologic left femur fracture s/p repair
Anemia
Acute kidney injury
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:
It was a pleasure taking care of you at [**Hospital1 18**].
You were admitted with altered mental status from high calcium.
As part of the workup for the high calcium, we discovered that
you had a cancer known as multiple myeloma. You underwent
chemotherapy and radiation to your leg. You also underwent
surgery for your left thigh fracture, which was repaired.
You will need extensive physical therapy and close oncology
follow-up after discharge.
Medication changes:
START
Tylenol 1g three times per day as needed for pain
Oxycodone 2.5-5mg every four hours as needed for pain
Colace 100mg twice per day
Senna 1-2 tabs as needed twice per day for constipation
Bactrim SS (400/80) 1 tab once per day
Lidocaine patch to area of pain twelve hours on, twelve hours
off
Keppra 750mg twice per day
Vitamin D 400mg once per day
Acyclovir 400mg every 8 hours
Lovenox 30mg syringe subcutaneously twice per day for 3 weeks
after orthopedic procedure (last day [**5-12**])
Senna 1-2 tabs twice per day as needed for constipation
STOP
Flexeril
Lasix
Spiriva
Otherwise take all medications as prescribed.
If your platelet count falls below 50 with bleeding, or below 30
without bleeding, please discontinue aspirin and lovenox.
Followup Instructions:
Department: HEMATOLOGY/BMT
When: THURSDAY [**2117-5-6**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3238**], MD [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: MONDAY [**2117-5-17**] at 9:15 AM
With: [**First Name11 (Name Pattern1) 4224**] [**Last Name (NamePattern4) 4225**], MD [**Telephone/Fax (1) 1228**]
Building: [**Hospital6 29**] [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **],[**First Name3 (LF) 92437**] R.
Address: 21 [**Doctor Last Name **] HWY [**Apartment Address(1) 24578**], [**Hospital1 **],[**Numeric Identifier 20089**]
Phone: [**Telephone/Fax (1) 9489**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2117-5-6**] at 2:30 PM
With: DR. [**First Name8 (NamePattern2) 610**] [**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
Department: NEUROLOGY
When: FRIDAY [**2117-5-14**] at 2:30 PM
With: DRS. [**Name5 (PTitle) **]/[**Doctor Last Name **] HAERENTS [**Telephone/Fax (1) 44**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 5849, 2851, 4019, 2724, 496, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1373
} | Medical Text: Admission Date: [**2139-8-31**] Discharge Date: [**2139-9-14**]
Date of Birth: [**2061-10-18**] Sex: F
Service: SURGERY
Allergies:
Latex / Benadryl / Statins-Hmg-Coa Reductase Inhibitors / Avapro
/ Beta-Blockers (Beta-Adrenergic Blocking Agts) / clonidine /
metoprolol / Diovan / Adhesive / Ultram / diltiazem / aspirin
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
asymptomatic right carotid stenosis
Major Surgical or Invasive Procedure:
Right carotid endartarectomy
History of Present Illness:
[**Known firstname **] [**Known lastname **] is a 77-year-old who saw Dr. [**Last Name (STitle) **] in consult
for carotid stenosis. She was having some vertigo and
potentially three years ago had some
left-hand weakness. She underwent carotid studies which showed
greater than 80% right carotid stenosis, and is considered
asymptomatic, despite the possibility of TIAs three years ago.
The patient was started on a full strength aspirin as an
outpatient and scheduled for elective right carotid
endartarectomy which she had done on [**2139-8-31**].
Past Medical History:
diastolic CHF (preserved EF)
HTN
GERD
OA
knee replacements
Social History:
married, remote smoking history, no current substance use
Family History:
daughter with hypothyroidism
Physical Exam:
98.6, 98.6, 63, 129/53, 20, 98 RA
CN II-XII intact, slight left facial droop stable and present
prior to admission
CTA BL
RRR
Neuro exam - [**6-4**] power throughout, sensation intact
Right nec incision - clean, dry, intact, healing well
Pertinent Results:
[**2139-9-1**] 02:00PM BLOOD WBC-18.3* RBC-3.42* Hgb-11.0* Hct-30.0*
MCV-88 MCH-32.3* MCHC-36.8* RDW-13.7 Plt Ct-272
[**2139-9-14**] 03:25AM BLOOD WBC-11.0 RBC-2.87* Hgb-9.3* Hct-26.4*
MCV-92 MCH-32.5* MCHC-35.3* RDW-12.6 Plt Ct-222
[**2139-9-1**] 04:06AM BLOOD Glucose-173* UreaN-29* Creat-1.4* Na-134
K-2.9* Cl-97 HCO3-26 AnGap-14
[**2139-9-3**] 02:07AM BLOOD Glucose-109* UreaN-47* Creat-2.6* Na-137
K-3.4 Cl-96 HCO3-28 AnGap-16
[**2139-9-3**] 12:05PM BLOOD Na-138 K-3.1* Cl-97
[**2139-9-4**] 05:03AM BLOOD Glucose-94 UreaN-51* Creat-2.3* Na-141
K-4.1 Cl-101 HCO3-29 AnGap-15
[**2139-9-4**] 02:03PM BLOOD Na-139 K-4.6 Cl-102
[**2139-9-5**] 01:54AM BLOOD Glucose-138* UreaN-66* Creat-2.2* Na-141
K-4.2 Cl-100 HCO3-30 AnGap-15
[**2139-9-5**] 02:33PM BLOOD UreaN-73* Creat-2.3* Na-139 K-4.1 Cl-96
[**2139-9-6**] 03:24AM BLOOD Glucose-129* UreaN-86* Creat-2.3* Na-141
K-3.9 Cl-97 HCO3-30 AnGap-18
[**2139-9-7**] 01:02AM BLOOD Glucose-117* UreaN-100* Creat-2.7* Na-141
K-4.6 Cl-95* HCO3-31 AnGap-20
[**2139-9-8**] 02:21AM BLOOD Glucose-104* UreaN-116* Creat-2.9*
Na-147* K-3.1* Cl-101 HCO3-31 AnGap-18
[**2139-9-8**] 03:21PM BLOOD Na-147* K-3.5 Cl-105
[**2139-9-9**] 02:10AM BLOOD Glucose-115* UreaN-107* Creat-2.4* Na-144
K-4.4 Cl-108 HCO3-25 AnGap-15
[**2139-9-9**] 04:28PM BLOOD Glucose-113* UreaN-104* Creat-2.2*
Na-149* K-3.6 Cl-115* HCO3-22 AnGap-16
[**2139-9-10**] 12:18AM BLOOD Glucose-127* UreaN-102* Creat-2.1*
Na-152* K-3.2* Cl-117* HCO3-21* AnGap-17
[**2139-9-10**] 07:58PM BLOOD Glucose-160* UreaN-83* Creat-1.8* Na-148*
K-3.2* Cl-120* HCO3-17* AnGap-14
[**2139-9-11**] 03:48AM BLOOD Glucose-121* UreaN-80* Creat-1.8* Na-148*
K-3.8 Cl-119* HCO3-19* AnGap-14
[**2139-9-13**] 06:20AM BLOOD Glucose-93 UreaN-49* Creat-1.7* Na-143
K-3.6 Cl-115* HCO3-20* AnGap-12
[**2139-9-14**] 03:25AM BLOOD Glucose-91 UreaN-42* Creat-1.7* Na-141
K-3.4 Cl-111* HCO3-19* AnGap-14
[**2139-9-2**] Echocardiogram
The left atrium is normal in size. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Tissue Doppler imaging suggests
an increased left ventricular filling pressure (PCWP>18mmHg).
Doppler parameters are most consistent with Grade II (moderate)
left ventricular diastolic dysfunction. Right ventricular
chamber size and free wall motion are normal. The number of
aortic valve leaflets cannot be determined. The aortic valve
leaflets are moderately thickened. There is no aortic valve
stenosis. Moderate (2+) aortic regurgitation is seen. The mitral
valve leaflets are moderately thickened. There is severe mitral
annular calcification. Trivial mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
IMPRESSION: Preserved [**Hospital1 **]-ventricular systloic function.
Diastolic dysfunction with an estimated PCWP > 18 mmHg.
Moderated aortic regurgitation. Moderate tricuspid
regurgitation. Borderline pulmonary artery hypertension.
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2139-9-8**]
11:04 AM
[**Hospital 93**] MEDICAL CONDITION:
77 year old woman s/p CEA and non-focal mental depression
REASON FOR THIS EXAMINATION:
Altered mental status
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: NPw TUE [**2139-9-8**] 6:07 PM
1. Scattered focal hypodensities likely indicating small vessel
ischemic
disease. Age is indeterminate; attention on followup is advised.
Consider MR
if clinically indicated and if there are no contraindications.
2. No evidence of hemorrhage, edema, masses, mass effect, or
infarction.
3. The ventricles are mildly enlarged and the sulci are grossly
normal in
caliber and configuration. Ventricular enlargement is likely
secondary to
normal age-related volume loss.
Final Report
INDICATION FOR STUDY: Status post endarterectomy, depression,
and altered
mental status. Study is to evaluate for possible structural or
mass defects.
COMPARISON EXAM: There are no comparisons available.
TECHNIQUE: Multidetector CT-acquired axial images from the
vertex to the
level of C1 without contrast displayed with 5-mm slice
thickness.
CT HEAD WITHOUT CONTRAST: There are scattered focal
hypodensities of
indeterminate age, most likely secondary to small vessel
ischemic changes;
attention to this finding on followup is advised. Consider MR
study if
clinically indicated and if there are no contraindications.
These scattered hypodensities follow no vascular distribution
and are
predominantly seen in the cortex. (in image 2a:8, image 2a:6 in
the right and left inferior temporal lobes, and in 2A:12 in the
anterior portion of the left lateral ventricle.) There are
vascular calcifications seen in multiple locations- these are
best seen in images 2a:12, 2a:9, and 2a:6. There is no evidence
of hemorrhage, edema, mass effect, or major infarction. The
ventricles are mildly enlarged secondary to normal age-related
volume loss; the sulci are grossly normal in caliber and
configuration.
IMPRESSION:
1. Scattered focal hypodensities of indeterminate age, likely
indicating
small vessel ischemic disease; attention on followup is advised.
MR can be
considered if clinically indicated and there are no
contraindications for
assessment of acute infarction.
2. No evidence of hemorrhage or mass effect.
Note Date: [**2139-9-11**]
Signed by [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2139-9-11**] at 5:51 pm Affiliation:
[**Hospital1 18**]
BEDSIDE SWALLOWING EVALUATION:
HISTORY:
Thank you for referring this 77 year old woman admitted on
[**2139-8-31**]
for planned R CEA in setting of greater than 80% right internal
carotid artery stenosis. On POD #1, was tolerating clears [**Name8 (MD) **]
RN
notes. Code blue was called for respiratory distress and
pulmonary edema with hematoma at surgical site. Pt intubated on
[**9-1**], extubated [**9-3**], and reintubated due to intolerance
associated
with stridor, wheezing, and respiratory distress. Extubated
again on [**2139-9-7**]. When pt with persistent altered mental status,
she was ordered for head CT on [**9-8**]. Results indicated scattered
focal hypodensities of indeterminate age, likely indicating
small
vessel ischemic disease, but no evidence of hemorrhage or mass
effect. RN notes from ICU indicate pt with slurred speech, weak
grasp, tongue deviating toward R and anterior spill of thin
liquids. Given negative head CT, it was felt mental status was
associated with uremic etiology. On [**9-9**], NGT was placed and
advanced post-pyloric. On [**9-10**], RN notes indicate pt tolerating
clear liquids. Most recent CXR on [**9-10**] states "Small left
pleural effusion, otherwise clear lungs with stable
cardiomegaly." WBC counts have fluctuated. Today we were
consulted to evaluate oral and pharyngeal swallow function to
promote advancing to regular diet. [**Name6 (MD) **] today's RN, tolerating
clears, purees, and meds.
EVALUATION:
The examination was performed while the patient was seated
upright in the chair on the VICU.
Cognition, language, speech, voice:
Pt awake, oriented to name, [**Hospital1 **], and month, correctly named date
when cued to look at the calendar, responded "19..." when asked
the year, responded no to [**2133**], [**2139**], and [**2148**]. Expressive
language was grossly fluent, utterances intermittently off-topic
and confused, speech was intelligible, voice moderately hoarse
and breathy.
Teeth: Full upper dentures and lower partial in place.
Secretions: Normal oral secretions.
ORAL MOTOR EXAM:
Mild left facial droop appreciated - daughter states multiple
times that this is baseline from a few years ago. Tongue
protruded midline with mildly reduced strength, adequate ROM.
Symmetrical palatal elevation noted. Gag deferred.
SWALLOWING ASSESSMENT:
PO trials included ice chips, thin liquid (tsp, cup, straw,
consecutive), puree, and bites of saltine cracker. Oral phase
grossly WFL without anterior spill or oral residue. Swallow
initiation was timely with adequate laryngeal elevation on
palpation. No coughing, throat clearing, wet vocal quality, or
O2
desats with POs.
SUMMARY / IMPRESSION:
Ms. [**Known lastname **] presented with a grossly functional swallowing
mechanism without overt s/sx of aspiration. Recommend she remain
on PO diet of thin liquids and regular consistency solids with
assistance with meal set up and feeding as needed. Please call,
page, or re-consult if there are further concerns.
This swallowing pattern correlates to a Functional Oral Intake
Scale (FOIS) rating of 7.
RECOMMENDATIONS:
1. PO diet: thin liquids, regular consistency solids.
2. Meds whole with water as tolerated.
3. [**Hospital1 **] oral care.
4. Assistance with meal set up and feeding as needed.
5. Please call, page, or re-consult if there are further
concerns.
____________________________________
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 39767**], M.S., CCC-SLP
Brief Hospital Course:
77F who was admitted on [**2139-8-31**] and had a right carotid
endarterectomy with bovine
pericardial patch angioplasty. She received 1500 cc of fluid
during the case and had an EBL of 200 cc. At postoperative
check, the patient was doing well, complaining of some
increasing phlegm production, but neuro intact and stable. She
was breathing 15 times a minute with an O2 sat of 100% on 3L NC.
She was requiring a nitro gtt and intermittent hydralazine to
keep her blood pressures in the desired range of 100-140.
Overnight she had some tachypnea and scattered wheezes, which
improved after a nebulizer treatment and she maintained her sats
on low nasal cannula. Her neck incision did slowly ooze blood,
requiring a few dressing changes but there was no airway
compression or rapidly expanding hematoma.
On [**9-1**], POD #1, the patient continued to have some increased
work of breathing,decreased urine output, CXR showed some fluid
overload and she was given lasix 80mg IV and put out about 100
cc of urine hourly throughout the day. She maintained her sats
in the mid 90's throughout the day on 2-3L NC. At 9pm, her work
of breathing continued to increase with RR 30-35, sats mid 90's,
an additional 40mg of lasix was given, without much improvement
in her respiratory status. A nonrebreather was placed and the
patient continued to breath 30-42 times a minute satting 90-98%.
Her neck incision continued to appear intact, with no pulsatile
mass or firmness.
The patient was transferred to the ICU and intubated for
flash pulmonary edema. BNP was increased to 13,000, she also had
a troponin leak to peak of .72. Atrius cardiology followed the
patient during her stay and felt that she was having demand
ischemia secondary to the fluid overload and diastolic heart
failure and did not feel she was having an MI. She had ongoing
labile blood pressures requiring treatment. Her creatinine
trended up to the 2.6-3.0 range with adequate urine output and
nephrology was consulted. They felt as if she had acute kidney
injury in the setting of hemodynamic instability and acute
tubular necrosis. They followed her care and her creatinine
trended down but has not yet reached her baseline.
On [**9-3**], POD#3, she had a low grade fever and her CXR showed
concern for possible RLL infiltrate and she was started on
vancomycin/cefepime to empirically treat for VAP. She was
extubated and required reintubation after 2 hours for tachypnea,
hypertension, respiratory distress. On [**9-4**], POD#4 it was decided
to start a three day course of methylprednisolone for upper
airway edema secondary to multiple attempts at
intubation/extubation. She rested on the ventilator over the
weekend during this steroid course and we continued diuresis,
monitoring her creatinine. She did develop a metabolic alkalosis
and hypokalemia which were treated. Her blood pressure
throughout her hospital stay was difficult to control and she
required standing metoprolol, hydralazine, addition of PO
agents, and intermittent IV hydralazine/metoprolol at times.
The patient completed her steroid course and was extubated on
[**9-7**], and there was a question of heme-tinged output from her
OGT, protonix was added. Lavage was negative, EGD was not
required. She remained in the ICU on [**2139-9-8**] and [**2139-9-9**]. Diamox
was used for ongoing diuresis, bicarb and creatinine were
monitored with a goal of [**1-31**].5 L negative daily. After
extubation she was slow to improve her mental status with an
elevated BUN/Cr, and a head CT was performed which was grossly
negative for an acute process. As her lab values normalized, and
with her family at bedside, her mental status did improve
gradually. The patient was transferred out of the ICU on [**9-10**].
She was given one day of trophic TF through a dophoff tube and
then passed a bedside swallow test on [**9-11**]. The dophoff was
discontinued and her diet was advanced. Her labs continued to
trend down, she tolerated a regular diet, and her blood
pressures were better controlled on her new regimen. Her mental
status improved significantly and she is now interactive and
appropriate. She had some loose stools over the weekend and a
c.diff was sent which was negative. She was out of bed and did
well with PT who recommended discharge to home. We felt as if
she would benefit from home PT as she strengthens.
Her discharge plan involves BP monitoring on a new regimen,
and close follow up to alter that regimen as necessary.
Additionally, she will finish her 2 week course of IV
antibiotics for ventilator acquired pneumonia. She will also
benefit from some home physical therapy. She will follow up with
Dr. [**Last Name (STitle) **] in 1 week and her primary physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] for
hospital follow up/BP control. She should also follow up with
her cardiologist Dr. [**First Name (STitle) **] [**Name (STitle) 33746**] at the [**Location (un) 38**] Center.
Medications on Admission:
omeprazole 20', losartan 100', hctz 25'', fluticasone 50'',
albuterol prn, asa 325, iron,
Discharge Medications:
1. fluticasone 110 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation [**Hospital1 **] (2 times a day).
2. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Six
(6) Puff Inhalation Q4H (every 4 hours).
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
4. vancomycin 750 mg Recon Soln Sig: One (1) Intravenous q48
for 3 doses.
Disp:*qs * Refills:*0*
5. cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q24H (every 24 hours) for 3 doses.
Disp:*3 Recon Soln(s)* Refills:*0*
6. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
7. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
9. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
11. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. iron 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once
a day.
13. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
-Status post right carotid endartarectomy with subsequent volume
overload requiring intubation, diuresis.
-Hypertension: difficult to control, requiring multiple agents
Discharge Condition:
Good
Discharge Instructions:
-Continue antibiotics for 3 more doses at home. Cefepime will be
given once daily and vancomycin will be given every other day
for a total of three more doses of each of the medications
-Physical therapy will work with you at home
-Home nursing will visit you at home, check your blood pressure,
monitor your neurologic status and help with your IV antibiotics
Followup Instructions:
-Follow up with [**First Name4 (NamePattern1) 17148**] [**Last Name (NamePattern1) 1391**] Nurse Practitioner [**First Name (Titles) **] [**Last Name (Titles) 3816**]
[**2139-9-15**] 2:20pm Internal Medicine B for a blood pressure check.
-Follow up with Dr. [**Last Name (STitle) **] for hospital follow up and blood
pressure management next week. Call her office to confirm
appointment.
-Follow up with Dr. [**Last Name (STitle) **] next week. Please call the office to
schedule your follow up appointment: [**Telephone/Fax (1) 1241**]
-Follow up with your cardiologist Dr. [**First Name (STitle) **] [**Name (STitle) 33746**]. Call for
an appointment.
Completed by:[**2139-9-14**]
ICD9 Codes: 5845, 5180, 2760, 4019, 4280, 2768, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1374
} | Medical Text: Admission Date: [**2128-11-21**] Discharge Date: [**2128-11-26**]
Date of Birth: [**2046-2-14**] Sex: F
Service: MEDICINE
Allergies:
Metformin
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
lethargy, hypercapnic respiratory failure
Major Surgical or Invasive Procedure:
intubation [**2128-11-21**]
History of Present Illness:
Ms. [**Known lastname **] is an 82F with PMH asthma, T2DM, HTN, OSA, dementia
who presents with four days of increasing lethargy and not
acting like herself. Daughters have noticed she's been
increasingly somnolent during the day and agitated at night.
Patient has had multiple nonspecific complaints over the past
several days: headache, weakness, heavy arms, stomach ache.
Daughters noted she's had a runny nose, no sick contacts. [**Name (NI) **]
fevers, chills, cough, changes in bowel movements, nausea or
vomitting. Upon leaving church this morning her legs gave out
from under her and she was lowered to the ground by her family.
Patient did not fall or strike her head. No LOC but confused,
intermittently responsive to family and repeating "I'm on the
ground" over and over again. Family gave her food incase pt was
hypoglycemic. No report of fever, chills, nausea, vomiting,
headache, or dysuria. She lives with her daughters. She was
hypoxia to 70s in the field. She has been intubated once
previously in [**12/2127**] for a similar presentation. Of note, she
appears to carry a diagnosis of adult onset asthma for which she
uses albuterol and advair only with respiratory illnesses. Has
not needed these medications recently. Nonsmoker. She has been
prescribed BIPAP for many years, but has not used it in the past
several months. Per recent PCP note in [**9-/2128**], she has had poor
tolerance to BiPAP. Patient with baseline dementia confused,
cannot remember daughters' names occasionally, but conversant,
and not incontinent of urine and stool.
.
In the ED inital vitals were 97.6 74 145/63 24 100% 15L
Non-Rebreather. Exam was notable for no wheezes, poor air
exchange. With the exception of a bicarb of 43, BMP and CBC was
reassuring. BNP 218 and troponin neg x1. Lactate was 1.0, UA was
unremarkable, and cultures were sent. Patient had a bicarb of 43
and ABG showed 7.19/127/49/51 just prior to initiating BIPAP.
Patient was intubated for apnea without complications. EKG
showed SR 71, unchanged from prior. CXR showed mild pulmonary
edema, with small bilateral pleural effusions. She was given
Methylprednisolone 125mg and Levofloxacin 750mg for COPD
exacerbation, though diagnosis of COPD is unclear. She improved
with nebs in the ED. Per report, there was concern for previous
aspiration given some food particles seen with intubation.
She has remained afebrile and HD stable.
.
Recent ABG on settings of CMV, FiO2 50%, Peep 5, TV 400, RR 22
is pH 7.52 pCO2 50 pO2 182 HCO3 42.
.
On arrival to the ICU, patient is intubated, sedated, not
opening her eyes or responding to commands.
.
Review of systems:
(+) Per HPI. Daughters note right hand swelling.
Unable to obtain further ROS as patient is intubated and
sedated.
Past Medical History:
-type 2 diabetes mellitus
-hypertension
-atypical peripheral neuropathy with cutaneous sensations ("dust
on her skin", seen by Neurology, on gabapentin + olanzapine) -
tactile hallucinosis per PCP
[**Name Initial (NameIs) 15372**]: appears to be adult onset asthma. [**2113**] spirometry is
restrictive physiology with bronchodilator response.
-macular edema s/p surgery
-neovascular glaucoma secondary to her proliferative diabetic
retinopathy
-OSA (prescribed BiPAP, not currently using)
-osteoarthritis
-dementia
-blind in left eye
Social History:
Patient is wheelchair bound due to old osteoarthritis and vision
loss. In setting of a few recent falls in her apartment, her
daughter stays with her at her apartment. Born and grew up in
the Carribean. Worked in a chocolate factory in [**Location (un) **] in the
[**2066**]. Arrived in the US in [**2077**]. Denies tobacco, EtOH, IVDA.
She lives with her daughter [**Name (NI) **] in [**Name (NI) 669**].
Family History:
Father with diabetes mellitus, died at age 69. Mother with
heart failure, died at age [**Age over 90 **]. Oldest daughter with diabetes
mellitus and polymyositis. Youngest daughter with anoxic brain
injury [**12-16**] trauma, in rehab.
Physical Exam:
Admission Exam:
Vitals: T: 97.6 BP: 160/94 P: 81 R: 22 O2: 100% (intubated)
General: intubated, sedated, comfortable appearing
HEENT: nonreactive surgical pupils, sclera anicteric, dry MM,
intubated
Neck: supple, JVP not elevated, no LAD
Lungs: coarse breath sounds bilaterally, no wheezes, rales,
ronchi appreciated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses dorsalis pedis, no clubbing
or cyanosis. 2+ edema to midthigh on left leg, 1+ edema to knee
in right leg. Arms without appreciable edema, good pulses.
Neuro: sedated.
.
Discharge Physical Exam:
Vitals: T96.9, HR89, BP 150/59 (130-160s/60-80s), RR18, O2Sat
99% on FM
Weight 120.6kg
General: elderly female lying in bed in NAD with eyes closed
HEENT: nonreactive surgical pupils bilaterally, sclera red but
anicteric, edentulous, moist mucous membranes with clear
oropharynx
Neck: Supple, JVP ~8-9cm
Lungs: No accessory muscle use, speaking in full sentences,
clear to auscultation bilaterally anteriorly with good air
movement, no wheezes, ronchi or rales
CV: Regular rate and rhythm with occasional premature beats,
normal S1 + S2, grade II/VI systolic murmur best heard at RUSB,
no radiation to carotids
Abdomen: +BS, obese, soft, nontender
GU: foley in place draining clear urine
Ext: WWP, no lower extremity edema, no sacral edema, 1+ DP/PT
pulses bilaterally
Neuro: A+O x3
Pertinent Results:
ADMISSION LABS:
[**2128-11-21**] 05:40PM BLOOD WBC-6.9 RBC-4.40 Hgb-12.2 Hct-40.5
MCV-92# MCH-27.6 MCHC-30.0* RDW-13.4 Plt Ct-134*
[**2128-11-21**] 05:40PM BLOOD Neuts-74.9* Lymphs-16.9* Monos-6.5
Eos-1.1 Baso-0.5
[**2128-11-23**] 04:31AM BLOOD PT-13.1* PTT-35.7 INR(PT)-1.2*
[**2128-11-21**] 05:40PM BLOOD Glucose-131* UreaN-10 Creat-0.7 Na-140
K-4.2 Cl-93* HCO3-43* AnGap-8
[**2128-11-21**] 05:40PM BLOOD proBNP-218
[**2128-11-21**] 05:40PM BLOOD cTropnT-<0.01
[**2128-11-21**] 05:40PM BLOOD Calcium-9.4 Phos-3.9 Mg-2.0
[**2128-11-21**] 05:50PM BLOOD Type-ART pO2-49* pCO2-127* pH-7.19*
calTCO2-51* Base XS-14
[**2128-11-21**] 05:50PM BLOOD Hgb-13.0 calcHCT-39 O2 Sat-73 COHgb-3
.
DISCHARGE LABS:
[**2128-11-24**] 02:52AM BLOOD WBC-7.3 RBC-4.41 Hgb-12.5 Hct-38.5 MCV-88
MCH-28.3 MCHC-32.3 RDW-14.8 Plt Ct-149*
[**2128-11-24**] 02:52AM BLOOD PT-13.2* PTT-37.2* INR(PT)-1.2*
[**2128-11-25**] 05:49AM BLOOD Glucose-243* UreaN-15 Creat-0.8 Na-141
K-3.7 Cl-101 HCO3-35* AnGap-9
[**2128-11-25**] 05:49AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.0
.
MICROBIOLOGY:
[**2128-11-21**] 6:17 pm URINE Site: CATHETER
**FINAL REPORT [**2128-11-22**]**
URINE CULTURE (Final [**2128-11-22**]):
STAPHYLOCOCCUS SPECIES. ~[**2116**]/ML.
.
-Blood Cx [**2128-11-21**] Pending, NGTD x2 as of [**11-26**]/12pm
.
IMAGING:
.
-[**2128-11-22**] ECHO:
The left atrium is normal in size. The estimated right atrial
pressure is 5-10 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
systolic function. No significant valvular disease.
.
-[**2128-11-22**] LENI Left leg:
IMPRESSION: No evidence of deep vein thrombosis.
.
-[**2128-11-23**] CXR
IMPRESSION: An AP chest performed with the patient rotated
severely to the
right, excludes lateral right lower chest. It shows moderate
left pleural
effusion stable or increased since [**11-22**], but improvement in
pulmonary
vascular engorgement and mild edema. Severe right lower lobe
atelectasis is
presumed and the volume of right pleural effusion cannot be
assessed. There
is no pneumothorax seen along the imaged pleural surfaces. ET
tube is in
standard placement. Right central venous line ends low in the
SVC and a
nasogastric tube passes below the diaphragm and out of view.
Heart is not
appreciably enlarged, but difficult to compare with prior
images.
Brief Hospital Course:
82 yo female with obstructive sleep apnea admitted with
hypercarbic respiratory failure due to not wearing home BIPAP
and acute diastolic heart failure.
.
ACTIVE ISSUES:
# Hypercarbic respiratory failure/Obstructive sleep apnea:
Patient was initially intubated and admitted to the ICU. Patient
is well known to have obstructive sleep apnea and probable
obesity hypoventilation syndrome with poor compliance with home
night time BIPAP. She admitted to not wearing her home BIPAP the
week prior to presentation and it was confirmed that part of her
BIPAP machine was not working. During her admission she did not
have evidence of pneumonia, LENIs were negative, and
echocardiogram showed a preserved biventricular systolic
function without pulmonary hypertension. Therefore, it was felt
that her hypercarbia was due to not wearing BIPAP for successive
days leading to slow increase in her PCO2. She also may have a
component of central apnea. Her BIPAP company was informed of
BIPAP dysfunction and plans were made to have it fixed. Post
extubation she had no issues with BIPAP in the hospital although
she did complain of it burning her nose. She was discharged to
rehab and will have her home BIPAP serviced before she returns
home.
#Acute diastolic heart failure:
Patient was diuresed in the ICU after intubation and echo showed
preserved EF. Given that she was volume overloaded on
presentation, she was felt to have acute diastolic heart failure
and was discharged on Lasix instead of hydrochlorothiazide which
she was taking prior to admission.
.
CHRONIC ISSUES:
.
#Type 2 Diabetes mellitus: Most recent A1c 7.1% in 9/[**2127**]. On
NPH 80units Qam and RISS at home. Originally ordered for [**11-15**]
dose NPH, however sugars remained low while NPO and did not
receive NPH. NPH stopped and patient was managed on a sliding
scale during her [**Hospital Unit Name 153**] stay. After transfer to the floor, she was
restarted on 60 units of NPH in the AM and a humalog sliding
scale.
.
#Hypertension: SBPs were in the 140s-150s while off all home
medications. Home lisinopril was restarted in the [**Hospital Unit Name 153**] with
systolics decreasing to 110s-120s. HCTZ and diltiazem held
during stay in [**Hospital Unit Name 153**], but were restarted after transfer to the
floor, where her pressures remained stable.
.
# Neuropathy/tactile hallucinosis: Initially held Gabapentin,
zyprexa during [**Hospital Unit Name 153**] stay in case this was causing decreased
mental status. Both were restarted on transfer to the medical
floor.
.
TRANSITIONAL ISSUES:
.
Issues of need to wear BIPAP were discussed with her daughter as
well as the importance of using the BiPAP despite the tactile
neuropathy on her face was stressed.
.
The following changes were made to her medications:
NEW:
-Heparin injections to prevent blood clots while she is at rehab
-Furosemide (lasix), to replace hydrochlorothiazide diuretic.
.
CHANGED: none
.
STOPPED:
-Hydrochlorothiazide
Medications on Admission:
Betimol 0.5 % Eye Drops 1 (One) drop(s) both eyes three times a
day (daughters do not believe she takes this, but are unsure)
latanoprost 0.005 % Eye Drops 1 drop(s) both eyes at bedtime
brimonidine 0.15 % Eye Drops 1 drop(s) both eyes three times a
day
Zyprexa 2.5 mg Tab tid for strange sensations on the skin and 2
qhs.
Advair Diskus 250 mcg-50 mcg/dose for Inhalation 1 inhalation po
BID
senna 8.6 mg Tab [**Hospital1 **] as needed for constipation
Humulin R 100 unit/mL Injection ISS
NPH 80 units in am
Cholecalciferol (Vitamin D3) 400 unit Chewable Tab 2 Tablet(s)
Qday calcium carbonate 200 mg (500 mg) Chewable Tab TID
Triamcinolone Acetonide 0.1 % Cream apply to affected areas [**Hospital1 **]
Enteric Coated Aspirin 81 mg Tab, Delayed Release Qday
Acetaminophen 500 mg Tab 2 Tablet(s) by mouth at bedtime
DILT-XR 240 mg Cap one Capsule Qday
albuterol sulfate 2.5 mg/3 mL (0.083 %) Neb Solution TID prn
asthma flares
ProAir HFA 90 mcg/Actuation Aerosol Inhaler 2 inhalations orally
up to qid as needed for flare of asthma (daughters do not
believe she takes this)
hydrochlorothiazide 12.5 mg Tab Qday
lisinopril 20 mg Tab [**Hospital1 **]
Trusopt 2 % Eye Drops 1 drop(s) both eyes TID
ibuprofen 600 mg Tab up to tid arthritis pain
docusate sodium 100 mg Cap prn [**Hospital1 **]
gabapentin 300 mg Cap 1 Capsule(s) by mouth up to [**Hospital1 **]
prednisolone acetate 1 % Eye Drops, Susp 1 drop(s) topical
4x/day left eye
Discharge Medications:
1. Betimol 0.5 % Drops Sig: One (1) Ophthalmic three times a
day: both eyes.
2. latanoprost 0.005 % Drops Sig: One (1) Ophthalmic at
bedtime: both eyes.
3. brimonidine 0.15 % Drops Sig: One (1) Ophthalmic three times
a day: both eyes.
4. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO TID (3 times a day) as needed for skin sensations,
agitation.
5. olanzapine 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. cholecalciferol (vitamin D3) 400 unit Tablet, Chewable Sig:
Two (2) Tablet, Chewable PO once a day.
9. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO three times a day.
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO at
bedtime.
12. diltiazem HCl 240 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation three times a day as
needed for shortness of breath, wheezing.
14. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2)
Inhalation four times a day as needed for shortness of breath
or wheezing.
15. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
16. lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
17. Trusopt 2 % Drops Sig: One (1) Ophthalmic twice a day: both
eyes.
18. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for arthritis pain.
19. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
20. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
21. prednisolone acetate 1 % Drops, Suspension Sig: One (1)
Ophthalmic four times a day: LEFT eye.
22. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
23. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: Sixty (60) Subcutaneous qAM.
24. insulin lispro 100 unit/mL Cartridge Sig: One (1)
Subcutaneous once a day: Per Insulin sliding scale.
25. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Primary diagnosis:
Hypercarbic respiratory failure
Secondary diagnoses:
Diabetes
Hypertension
Neuropathy
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 privilege to provide care for you here at the [**Hospital1 **] Hospital. You were admitted because you passed
out, and were found to have trouble getting enough oxygen. You
were briefly intubated and kept in the intensive care unit, but
you were transferred to the regular medical floor after your
breathing stabilized. Your condition has improved and you can be
discharged to home. It is important that you continue to use
your breathing machine at night when you sleep, so that you can
get enough oxygen.
The following changes were made to your medications:
NEW:
-Heparin injections to prevent blood clots while you are at
rehab
-Furosemide (lasix), replaces hydrochlorothiazide as your
diuretic.
CHANGED: none
STOPPED:
-Hydrochlorothiazide
Please keep your follow-up appointments as scheduled below.
Followup Instructions:
Department: [**Hospital3 1935**] CENTER
When: WEDNESDAY [**2128-12-15**] at 10:20 AM
With: EYE IMAGING [**Telephone/Fax (1) 253**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 1935**] CENTER
When: WEDNESDAY [**2128-12-15**] at 10:40 AM
With: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 249**]
When: TUESDAY [**2128-12-21**] at 1:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2128-11-26**]
ICD9 Codes: 4019, 3572, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1375
} | Medical Text: Admission Date: [**2184-10-13**] Discharge Date: [**2184-10-19**]
Date of Birth: [**2115-11-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Airway obstruction
Major Surgical or Invasive Procedure:
tracheotomy change [**2184-10-13**], [**2184-10-14**]
chest tube placement [**2184-10-14**]
flexible bronchoscopy [**2184-10-15**]
History of Present Illness:
68-year-old male who is status post chemo XRT for a T2 N2B right
tonsillar squamous cell carcinoma who was recently admmitted for
a pneumonia. Due to respiratory distress received a tracheotomy
on [**2184-10-2**] per the ORL service. The patient did well post-op and
was discharge to rehab. On the day of admission, nursing at
rehabilitation noted difficulty with suctioning and on deep
suctioning some tracheal bleeding. He was transferred to [**Hospital1 18**]
for evaluation. Of note, the patient has a 7 portex cuffed trach
tube, a different
tube than at discharge.
While in the ED, complete clogging of the trach tube was noted
on ORL evaluation with clots coming from the trach. Respiratory
was unable to pass a suction. The ORL service was consulted for
evaluation.
Outside records from [**Location **] indicate that the patient was 2
receive 2 unit PRBCs for a HCT of 22 today. Also, is WBC count
was 25 with C.diff results pending from rehab and was
emperically started on flagyl. He was currently receiving
vancomycin for MRSA pneumonia.
Past Medical History:
Hypertension
CVA- "small strokes,"
Exploratory laparatomy about 20 yrs ago for incarcerated hernia
Social History:
Previous gas station maintenance worker, 40 pack-yr history of
smoking and current smoker, drank 2-3 beers a day before the
dysphagia started.
Family History:
Noncontributory.
Physical Exam:
VS: HR 110s BP 161/72 T 101 97% on trach mask
General: NAD, lying in bed
HEENT: tongue slightly protruding, firm mass right jaw and
superior
NECK: radiation changes anterior/right neck. Tracheostomy.
Gurgling sounds with breathing.
HEART: Regular rhythm, tachycardic without murmurs.
LUNGS: Diffuse rhonchorous sounds anterior and posterior chest
ABD: Soft, nondistended, PEG-tube site is clean dry and intact.
SKIN: Warm and dry without rashes.
EXTREMITIES: Warm, no edema.
Psych: Alert and oriented with normal affect.
Pertinent Results:
Admission Labs:
[**2184-10-13**] 07:47PM LACTATE-1.7
[**2184-10-13**] 07:00PM GLUCOSE-169* UREA N-24* CREAT-0.7 SODIUM-132*
POTASSIUM-3.8 CHLORIDE-89* TOTAL CO2-36* ANION GAP-11
[**2184-10-13**] 07:00PM CK(CPK)-28*
[**2184-10-13**] 07:00PM cTropnT-0.04*
[**2184-10-13**] 07:00PM CK-MB-NotDone
[**2184-10-13**] 07:00PM WBC-23.0*# RBC-3.04* HGB-8.2* HCT-25.3*
MCV-83# MCH-27.1 MCHC-32.6 RDW-15.4
Discharge Labs:
[**2184-10-19**] 03:43AM BLOOD WBC-23.5* RBC-3.39* Hgb-9.3* Hct-29.3*
MCV-86 MCH-27.6 MCHC-32.0 RDW-14.3 Plt Ct-594*
[**2184-10-19**] 03:43AM BLOOD Glucose-154* UreaN-14 Creat-0.6 Na-132*
K-4.0 Cl-97 HCO3-26 AnGap-13
[**2184-10-19**] 03:43AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.1
Brief Hospital Course:
68yo M squamous cell throat cancer w recent hx of pneumonia and
ICU stay, s/p Trach/PEG, presented w tracheostomy tube in false
lumen.
#) Tracheostomy Replacement: on presentation patient initially
had bleeding around his trach site, and his ET tube was found to
be full of clots, in the ED, his tracheotomy tube replaced.
While changing the tube, a false passage was noted. This passage
was not present at discharge. On HD 2, the tracheotomy tube
migrated into the false passage and required a second procedure
to secure the airway. Which was complicated by a left
pneumothorax seen on follow-up chest xray, and a chest tube was
placed by the SICU team. The chest tube was removed [**10-17**] with
small residual apical pneumothorax, patient will need repeat
chest x-ray in [**2-3**] days after discharge to make sure the
pneumothorax has not worsened.
#) Leukocytosis: patient with persistent leukocytosis with white
blood cell counts over 20, and he continued to have low grade
temps. He was recultured, C.diff was sent, and his repeat
sputum culture also showed MRSA, which was thought to be
colonization rather then infection. His chest x-ray on the day
of discharge showed improvement in LLL.
#) Nutrition: Continuous tube feeds were transitioned to bolus
tube feeds and the patient appeared to tolerate well with low
residuals.
#) Hypertension: overall his BP was well controlled but he was
hypertensive in the morning, so he may need his medications
split to morning and evening meds.
Medications on Admission:
1. Insulin Sliding scale
2. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze
3. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
6. Magnesium Sulfate IV Sliding Scale
7. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
8. MetRONIDAZOLE (FLagyl) 250 mg PO TID
9. Atenolol 100 mg PO DAILY
10. OxycoDONE Liquid 5 mg PO Q4H:PRN pain
11. Calcium Gluconate IV Sliding Scale
12. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN mouth pain
13. Senna 1 TAB PO BID:PRN
14. Docusate Sodium (Liquid) 100 mg PO BID
15. Ferrous Sulfate 325 mg PO/NG DAILY
16. Sodium Chloride Nasal [**1-2**] SPRY NU QID
17. Furosemide 20 mg PO BID
18. Heparin 5000 UNIT SC TID
19. Vancomycin 1000 mg IV Q 24H
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day (2) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for wheezing.
2. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Month/Day (2) **]: Five (5)
mL PO DAILY (Daily): please give via g-tube.
3. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: One (1) Inhalation
Q6H (every 6 hours) as needed for wheeze.
4. Aspirin 81 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Insulin Regular Human 100 unit/mL Solution [**Month/Day (2) **]: One (1)
Injection ASDIR (AS DIRECTED).
6. Lisinopril 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
7. Atenolol 50 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY (Daily).
8. Oxycodone 5 mg/5 mL Solution [**Month/Day (2) **]: Five (5) ml PO Q4H (every 4
hours) as needed for pain.
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Sodium Chloride 0.65 % Aerosol, Spray [**Last Name (STitle) **]: [**1-2**] Sprays Nasal
QID (4 times a day).
11. Acetaminophen 160 mg/5 mL Solution [**Month/Day (2) **]: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain.
12. Phenol 1.4 % Aerosol, Spray [**Age over 90 **]: One (1) Spray Mucous
membrane Q4H (every 4 hours) as needed for mouth pain.
13. Docusate Sodium 50 mg/5 mL Liquid [**Age over 90 **]: One Hundred (100) mg
PO BID (2 times a day).
14. Senna 8.8 mg/5 mL Syrup [**Age over 90 **]: Five (5) ML PO BID (2 times a
day) as needed for constipation: Please give via PEG .
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Respiratory Distress
Discharge Condition:
At the time of discharge patient had a stable white blood cell
count, had been having low grade temps but was not febrile,
tolerating his tube feeds, and considered medically stable for
discharge to rehab.
Discharge Instructions:
*Do not change trach tube until [**2184-11-12**]. This time is required
for maturation of the tracheal tract.
Dear Mr. [**Known lastname 28253**],
You were admitted to the hospital because you were having
difficulty breathing. The Otolaryngology Surgeons and
Interventional Pulmonology doctors helped replace your
tracheostomy tube so that you should be able to breathe better.
Your tracheostomy tube was replaced with a longer tube to help
prevent this from happening again in the future. During the
replacement of your tracheostomy, the procedure was complicated
by a pneumothorax (left lung collapse) and you had a chest tube
placed. After the lung reinflated you were able to have the
chest tube removed.
During your time in the hospital you completed your course of
vancomycin for your prior pneumonia and PICC line was taken out.
No other changes were made to your medication regimen.
Please call your doctor or return to the hospital if you
experience any shortness of breath, difficulty breathing, chest
pain, worsening cough or sputum production, blood from around
your trach site or any other concerning symptoms.
Followup Instructions:
Please be sure to keep your scheduled appointments:
Provider: [**First Name4 (NamePattern1) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 41**]
Date/Time:[**2184-10-22**] 10:40
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2184-11-5**] 11:00
ICD9 Codes: 2761, 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1376
} | Medical Text: Admission Date: [**2157-7-9**] Discharge Date: [**2157-7-15**]
Date of Birth: [**2099-5-3**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
"I throw up blood"
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname **] is a Vietnamese-speaking 58 y.o. man with a PMH of a
positive PPD, depression, PTSD, POW during [**Country 3992**] war, hernia
with repair, and chronic back pain. He was admitted to the ICU
[**2157-7-9**] with complaints of dizziness, HA, fatigue, dyspnea, and
a 13 lb wt loss over the last one month. Pt also c/o spitting up
BRB since one day prior to admission with reports of 400cc
hemoptysis in the ED. He also c/o nausea and vomiting. He
denies CP/Palpitations/fevers chills/sick contacts. [**Name (NI) **] has a
history of a positive PPD with 6 months INH treatment. He
endores abdominal pain which he has had since his bilateral
hernia repairs. He also endorses urinary hesitancy but denies
dysuria. Recent colonoscopy showed adenoma, no bleeding.
While in the ICU there were no witnessed episodes of hemoptysis
or bloody emesis. The patient's Hct continued to fluctuate,
dropping from 39 to 27 and then returning to 33. Bronchoscopy
did not show any evidence of acute bleed, and showed normal lung
findings. The patient was guiac negative, and studies for
hemolysis were also negative. CXR and CT were negative for
pathology. NG lavage was negative.
On the day of transfer, the patient reported he was still
spitting up blood. Given his previous psych history of
depression, PTSD, and possible psychosis, he was transferred to
the floor for further psychiatric evaluation.
Past Medical History:
1. Posttraumatic stress disorder.
2. Status post bilateral inguinal hernia repair.
4. h/oPPD pos, tx with INH x 6 mo.
5. chronic LBP
6. migraines
7. h/o R shoulder [**Doctor First Name **].
8. urinary retention
Social History:
Social history: Came from [**Country 3992**] 6 yrs ago and lives with wife.
Smokes 3 [**Name2 (NI) 26105**] per day, denies EtOH and drugs
Family History:
noncontributory
Physical Exam:
Vitals: T 97.2 HR 76 RR 20 BP 130/70 95%RA
Gen: Vietnamese speaking, unable to communicate, NAD
HEENT: PERRL, anicteric, OP clear w/o blood, nares w/o blood,
MMM, neck supple w/o LAD
CV: RRR, no m/r/g, nl s1s2
Resp: CTAB
Abd: +BS, soft, tender BLQ to palpation, no peritoneal signs,
no masses
Ext: no edema, nontender, 2+ DP pulses B
Pertinent Results:
[**2157-7-9**] 11:56AM HGB-12.6* calcHCT-38
[**2157-7-9**] 11:30AM GLUCOSE-95 UREA N-12 CREAT-0.8 SODIUM-142
POTASSIUM-4.3 CHLORIDE-107 TOTAL CO2-27 ANION GAP-12
[**2157-7-9**] 11:30AM WBC-4.0 RBC-4.09* HGB-12.7* HCT-39.1* MCV-95
MCH-31.0 MCHC-32.5 RDW-12.8
[**2157-7-9**] 11:30AM PT-12.6 PTT-29.8 INR(PT)-1.0
[**2157-7-9**] 11:30AM PLT COUNT-206
[**2157-7-9**] 11:30AM cTropnT-<0.01
[**2157-7-9**] 11:30AM LIPASE-20
[**2157-7-9**] 05:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2157-7-13**] WBC 6.0 Hgb 12.1 Hct 33.1 repeat Hct 32.0 pltl
173
[**2157-7-13**] Na 141 K 3.3 Cl 105 HCO3 31 BUN 9 Cr 0.7
Glu 86
Ca 7.6 Mg 1.9 Phos 2.5
[**2157-7-12**] Hapto 113
Brief Hospital Course:
58 y.o. Vietmanese man with h/o +PPD, with 2-3 wks increasing
fatigue, wt loss, and spitting up blood x 1 day. The patient
presented to the ED hemodynamically stable. In ED, coughed up
400 cc of BRB. CXR clear, NG lavage neg. SBP decreased into the
80's (baseline 100-110), HR up to 70's (baseline 40-50's). HCT
decreased from 39 to 35.8, then to 36.9 after 8 L NS. Torso CT
neg. SBP further dropped into the 70's after IVF, but patient
was mentating well, with good urine output. RIJ central line
placed. Rec'd 4 mg IV dex given hypotension and 7.6% eos on
peripheral smear. No blood products rec'din ED. CT, CXR
negative.
Mr. [**Known lastname **] was transferred to the ICU in a negative pressure room,
given his h/o +PPD and new hemoptysis with constitutional
findings, to r/o TB (although neg CXR/CT, afebrile). Other
possible etiologies included upper GI bleed (although NG lavage
neg, Guaiac neg) or nasopharyngeal dx (no h/o trauma, no active
nasal or OP bleeding). Other respiratory etiologies were also
considered including resp AVM or resp-renal d/o (nml cr).
IV Fluids with NS were continued and the patient maintained good
BP's, without the need for pressor support. HCT decreased from
30.3-->28.9-->27.7. No active bleeding per mouth or nose
appreciated. No hemoptysis or hematemesis. He was transfused
with 1U PRBC's and HCT increased to 30. It remained stable at 30
overnight. Bronchoscopy was performed in the ICU, and
demonstrated normal airways with no bleeding. AFB per BAL was
negative, and sputum AFB also negative.
The patient was discussed with both GI and [**Known lastname **], who felt given
his clinical stability and stable HCT, endoscopy/fiberoptic
scope were not indicated at this time. Mr. [**Known lastname **] was set for
discharge home from the ICU given his improvement over the last
two days, however on [**7-13**] he again complained of spitting up BRB
overnight. However, no bleeding was seen overnight either by the
nursing staff or by the housestaff. There was no blood seen per
mouth/nose or blood on the pillows/sheets. In addition, the
patient reported spitting up over a liter of blood, which would
not have gone un-noticed with continual care in the ICU setting.
Therefore, we did not feel comfortable sending him home with the
thought that he might be confused or delusional. He does have a
psych history w/ PTSD for which he recieves medications. In
addition he appeared to have a flat affect and per his family
seemed anxious/depressed about his current situation. Psychiatry
evaluated the patient and found him stable for discharge. He was
also encouraged to follow-up with his home PCP and Psychiatrist.
Physical therapy also evaluated the patient and recommend
continued PT care. Hct remained stable 33-34 while on the floor,
and he was discharge to home
Medications on Admission:
meds:
BUTALBITAL/APAP/CAFFEINE [**Medical Record Number 3668**]--Twice a day
COMBIVENT 103-18MCG--2 pffs [**Hospital1 **]-qid
DEPAKOTE 250MG--Three times a day
FLUOXETINE HCL 20MG--Twice a day
LORATADINE 10MG--One by mouth every day
NAPROSYN 500MG--Twice a day as needed
PROTONIX 40MG--By mouth every day as needed
TRILEPTAL 600MG--Three times a day
Venlafaxine
tramadol 600MG--Three times a day
Discharge Medications:
1. Venlafaxine HCl 75 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Divalproex Sodium 250 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO TID (3 times a day).
3. Oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-31**]
Puffs Inhalation Q6H (every 6 hours) as needed.
5. Acetaminophen-Caff-Butalbital [**Medical Record Number 3668**] mg Tablet Sig: [**12-31**]
Tablets PO BID (2 times a day).
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Home With Service
Facility:
[**Hospital6 1952**], [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnoses:
1. Hemoptysis
2. Delirium
Secondary Diagnoses:
1. PTSD
2. +PPD
3. Chronic bilateral abdominal pain
Discharge Condition:
good
Discharge Instructions:
1. Please follow up with primary care physician [**Last Name (NamePattern4) **] [**12-31**] weeks
Please recheck calcium, phosphorus at the office and screen for
hyperparathyroidism
2. Please take medications as directed
3. Please have your PCP check your Valproic acid level
4. Please have your PCP recheck your blood counts (Hematocrit)
5. Call your PCP or return to the ED if you have fevers, chills,
blood coming from your nose, mouth, vomit, or stool.
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2157-8-9**] 9:30
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Hospital1 7975**] INTERNAL MEDICINE Where: OFF CAMPUS
[**Hospital1 7975**] INTERNAL MEDICINE Phone:[**Telephone/Fax (1) 3666**] Date/Time:[**2157-9-13**]
9:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 7976**]. [**Last Name (LF) 766**], [**8-8**]. 2:25.
Provider: [**Name Initial (NameIs) **] (Ears, Nose, Throat Surgery). Please call ([**Telephone/Fax (1) 26106**]
to schedule an appointment
ICD9 Codes: 4589, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1377
} | Medical Text: Admission Date: [**2197-4-14**] Discharge Date: [**2197-6-6**]
Date of Birth: [**2197-4-14**] Sex: M
Service: Neonatology
HISTORY: Baby [**Name (NI) **] [**Known lastname **] [**Known lastname 55312**] is a former 32 week
gestation male delivered by cesarean section for intrauterine
growth restriction with low amniotic fluid index and absent
diastolic flow.
PERINATAL HISTORY: Mother is a 30 year-old primipara, IUI
conception, estimated date of confinement [**2197-6-9**]. Prenatal
screens: A positive antibody negative, RPR nonreactive,
hepatitis B surface antigen negative, GBS unknown. This
pregnancy was complicated by echogenic bowel on ultrasound,
intrauterine growth restriction less than third percentile,
decreased AFI, declined amniocentesis. Transferred from [**Hospital6 38673**] with absent diastolic flow with estimated
fetal weight of 743 grams, biophysical profile 8 out of 8,
positive fetal movement, beta complete. Cesarean section on
delivery date due to breech presentation, at first with no
spontaneous respiratory effort but heart rate greater than
100. Baby received stimulation and blow-by O2 resulted in
improved color, tone and respiratory effort. Apgars 7 at one
minute, 8 at five minutes. Baby was transferred to the
Newborn Intensive Care Unit.
PHYSICAL EXAMINATION ON ADMISSION: Birth weight 850 grams,
discharge weight 2085. Birth length 36 cm. Discharge length
42 cm. Admission head circumference 25.75, discharge head
circumference 33.5. Symmetrically, less than 10th percentile.
Overall appearance consistent with intrauterine growth
restriction at 32 weeks, breech appearance, dysmorphic
cranial shape with prominent forehead, long thin triangular
shaped, slightly prominent upturned nose, slightly high arched
palate, question abnormal ear curve though normally set. No
clinodactyly but tri metacarpal joint hyperextended on first
four fingers of left hand. Could not palpate left testicle.
AFOF. Red reflex present. Bilaterally pupils quite dilated.
Mild intercostal retraction. Breath sounds quite clear and
equal, regular rate and rhythm without murmur, 2+ peripheral
pulses including femorals. Normal back and extremities. Skin
pink, well perfused diffusely. Slightly decreased tone versus
weakness. Admission dextrose stick 53.
REVIEW OF HOSPITAL COURSE BY SYSTEM:
Respiratory: The infant was in room air, did not require any
respiratory support and has remained respiratorily stable
throughout this admission.
He was started on caffeine on day of life 7 until day of life
14 for apnea and bradycardia of prematurity. On day of life
38 he had increased apnea and bradycardia consistent with
clinical symptoms of sepsis. See Infectious Disease below.
At the time of discharge he has been without apnea,
bradycardia or desaturations for greater than five days. He
is respiratorily stable.
Cardiovascular: The baby had stable transition
cardiovascularly. He did not require any pressor support,
had a soft intermittent murmur which resulted in an
echocardiogram on [**3-22**], day of life 6 which showed no PDA and
a small PFO. The baby has been cardiovascularly stable with
no further issues. Baseline blood pressure is systolics in
the 60s to 70s, diastolics in the 30s to 40s and means in the
50s to 60s. Baseline heart rate is 130 to 170.
Fluid, electrolytes and nutrition: The baby initially was
n.p.o. with a peripheral line being placed. A PICC line
centrally was placed on day of life 2 which remained in place
until day of life 17. He started on trophic feedings on day
of life 2 and received trophic feedings for two days and then
was noted to have large bilious aspirates which resulted in
his being placed n.p.o. and transferred to the [**Hospital3 18242**] for a lower GI contrast study to rule out
obstruction. This proved to be within normal limits. He
returned to the [**Hospital1 69**], resumed
trophic feeding and advanced to full enteral feedings on day
of life 7 to full feedings by day of life 17. This
advancement progressed slowly without major incident. He then
had his caloric density increased to 30 calories per ounce
with Promod at 150 cc per kilo per day. On day of life 38 he
again was made n.p.o. in preparation for the operating room
for what was thought to be a testicular torsion. See GI
below. When he returned he again had feedings reintroduced
and advanced to full calories again without incident. At the
time of discharge he is feeding breast milk 28 (which is
achieved with 4 calories per ounce of NeoSure powder and 4
calories per ounce of corn oil) ad lib plus nursing well with
mom, taking in greater than 140 cc per kilo per day. He is
also on supplemental ferrous sulfate .15 ml p.o. daily which
equals 2 mg per kilo per day and this is 25 mg per ml
solution. He is also on Vi-Daylin 1 cc p.o. daily. He also
has had diaper rash with excoriation which has been protected
with Criticaid but currently requires only Desitin as needed.
Last electrolytes on [**5-23**]: sodium 141, potassium 4.1,
chloride 107, CO2 25, phosphorus 7.2, calcium 10.9, alk phos
of 464. Discharge weight, length, head circumference noted
above under "Exam".
GU: As stated above, the baby was transferred to the
[**Hospital3 1810**] for what was thought to be a testicular
torsion associated with multiple episodes of apnea and
bradycardia on [**2197-5-22**]. In the operating room both testes
appeared viable and the urology team suspected intermittent
right torsion/detorsion.
The operative procedure included right scrotal exploration,
right inguinal exploration, right inguinal hernia repair and a
bilateral orchiopexy. Findings of edematous and reactive
tissue throughout the bilateral scrotum and right inguinal
region prompted an empiric diagnosis of orchitis. Infant
tolerated the procedure well, was extubated in the operating
room and transferred back to the [**Hospital3 1810**] Neonatal
Intensive Care Unit and then ultimately back to the Newborn
Intensive Care Unit at [**Hospital1 69**]
within a few hours. He had follow up bladder and kidney
ultrasounds as he recovered postoperatively which were within
normal limits. Plan is for him to follow up with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 3060**], urologist at the [**Hospital3 1810**] one month after
discharge, telephone number [**Telephone/Fax (1) 55313**]. His incisions have
healed nicely and the edema and inflammation have resolved.
GI: Peak bilirubin was 8.2/5.4 day of life one. Baby
responded to phototherapy and had a rebound bilirubin of
2.4/1.4. This high direct bilirubin was followed with
subsequent samples being 2.3 and then ultimately 1.0 on [**5-4**].
This elevated conjugated hyperbilirubinemia was thought to be
related to TPN on treatment as well as history of intrauterine
growth restriction.
Infectious disease: The baby had a blood culture and a CBC
sent on admission because of his prematurity and growth
restriction and an admission white count of 5 thought to be
related to intrauterine growth retardation status.
Differential included 21% polys, 0 bands, 72% lymphs; platelet
count of 214,000; hematocrit of 46.2. He was not started on
antibiotics. Cultures remained negative. CMV screening was
negative and he again had a blood culture sent on day of life
11 at the time he was having bilious aspirates. His white
count at that time was 8.4 with 32 polys, 1 band, platelet
count of 31,000, hematocrit of 37.6. Blood cultures were
negative. He was again evaluated for infection on day of life
26 because of increase in apnea and bradycardia but had a
benign CBC with a white count of 13.9, 15% polys, 2% bands,
platelet count of 538,000, hematocrit of 28.7 with
reticulocyte count of 4.6. Blood cultures were again
negative.
On day of life 38 ([**2197-5-22**]) he had a blood culture and CBC
done prior to going to the operating room for his exploration
for concern over testicular torsion. At that time his white
count was 9.1 with 40% polys, 4% bands, 45% lymphs and 308,000
platelets. Hematocrit of 28.1, retics 8.2%. Blood culture
ultimately grew group B strep. A lumbar puncture on [**5-26**]
yielded CSF with 2 wbc, 2100 rbc, and reassuring chemistries
with negative culture. He was treated with ampicillin and
gentamicin, received seven days of gentamicin and a full ten
days of ampicillin from his negative culture on [**5-23**]. The
question of whether this organism was related to the findings
of scrotal inflammation was not definitively answered, as
there were no urine or tissue specimens available for culture.
Hematology: Blood counts as noted under Infectious Disease.
Received no transfusions during this hospitalization.
Receiving iron supplements for anemia of prematurity.
Genetics: Karyotype 46XY.
Neurology: The baby had serial head ultrasounds that were
within normal limits, showed no intraventricular hemorrhage
and no periventricular leukomalacia.
Auditory screening was performed with automated auditory
brain stem response. The baby passed.
Ophthalmology: Infant had serial eye examinations done and
was shown to be mature retinas on [**5-24**] with a plan to follow
up in eight months.
Psychosocial: Parents visiting frequently, looking forward to
[**Known lastname 43073**] discharge home.
DISCHARGE DISPOSITION: Home with family.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 19419**], [**Hospital 246**]
Pediatrics, [**Telephone/Fax (1) 37501**].
CARE RECOMMENDATIONS: Continue feedings of breast milk 28
calories in addition to nursing as described above. Might
consider supplemental nursing system (has not been initiated
as yet). Medications: Fer-In_Sol and Vi-Daylin as stated
above. Car seat position screening: passed. State Newborn
Screening: serial screens were sent and were all within normal
limits.
IMMUNIZATIONS RECEIVED: Hepatitis B vaccine on [**5-16**].
IMMUNIZATIONS RECOMMENDATION: Synagis RSV prophylaxis
should be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants
meeting any of the following three criteria: 1) born at less
than 32 weeks, 2) born between 32 and 35 weeks, with any two
of the three following criteria: day care during RSV season, a
smoker in the household, neuromuscular disease, airway
abnormalities or school age siblings or 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 other out of home care givers.
FOLLOW UP APPOINTMENT: As stated above with primary care
physician and with Dr. [**Last Name (STitle) 3060**], urology at the [**Hospital3 18242**]. Ophthalmology follow-up is recommended at 8 months
of age and audiologic evaluation by one year.
DISCHARGE DIAGNOSIS:
1. Former 32 week premature infant.
2. Unconjugated hyperbilirubinemia and conjugated
hyperbilirubinemia, both resolved.
3. Status post bilateral orchiopexy with right inguinal
hernia repair.
4. Intrauterine growth restriction and small for gestational
age.
5. Status post orchitis.
6. Status late onset group B strep sepsis.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**First Name (Titles) **] [**Last Name (Titles) 42702**] 50-563
Dictated By:[**Last Name (NamePattern1) 36251**]
MEDQUIST36
D: [**2197-6-6**] 15:51
T: [**2197-6-6**] 15:52
JOB#: [**Job Number 55314**]
ICD9 Codes: 7742 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1378
} | Medical Text: Admission Date: [**2172-3-15**] Discharge Date: [**2172-3-18**]
Date of Birth: [**2111-8-3**] Sex: F
Service: 1
HISTORY OF PRESENT ILLNESS: The patient is a 60 year old
female with no known coronary artery disease who presented to
[**Hospital6 5016**] around noontime on [**2172-3-15**],
with respiratory distress. The family said that the patient
had cold-like symptoms lasting about three days with cough,
fatigue, subjective fevers. The patient's progressive
dyspnea improved with upright positioning. On the night
prior to admission to [**Hospital6 5016**], the patient was
experiencing increased cough and shortness of breath. The
patient was brought by ambulance to the Emergency Room at
[**Hospital6 5016**], where her oxygen saturation was
reportedly around 60% initially with arterial blood gas
showing oxygen saturation around 30%. Apparently on
examination, the patient had markedly decreased breath sounds
on her left side, with chest x-ray showing a 25%
pneumothorax.
The patient was intubated for respiratory distress and a
chest tube was placed anteriorly. The patient's initial EKG
showed globally diffuse ST segment depressions of 2 to 3 mm
in leads V2 through V6, II, III and AVF. After intubation
and after chest tube placement, EKG showed near complete
resolution of EKG changes. At midnight, the patient's EKG
showed no ST segment depressions in V1 through V6, slight T
wave flattening in the inferior leads. The patient's initial
CK was 600 range with an MB index of 5.7, negative troponin.
The patient had required Dopamine at low doses to maintain
her systolic blood pressures greater than 90.
On transfer to [**Hospital1 69**], the
patient remained intubated and not sedated. The patient
denied pain or shortness of breath on transfer.
PAST MEDICAL HISTORY:
1. Presumed emphysema.
ALLERGIES: Penicillin.
MEDICATIONS:
1. NyQuil p.r.n.
FAMILY HISTORY: The patient's grandfather died a sudden
death at age 32. The patient admits to an extensive history
of heart disease in the family.
SOCIAL HISTORY: The patient has smoked 1.5 pack per day
tobacco for 40 years. The patient admits to rare alcohol
consumption.
PHYSICAL EXAMINATION: On admission, temperature 98.6 F.;
blood pressure 89/45; pulse 98; respirations 16; oxygen
saturation 100%. In general, the patient is awake,
intubated, very alert. Head and Neck examination: Pupils
equally round and reactive to light; extraocular muscles are
intact. Sclerae anicteric. Endotracheal tube in place. NG
tube in place. No jugular venous distention. Chest and
Lungs: Distant, scant wheezes, equal breath sounds
bilaterally. No rales. Cardiovascular: Distant heart
sounds. Regular rate and rhythm. Normal S1 and S2. No S3
or S4. No murmurs, rubs or gallops. Abdomen: Good bowel
sounds in all four quadrants. Soft, nontender, nondistended.
Extremities: No cyanosis, clubbing or edema. Difficult to
palpate dorsalis pedis pulses bilaterally. Neurologic
examination: Awake, alert, communicating appropriately,
moving all four extremities; nonfocal.
LABORATORY: On admission, white blood cell count 13 with
differential yielding 88% neutrophils, 8% lymphocytes, 3%
monocytes, 0.2% eosinophils. Hematocrit 37.1, platelets 200,
PTT 26.9, INR 1.2. Sodium 143, potassium 3.5, chloride 105,
bicarbonate 26, BUN 12, creatinine 0.6, glucose 85. CK
pending.
Chest x-ray showing trace left apical pneumothorax, bullous
emphysematous changes diffusely.
EKG #1 on [**3-15**] at 02:00 p.m. showing sinus tachycardia
at 112 beats per minute, normal axis, normal intervals, [**Street Address(2) 11741**] depressions in V2 through V6, [**Street Address(2) 1766**] depressions in II,
III, AVF.
EKG #2 taken on [**3-15**] at 03:00 p.m., showing sinus
tachycardia at 137 beats per minute, 1 to [**Street Address(2) 1766**] depressions
in V1 through V6, [**Street Address(2) 4793**] depression in II, III, AVF.
EKG #3 taken on [**3-16**] at 12:30 a.m., showing normal
sinus rhythm at 99 beats per minute, normal axis, normal
intervals, resolution of ST and T wave changes.
BRIEF SUMMARY OF HOSPITAL COURSE: The impression was that
this is a 68 year old female with no prior known coronary
artery disease with likely chronic obstructive pulmonary
disease and emphysema secondary to extensive tobacco use,
transferred here with left pneumothorax and EKG changes with
global T wave inversions and increased cardiac enzymes, ruled
in for myocardial infarction.
1. Cardiovascular: A) Ischemia. Initially, it was not
clear if this patient's EKG changes and elevated cardiac
enzymes were consistent with thrombotic coronary disease or
more related to severe hypoxia suffered during the patient's
pneumothorax. The patient did not present with anginal type
symptoms or any history of such symptoms. The patient was
treated as if this was true intra-coronary disease. The
patient was placed on a heparin drip and was started on
aspirin. Beta blocker and ACE inhibitor were not started
secondary to hypotension and the prospect of starting a beta
blocker did not exist, taking into consideration this
patient's severe presumed obstructive lung disease. The
patient's cardiac enzymes were cycled, and CKs trended down
into the 200s with a negative MB index and negative troponin
throughout. Serial electrocardiograms were followed, showing
complete resolution of initial EKG changes on presentation to
[**Hospital6 5016**].
An echocardiogram was done one day after admission, showing
normal overall left ventricular systolic function with an
ejection fraction of greater than 55%,
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**]
Dictated By:[**Name8 (MD) 2692**]
MEDQUIST36
D: [**2172-3-18**] 15:17
T: [**2172-3-18**] 15:26
JOB#: [**Job Number 38996**]
ICD9 Codes: 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1379
} | Medical Text: Admission Date: [**2166-10-8**] Discharge Date: [**2166-10-18**]
Date of Birth: [**2166-10-8**] Sex: F
Date of Discharge: [**2166-10-18**]
Service: NB
HISTORY: Baby girl [**Known lastname 3640**] is the 2095 gram product of a 34 and
[**6-15**]-week (EDC [**2166-11-23**]) born to a 25-year-old G1/P0 (to 1) mother
with a history of asthma.
PRENATAL SCREENS: Blood group A+, antibody negative,
hepatitis B antigen negative, RPR nonreactive, rubella
immune, GBS negative. No sepsis risk factors.
PREGNANCY HISTORY: Unremarkable.
DELIVERY COURSE: The infant was delivered by spontaneous
vaginal delivery. She emerged vigorous with good cry. Apgar's
8 at one minute and 9 at five minutes. The infant was
admitted to the neonatal intensive care unit for prematurity.
PHYSICAL EXAMINATION ON ADMISSION: Weight 2095 grams, 25th
to 50th percentile; length 43.5 cm, 25th percentile; head
circumference is 31.5 cm, 25th to 50th percentile. Anterior
fontanelle open and flat. Palate and clavicles intact. Red
reflex positive bilaterally. Clear breath sounds with
aeration. Moderate grunting with mild retractions. A regular
rate and rhythm, no murmur, 2+ femoral pulses. Abdomen soft.
No masses. Normal female genitalia. Patent anus. Tone is
appropriate for gestational age.
HOSPITAL COURSE BY SYSTEMS:
1. CARDIOVASCULAR: Remained stable through hospital stay. A
soft systolic murmur was noticed on day of life #4. A
chest x-ray was done and was unremarkable. A 4-extremity
blood pressure and EKG were within normal limits.
Cardiology was consulted, and an echo with a structurally
normal heart. Murmur is due to PPS.
2. RESPIRATORY: Baby [**Known lastname 3640**] remained stable through hospital
course. She was placed on room air on admission, and
remained without any oxygen support through the entire
hospital course. She was followed for apnea of
prematurity. Her last episode was on [**10-12**]. She
remained spell free since then.
3. FLUIDS/ELECTROLYTES/NUTRITION/GI: On admission, she was
made n.p.o. and started on IV fluids with D-10-W. Feeds
were introduced on day of life #2. She advanced to full
feeds by day of life #4, and remained p.o. ad lib since
then. She is currently at breast milk 24, supplemented
with Similac. She demonstrated good weight gain, and her
discharge weight is 2090 grams on [**10-17**]. She was
followed for hyperbilirubinemia. Her bilirubin peaked at
day of life #3 at 12/0.3. She was treated with
phototherapy; and she is off phototherapy since day of
life #6, [**10-14**]; and her rebound bilirubin was 7.4
on [**10-15**]. At the time of discharge her weight was
2115 grams.
4. HEMATOLOGY: Initial CBC with a hematocrit of 36.7. No
blood transfusions were given through the hospital stay.
5. INFECTIOUS DISEASE: Initial CBC and blood culture were
done. CBC was 11.5 white blood cells, 17 poly's, 1 band,
73 lymphocytes, hematocrit 36.7, platelets 294. Blood
cultures remained negative. She was not treated with
antibiotics through her hospital stay.
6. NEUROLOGY: Exam appropriate for age. Remained stable
through hospital stay.
7. AUDIOLOGY: A hearing screen was done prior to discharge,
and she passed it on both ears.
8. OPHTHALMOLOGY: Ophthalmologic exam is not indicated.
Infant is 34 weeks, premature.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Discharged home with parents.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name (STitle) **] [**Name (STitle) 69462**], [**Location (un) 55**]
Peds; phone # ([**Telephone/Fax (1) 69463**].
CARE AND RECOMMENDATIONS:
1. Feeds at discharge: P.o. ad lib breast milk supplemented
to 24 calories with Similac.
2. Medications: None.
3. Car seat test was passed prior to discharge.
4. State newborn screen was done prior to discharge and
pending.
IMMUNIZATIONS RECEIVED: Hepatitis B was given on [**2166-10-14**].
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria: (1) born at less than 32
weeks; (2) born between 32 and 35 weeks with 2 of the
following: Daycare during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities, or
school-age siblings; or (3) with chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age (and for the first 24 months of the child's life)
immunization against influenza is recommended for household
contacts and out of home caregivers.
DISCHARGE FOLLOWUP: A follow-up appointment is scheduled
with primary care doctor.
DISCHARGE DIAGNOSES: Prematurity at 34 and 4/7 weeks; mild
respiratory distress; rule out sepsis; hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Doctor First Name 69464**]
MEDQUIST36
D: [**2166-10-17**] 10:14:54
T: [**2166-10-17**] 10:52:50
Job#: [**Job Number 69465**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1380
} | Medical Text: Admission Date: [**2169-8-27**] Discharge Date: [**2169-8-31**]
Date of Birth: [**2103-6-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
LLE erythema and swelling and lightheadedness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
PCP: [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **]
Dr. [**Known lastname **] is a 66 yo man who presents with 2 days of fever
and LLE redness and swelling. He recalls getting a bug bite on
[**8-24**] when out at [**Location (un) 14753**] for the day. On Friday, he developed
redness and swelling of the left anterior lower leg. Friday
night he had high fevers, up to 104, as well as increased
urinary frequency (voiding every hour). No dysuria. He also
notes decreased PO intake for the past 24 hours. Felt
lightheaded when standing on the day of admission and so called
his PCP's office and was referred to the ED. No sick contacts
though his two young grandsons (age 1 and 6) are visiting. No
history of DVT or cellulitis in the past. Denies chest pain,
cough, SOB, abdominal pain, nausea, vomiting.
In the ED, initial vs were: T 97.6, P 64, BP 82/54, R 18, O2 sat
99% on RA. BP was somewhat fluid responsive however would
persistently dip back down to the 80s systolic. After receiving
a total of 5L IVF, his BP stabilized in the high 90s. Left
lower leg was notably erythematous and swollen. Labs notable
for WBC 21.7, lactate 2.1-->2.6 despite IVF, Cr 2.1 (baseline
1.2-1.3). Xray of the left tib/fib was unremarkable without
subcutaneous air. He was given unasyn and vanco and tylenol.
He was admitted to the ICU. The patient had good PO intake, so
he was given free access to fluids and encouraged to drink and
eat. While in the ICU he was continued on Cipro for coverage of
possible UTI and cellulitis and Vancomycin for coverage of
possible MRSA. He was afebrile until 1400 on [**8-27**] when he was
febrile to 101.3. Cellulitis margins did not progress on
current antibiotic regimen. Required bolus of 500cc ivf for
systolic blood pressure in the 100's improved to 120's.
Outpatient hypertension medications and flomax were in icu.
Past Medical History:
Prostate CA-- being observed with watchful waiting
Hypertension
Hyperlipidemia
Social History:
Widowed, lives alone. His only daughter is currently visiting
from [**Location (un) **] with his son-in-law and 2 young grandsons.
Pediatric ID physician at [**Hospital1 2177**]. Quit smoking 10-15 years ago.
Occasional EtOH use.
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 96.5, BP: 98/63, P: 62, R: 15, O2: 95% on 2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Mild bibasilar rales, no wheezes
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: L anterior lower leg is swollen, erythematous, and mildly
tender to touch; area of erythema appears to be somewhat receded
from the border outlined in the ED; 2+ bilateral pedal pulses,
[**6-20**] lower extremity motor strength bilaterally
Pertinent Results:
On admission:
[**2169-8-26**] 07:20PM WBC-21.7*# RBC-4.67 HGB-14.4 HCT-41.4 MCV-89
MCH-30.8 MCHC-34.8 RDW-13.4 PLT COUNT-247
NEUTS-95.5* LYMPHS-2.0* MONOS-2.0 EOS-0.3 BASOS-0.2
[**2169-8-26**] 07:20PM GLUCOSE-145* UREA N-30* CREAT-2.1* SODIUM-139
POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-25 ANION GAP-17
U/A
[**2169-8-26**] 10:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2169-8-26**] 10:30PM URINE HYALINE-6*
[**2169-8-26**] 10:30PM URINE RBC-0-2 WBC-[**1-5**]* BACTERIA-FEW
YEAST-NONE EPI-0-2
On discharge:
[**2169-8-31**] 06:20AM BLOOD WBC-8.7 RBC-4.31* Hgb-13.4* Hct-38.7*
MCV-90 MCH-31.1 MCHC-34.7 RDW-13.6 Plt Ct-265
[**2169-8-31**] 06:20AM BLOOD Glucose-130* UreaN-12 Creat-1.3* Na-137
K-4.1 Cl-103 HCO3-25 AnGap-13
Imaging:
Tib/fib xray [**2169-8-26**]: 1. No gas in the soft tissues. No
osteolysis.
2. A small fragment below the medial malleolus likely represents
an avulsion injury, age indeterminant, probably old. Correlate
clinically.
Chest PA/Lat [**2169-8-26**]: 1. Left lower lobe airspace opacification
consistent with early pneumonia. 2. Incompletely characterized
suspected lytic lesion of the fourth rib. Consider dedicated rib
series for further characterization.
Left LE US [**8-27**]: No evidence of DVT in the left lower extremity.
Peroneal veins not well seen. PTV well patent.
CT lower extremity with contrast [**8-28**]: Diffuse subcutaneous
edema throughout the left leg and ankle in keeping with
cellulitis. No focal fluid collections.
Foot AP/Lat/Obl left [**8-28**]: Three views of the foot show no
evidence of acute bone or joint space abnormality. No evidence
of calcaneal spurring. Views of the ankle show no acute bone
abnormality. Areas of vascular calcification are seen.
Brief Hospital Course:
Dr. [**First Name (STitle) **] is a 66 year old man presented with two days of
high fever and LLE erythema, swelling, urinary urgency,
hypotension, and now transferred to the floor after a day in ICU
receiving antibiotics and fluid resuscitation.
The swelling of the leg was most likely cellulitis, and he was
ruled out on DVT, necrotizing fasciitis and osteomyelitis. The
patient had hemodynamic improvement and the leukocytosis was
trending downwards on vancomycin and ciprofloxacin, but had a
spike in temperature in the early AM of [**8-28**]. In order to give
the patient more broad spectrum coverage, the patient was
switched from Ciprofloxacin to Unasyn. his blood and urine
cultures remained negative. He was discharged to complete a
course of augmentin.
The patient also initially presented with acute on chronic renal
failure: The patient presented with an elevated creatinine of
1.8 (baseline 1.2). With bolus fluids, treatment of his
infection and increased PO intake, his creatinine reduced to
1.4. BUN/Cr ratio slightly less than 20:1. The patient was
likely pre-renal from likely sepsis vs. volume depletion. His
creatinine improved with hydration and improvement of his blood
pressure, and it trended down to near his baseline on discharge.
His home BP medications were held until a day prior to
discharge, when he was started on amlodipine, valsartan, and
atenolol. Patient was told to re-start on his
hydrochlorothiazide four days after discharge.
Lastly, a lytic bone lesion on CXR: Radiology commented on a
lytic bone lesion on the 4th right rib incidentally found on
CXR. The patient has no symptoms. In addition, the patient might
also have another lytic lesion on the left side. We recommend
dedicated rib series in the future for further characterization.
Medications on Admission:
Atenolol 50mg PO BID
Amlodipine 10mg PO daily
HCTZ 25mg PO daily
Valsartan 320mg PO daily
Atorvastatin 10mg PO qHS
Flomax 0.4mg PO daily
Vicodin 5mg-500mg 1-2 tabs QID prn
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 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO Q AM ().
8. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-17**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
10. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO every six (6) hours as needed for foot pain for 4 days: Do
Not combine with additional tylenol.
Disp:*32 Tablet(s)* Refills:*0*
11. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis
Septic Shock
Discharge Condition:
Good, afebrile
Discharge Instructions:
You were admitted to the hospital and found to have a cellulitis
infection of your leg, along with fevers and hypotension. You
were supported with fluids and antibiotics. Your blood pressure
returned to baseline and your antihypertensive medications, with
the exception of hydrochlorothiazide, were restarted.
You should continue taking augmentin for seven more days.
You should begin taking hydrochlorothiazide on [**2169-9-3**].
You will be given a prescription for vicodin to treat your foot
pain.
Do NOT take additional acetominophen with this medication, as
the maximum allowed dose of acetominophen is 4000mg daily.
Please continue taking your other medications as prescribed.
Please try to ambulate as tolerated. When at rest, please rest
with your foot raised.
Please call your doctor or return to the hospital if you
experience fever, chest pain, shortness of breath, abdominal
pain, worsening leg redness, bleeding, or any other concerning
symptom.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. Phone:[**Telephone/Fax (1) 277**]
Date/Time:[**2170-1-24**] 10:00
MD: NP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: [**Company 191**],
Date and time: [**2169-9-12**] 11:00am
Location: [**Location (un) 830**] [**Hospital Ward Name 23**] Building [**Location (un) 895**] North
Suite
Phone number: [**Telephone/Fax (1) 250**]
ICD9 Codes: 0389, 5849, 2768, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1381
} | Medical Text: Admission Date: [**2113-6-4**] Discharge Date: [**2113-6-10**]
Date of Birth: [**2055-3-17**] Sex: M
HISTORY OF PRESENT ILLNESS: This is a 58-year-old male with
a 5-year history of a large right lobe cavernous hemangioma.
He was admitted to [**Hospital1 69**] on
[**5-31**] after experiencing the subacute onset of fevers,
time to have had a intrahepatic mass bleed requiring 2 units
of packed red blood cells. He stabilized and sent home for
the weekend with plans to come back on [**6-4**] to undergo the
resection of this hemangioma which had now become unstable.
PAST MEDICAL HISTORY: Past medical history significant for
hypercholesterolemia which has since resolved.
MEDICATIONS ON ADMISSION: None.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION ON PRESENTATION: Examination at the
time of admission revealed his lungs were clear to
auscultation bilaterally. His heart had a regular rate and
rhythm. His abdomen was soft, nontender, and nondistended.
His extremities were warm and well perfused.
HOSPITAL COURSE: The patient was admitted to the General
Surgical Service on [**2113-6-4**]. Initial laboratory values
at that time demonstrated a hematocrit of 34.2, an alkaline
phosphatase of 559, and a total bilirubin of 2. The rest of
his laboratories were unremarkable.
On [**6-5**], the patient underwent an uncomplicated resection
of the hemangioma of his right hepatic lobe with minimal
resection of the liver parenchyma itself. The patient
tolerated the procedure well.
Overnight, the patient was recovered in the Surgical
Intensive Care Unit predominantly because of a 5.5-liter
blood loss intraoperative. He remained intubated until
postoperative day one at which time he was extubated without
difficulty.
He was transferred to the floor on postoperative day one and
had an uneventful postoperative course thereafter. He
continued to have low-grade fevers postoperatively, but by
the day of discharge had remained afebrile for greater than
24 hours.
On postoperative day four, the patient passed flatus and had
a bowel movement, and his diet was advanced without
difficulty. His urine output had remained more than adequate
throughout his hospital stay. The Foley catheter was
discontinued on postoperative day three. His total bilirubin
rose to 8 on the day of operation but continued to trend
downward to 2 on postoperative day four. His hematocrit had
dropped to 29 postoperatively after resuscitation and blood
products. On the day of discharge, his hematocrit has
stabilized at around 27. The pathology on the specimen was
positive only for hemangioma with areas of infarct. He had a
blood culture from [**6-6**] that grew out 1/4 bottles positive
for guaiac-negative Staphylococcus; consistent with a skin
contaminant and was not treated for such.
On the day of discharge, the patient had remained afebrile,
was tolerating a regular diet, was voiding freely with normal
bowel movements, and having his pain controlled on oral
myelodysplastic syndrome. On the day of admission, the
lateral [**Location (un) 1661**]-[**Location (un) 1662**] drain was removed. The medial drain
was left in place.
MEDICATIONS ON DISCHARGE: The patient was restarted on all
of his preadmission medications with the inclusion of
Percocet one to two tablets p.o. q.4-6h. p.r.n. for pain.
PHYSICAL EXAMINATION ON DISCHARGE: The patient's lungs were
clear to auscultation bilaterally. His heart had a regular
rate and rhythm with no murmurs, rubs or gallops. His belly
was soft and nondistended with mild incisional tenderness
along the Chevron incision. The wound was clean, dry, and
intact.
DISCHARGE DIAGNOSES: Right hepatic lobe hemangioma, status
post resection and cholecystectomy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**Last Name (NamePattern1) 3801**]
MEDQUIST36
D: [**2113-6-13**] 14:55
T: [**2113-6-13**] 16:21
JOB#: [**Job Number 4568**]
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1382
} | Medical Text: Admission Date: [**2172-4-20**] Discharge Date: [**2172-4-28**]
Date of Birth: [**2132-8-14**] Sex: M
Service: Trauma
HISTORY OF PRESENT ILLNESS: The patient is a 39-year-old
gentleman unrestrained driver of a car that hit a wall with
significant damage to the car and no loss of consciousness.
The patient was hemodynamically stable, taken to [**Hospital 48386**]
Hospital, where multiple x-rays demonstrated pelvic and foot
fractures, which is transferred to [**Hospital3 **] for further
treatment.
PAST MEDICAL HISTORY:
1. Psychotic disorder with history of multiple psychiatric
admissions.
2. History of three previous severe motor vehicle collisions.
PAST SURGICAL HISTORY:
1. Laparotomy from previous motor vehicle collision.
2. Left hip fracture that was fixed surgically.
3. Multiple long bone fractures also fixed surgically.
MEDICATIONS:
1. Depakote.
2. Haldol.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Two pack per day smoker, lives alone.
PHYSICAL EXAMINATION: Initial vital signs: Temperature of
98.4, blood pressure 130/80, respiratory rate 16, and sating
99%, heart rate 99. Patient had a right cheek laceration
around 4 cm. Pupils are equal, round, and reactive to light.
There is periorbital ecchymoses. Tympanic membranes are
clear. Lungs are clear to auscultation bilaterally. Heart
regular, rate, and rhythm. Abdomen is soft, nontender,
nondistended. Pelvic: Tenderness to palpation. There is a
4 cm laceration over the right knee with exposure of the
joint.
INITIAL LABORATORIES: Hematocrit of 39 and urine screen was
positive for cocaine and opiates, and serum tox is negative.
Chest x-ray showed no widen mediastinum and no fracture.
Pelvis x-ray showed a left acetabular fracture.
CT scan of the head shows subarachnoid hemorrhage of the left
and right frontal. Abdominal CT scan showed minimal amount
of fluid around the liver. Chest CT scan showed large right
middle lobe collection and air fluid level in the right lower
lobe. Pelvic CT scan showed right acetabular fractures that
is intraarticular, and left rami fracture. CT scan of the
spine was negative. Knee films show a right patellar
fracture. X-rays of the left hand showed multiple metacarpal
injuries, fractures. Right foot film showed metatarsal
fractures, multiple.
Orthopedics was consulted, and patient went to the operating
room for washout of the right knee and repair of the patella.
The acetabular fractures were not fixed per Orthopedics. The
patient remains nonweightbearing on the right and touchdown
weightbearing on the left, and weightbearing as tolerated on
the left.
Per Neurosurgery, repeat CT scan of the head was obtained.
Showed improvement in the bleed. Therefore, no operative
management was required. Psychiatry consult was obtained as
well. A sitter was recommended given the patient's possible
suicidal tendency. The patient was told to continue his
depakote. He is diagnosed with schizo-affective disorder by
history, cocaine dependence, and resolving delirium.
The patient was transferred to the floor on [**2172-4-25**].
Patient also had a bronchoalveolar lavage to better assess
the fluid collection as well as workup of elevated
temperature. They all grew gram-negative rods and a fungi,
thus not [**Female First Name (un) 564**] albicans. Patient was started on Levaquin
for duration of [**6-18**] days as well as fluconazole for 7-10
days.
The patient was stable on the floor, hemodynamically stable,
and patient is tolerating po and sitter was discontinued.
The patient also had a Physical Therapy consult, which
recommended physical therapy 3x a week. Given the patient's
weightbearing status, the patient will be transferred to
rehabilitation facility for further evaluation and further
management.
DISCHARGE MEDICATIONS:
1. Lovenox 30 mg subQ [**Hospital1 **] x1 week, then 60 mg subQ [**Hospital1 **].
2. Levaquin 500 mg po q day until [**5-3**].
3. Fluconazole 200 mg po q day until [**5-3**].
4. Percocet 1-2 tablets po q4-6h for pain.
5. Albuterol.
6. Colace.
7. Depakote 1,000 mg po bid starting on the 20th and prior to
that, 750 mg.
CONDITION ON DISCHARGE: Good.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18153**], M.D. [**MD Number(1) 18154**]
Dictated By:[**Last Name (NamePattern1) 19796**]
MEDQUIST36
D: [**2172-4-27**] 12:59
T: [**2172-4-27**] 13:11
JOB#: [**Job Number 48387**]
ICD9 Codes: 2851, 486 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1383
} | Medical Text: Admission Date: [**2179-10-31**] Discharge Date: [**2179-11-12**]
Date of Birth: [**2128-2-5**] Sex: M
Service: MEDICINE
Allergies:
Latex
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Low urine output
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 51 year-old M w/ a h/o MS, quadraparesis, HTN,
[**First Name3 (LF) 12382**] lung disease, chronic constipation and SBOs s/p
ileostomy, multiple UTIs (also s/p suprapubic tube) presents
with SBO and UTI. Of note he was just recently discharged from
the [**Hospital1 18**] on [**10-28**] for an admission for a UTI (negative cultures)
treated with cipro, shingles treated w/ acyclovir and SBO
evaluated by surgery but managed conservatively. He returns
today as his home health aide had noticed his decreased urine
output, 75cc overnight when he usually has about 1 liter
overnight. His ostomy output has been high. The patient himself
was not sure if he has had a change in his ostomy output or
suprapubic output.
.
Over the past two weeks he has had mild earaches, a sorethroat
as well as some rhinorrhea. He has not noticed any watery /
itchy eyes, any visual changes, or any new neurologic symptoms.
He denies any abdominal pain and has not subjectively noticed
any change in abdominal distention. He denies any pain in
regards to his zoster (now or when diagnosed). Denies CP, has
an occasional cough that is not worsening. Of note, his sister
reports he does not report pain unless it is extreme.
.
In the ED, he was noted to be severely dehydrated on exam. His
BP nadir was 79/43 and HR peak was 97. T 99 (he usually "runs
low"), new ARF 1.4 up from 0.6. Rec'd levo / flagyl / vanc.
Seen by Surgery who state the SBO is not high grade and he is
losing fluid from ileostomy. NGT placed. Rec'd 6L of fluids.
VS prior to transport were: HR 72 BP 112/79 100% 4L NC
(initially sating well on RA but may have aspirated w/ NGT
plcmt- desat to 92% w/ coughing and SOB).
Past Medical History:
-MS
[**Name13 (STitle) 95154**], LE weaker than UE
-HTN
-[**Name13 (STitle) **] lung disease
-obstructive sleep apnea, on nocturnal BiPAP (IPAP 16, EPAP 14)
-Severe gastroparesis
-Chronic constipation s/p colectomy with ileostomy
-Recurrent UTIs with suprapubic cath (changed monthly)
-Hyponatremia
-Appendectomy
-Left axillary lumpectomy
Social History:
Lives at home with parents and sister; has home health aid. No
alcohol. Quit smoking in [**2159**], with a 10-year tobacco history.
Family History:
Non-contributory
Physical Exam:
Vitals: T: 95.5 BP: 132/68 HR: 77 RR: 12 O2Sat: 98-100% on
RA
GEN: Well-appearing, well-nourished, no acute distress
HEENT: PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM,
OP Clear
NECK: JVP 7-8cm, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, 1/6 SEM @ USB w/o radiation
PULM: Lungs L base rales
ABD: distended, BS hypoactive, mild LLQ tenderness. No rebound
or guarding. Suprapubic site looks c/d/i. Ileostomy pink w/
bilious watery output.
EXT: No C/C/E, no palpable cords.
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
intact. + rotatory nystagmus. UE: [**6-7**] stregnth in grip, bicep,
triceps, deltoid, and trapezius. LE - [**Month/Day (1) 5348**] inability to
move lower extremities. significant bilateral clonus in lower
extremities. Reflexes 2+ UE bilat symmetrical, LE 3+ bilat
symmetrical.
Pertinent Results:
On Admission:
[**2179-10-31**] 10:25AM WBC-15.7*# RBC-3.71* HGB-11.2* HCT-33.4*
MCV-90 MCH-30.3 MCHC-33.6 RDW-14.7
[**2179-10-31**] 10:25AM NEUTS-83.9* LYMPHS-8.9* MONOS-6.1 EOS-1.0
BASOS-0.1
[**2179-10-31**] 10:25AM PLT COUNT-524*#
[**2179-10-31**] 10:25AM GLUCOSE-116* UREA N-15 CREAT-1.4* SODIUM-128*
POTASSIUM-5.1 CHLORIDE-94* TOTAL CO2-23 ANION GAP-16
[**2179-10-31**] 12:05PM URINE RBC-[**4-7**]* WBC->50 BACTERIA-MANY
YEAST-MANY EPI-0-2
[**2179-10-31**] 12:05PM URINE MUCOUS-MOD
[**2179-10-31**] 10:35AM LACTATE-2.4* K+-4.8
[**2179-10-31**] 12:05PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2179-10-31**] 12:05PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.010
[**2179-10-31**] 08:26PM URINE HOURS-RANDOM CREAT-105 SODIUM-55
[**2179-10-31**] 09:03PM LACTATE-0.9
Brief Hospital Course:
#. Partial small bowel obstruction: Within past 6 months he has
had several admits with partial obstruction. Presented with
considerable ileostomy output and hypotension. KUB and CT
abdomen consistent with partial obstruction. Surgery was
consulted and felt either partial SBO or unchanged from prior
admission given the amount of ostomy output. Recommended to
watch for cessation of output or signs of peritonitis, as these
would be indications of worsening and surgery would be
considered. At that time, there was no indication for surgery.
An NG tube was placed for gut decompression, and the patient was
kept NPO and given IVF. We attempted to match ostomy output with
IV fluids. Per Surgery recommendations, we consulted GI to
consider placement of G tube, given the frequency of these
episodes. Consideration was given to opening this tube for
decompression if he becomes obstructed again. He was evaluated
by GI on [**2180-11-1**], and they felt that G tube would not be
appropriate in the setting of an acute partial obstruction, and
we would re-address if this is something the family would want
in the future. If so, they recommended that IR may be more
appropriate for placement given his aspiration risks.
.
The possibility of undiagnosed Crohn's disease accounting for
distal small bowel strictures, which in turn have been
contributing to SBOs, was raised and discussed at length. If
confirmed, GI would recommend a trial of empiric steroids. The
GI team also contact[**Name (NI) **] Pathology to re-cut tissue from frozen
sections of colon, resected during prior surgeries, to look for
evidence of IBD. Of significant concern was that if Mr. [**Known lastname 26173**]
does have Crohn's, starting him on steroids would be
challenging. The risks could outweigh the benefits, and it
would be unlikely that steroids would reverse the small bowel
strictures already present. In addition, we would need to
involve his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 665**], and his neurologist, Dr. [**Last Name (STitle) 95158**],
in the discussion. We would also need to readdress his
overall goals of care, as his family has been considering
hospice care.
.
Given his prolonged NPO status, he was started on TPN. Mr.
[**Known lastname 95159**] obstruction gradually improved with NGT to suction, and
it was clamped on [**2179-11-8**]. His ostomy output increased and it
was decided to proceed with small bowel MR enterography to look
for evidence of bowel wall inflammation or strictures to support
the diagnosis of possible IBD. There was no evidence of this.
We concluded his recurrent SBOs are most likely secondary to
worsening multiple sclerosis. He continued to improve
clinically, and his NGT was removed on [**11-11**]. The following day
he had a swallowing evalution, which showed no evidence of
aspiration, and he was started on a regular diet. His family was
eager to take him home to gradually advance his diet there. TPN
was discontinued.
.
# UTI: No fevers on admission but he had leukocytosis and
hypotension, likely due to hypovolemia, as well as elevated
lactate. Prior pathogens have included Pseudomonas, with a MIC
of 9 for cefepime and zosyn, and MRSA. He was initially
empirically started on vancomycin and ceftazidime. Urine culture
grew few gram negatives (likely contaminant) and yeast. As his
leukocytosis and hypotension improved, and given the above urine
culture, ceftazidime was discontinued.
.
# Hypotension: This was attributed to hypovolemic shock, and
initially also possibly due to sepsis. This improved with IVF
resuscitation. In addition, given his initial hyponatremia and
hyperkalemia, a.m. cortisol was checked and found to be normal.
.
# Acute renal failure: On admission. FeNa 0.6% indicating likely
prerenal etiology. Resolved with administration of IVF.
.
# OSA: Desatting to 60s without BiPap. Needs to be on BiPap at
night. Has machine at home.
.
# Anemia: Hematocrit 27.8 on [**2179-11-2**], down from 33.4 at
admission. Was likely hemoconcentrated on admission given
dehydration. No evidence of acute blood loss. Hematocrit was
monitored daily, and he was maintained on his daily folic acid.
.
# Hypertension: Restarted on lisinopril per home regimen on
[**2179-11-2**]. Dose titrated up to 10 mg/day on [**11-10**] as patient was
persistently hypertensive.
.
# Multiple sclerosis: Methotrexate weekly given IM. Dose
confirmed with Neurologist.
.
#Goals of care: Patient lives with his supportive family, with
his mother as his primary caretaker along with his sister who
lives nearby. They are very devoted to him and recognize that
his disease is quite advanced. Discussions were held between
the patient's mother and sister and the attending, Dr. [**Last Name (STitle) **],
who also spoke with the patient's PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 665**]. They wish
to take Mr. [**Known lastname 26173**] home as soon as possible. They have a hospice
program that is ready to accept him into their care when they
are ready and know how to activate this benefit when they feel
it is time.
Medications on Admission:
Gabapentin 300 mg po q6hrs
Folic Acid 1 mg po daily
Metoclopramide 10 mg po qid AC and HS
Erythromycin 250 mg po q6hrs
Modafinil 200 mg po bid
Memantine 10 mg Tablet po bid
Lisinopril 5 mg po daily
Methotrexate Sodium 15mg (6x2.5mg tablets) po q week on sundays
Acyclovir 800 mg po q8hrs, end date [**2179-10-31**]
Ciprofloxacin 250 mg po q12hrs x 3 days, last day [**2179-10-31**]
Prilosec
Guaifenesin 600 mg po bid
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q6HRS ().
2. Memantine 5 mg Tablet Sig: Two (2) Tablet PO bid ().
3. Modafinil 100 mg Tablet Sig: Two (2) Tablet PO bid ().
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Methotrexate Sodium 15 mg Tablet Sig: One (1) Tablet PO once
a week: on Sundays.
7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO four times
a day: QAC and QHS.
8. Erythromycin 250 mg Tablet Sig: One (1) Tablet PO every six
(6) hours.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
10. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO twice a day.
Discharge Disposition:
Home With Service
Facility:
Gentiva
Discharge Diagnosis:
-- small bowel obstruction
-- chronic constipation s/p colectomy with ileostomy
-- multiple sclerosis
-- hypertension
-- [**Month/Day/Year 12382**] lung disease
-- obstructive sleep apnea on nocturnal CPAP
Discharge Condition:
Clinically stable, tolerating a regular diet.
Discharge Instructions:
You were admitted with recurrent small bowel obstruction. You
were treated with bowel rest and decompression via nasogastric
tube. You were followed closely by the GI consult team, and an
MRI enterogram did not show any evidence of inflammatory bowel
disease. After your obstruction improved, we clamped and
eventually removed your NG tube. You did well with a swallowing
evaluation and can eat and drink whatever you'd like when you go
home.
Followup Instructions:
Please contact your [**Name (NI) 6435**] office (Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 665**]) if you would
like an appointment.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2179-11-17**]
ICD9 Codes: 2761, 5990, 2930, 5849, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1384
} | Medical Text: Admission Date: [**2159-8-14**] Discharge Date: [**2159-8-18**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
OSH transfer for left thalamic hemorrhage
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname 915**] is an 86 year-old right-handed woman with a past
medical history including hypertension, hyperlipidemia, COPD on
3L O2, s/p pacemaker placement and TIAs who initially presented
to [**Hospital6 204**] with language difficulties and was
transferred to the [**Hospital1 18**] when she was found to have a left
thalamic hemorrhage in the context of hypertension (bp 154/87).
.
The patient's daughter [**Name (NI) **] explained that the patient seemed
well until about 8:30 pm on [**2159-7-14**]. At that time, she noticed
Ms. [**Known lastname 915**] was not contributing to the conversation as she
normally would. The patient ultimately spoke in full English
grammatically correct sentences that seemed to have little
relevance to the ongoing conversation. Her daughter recalls she
couldn't seem to follow her mother's train of thought. She did
not ask her mother to try to read or write. Concerned she might
be experiencing a vascular event, she tried to convince her
mother to take aspirin 325 mg (which she ultimately did). When
the symptoms did not resolve, she called the patient's PCP. [**Name10 (NameIs) **]
the recommendation of the PCP, 911 was called and the patient
was
transported to [**Hospital6 204**]. There initial vital
signs included a blood pressure of 154/87, hr 83, rr 16, O2 sat
94% on 2L. An initial examination was not available for review.
A non-contrast CT of the head was performed and demonstrated a
left thalamic hemorrhage. Accordingly, the patient was
transferred to the [**Hospital1 18**] for further evaluation and care. At
the
time of the interview, the patient agrees she seems to be having
some difficulty using the right words to communicate her
Past Medical History:
- hypertension
- hyperlipidemia
- CAD, s/p MI
- CHF (EF unknown)
- COPD, on 3 L suppl O2 at baseline
- TIA - details of events unknown
- reports of DM denied by patient and family
PAST SURGICAL HISTORY
- pacemaker placement (family unaware of reason)
- CABG
- bilateral cataract repair
Social History:
- retired nurse supervisor
- lives independently
- has four children (although she initially tells me she has
three)
- has one grandchild
Family History:
negative for known neurological conditions
Physical Exam:
General: Awake, cooperative, NAD.
HEENT: Normocepahlic, atraumatic, no scleral icterus noted.
Mucus
membranes dry, no lesions noted in oropharynx
Neck: Supple.
Cardiac: Regular rate, III/VI harsh blowing systolic murmur
Pulmonary: Lungs clear to auscultation bilaterally anteriorly.
Abdomen: Round. Normoactive bowel sounds. Soft. Non-tender,
non-distended.
Extremities: Warm, well-perfused.
Skin: no rashes or concerning lesions noted.
NEUROLOGIC EXAMINATION:
Mental Status:
* Degree of Alertness: Alert.
* Orientation: Oriented to person, "hospital," initially names
year as [**2108**] - and then indicates she knows this is incorrect
* Attention: Attentive. Able to name the days of the week
backwards without difficulty.
* Memory: Pt able to repeat 3 words immediately and recall 0/3
unassisted at 30-seconds (repeated trials at this point) and 0/3
at the next 30 second interval. Able to correctly identify
birthdate.
* Language: Language is fluent with evidence of paraphasic
errors
(eg "closet" for cabinet). Repetition is intact. Comprehension
appears intact; pt able to correctly follow basic midline and
appendicular commands. Prosody is normal. Pt able to name high
(pen) and low frequency objects (knuckles) without difficulty.
Of NIH card items, refers to glove as "wrist" and cactus as
"mushroom" otherwise correct. [**Location (un) **] and writing abilities
intact.
* Calculation: Pt able to calculate number of quarters in $1.50
* Neglect: No evidence of sensory of neglect.
* Praxis: No evidence of apraxia (mimes tooth brushing).
Cranial Nerves:
* I: Olfaction not evaluated.
* II: surgical pupils with right 4--> 3mm, left 3 --> 2 mm.
Visual fields full to confrontation (despite claim above).
Fundi
not well-visualized.
* III, IV, VI: EOMI without nystagmus. Normal saccades.
* V: Facial sensation intact to light touch in the V1, V2, V3
distributions.
* VII: subtle decrease in excursion of right aspect of mouth
with
showing of teeth (sons indicate at baseline)
* VIII: Hearing intact to finger-rub bilaterally.
* IX, X: Palate elevates symmetrically.
* [**Doctor First Name 81**]: 5/5 strength in trapezii bilaterally.
* XII: Tongue protrudes in midline.
Motor:
* Bulk: No evidence of atrophy.
* Tone: Normal.
* Drift: No pronator drift (although does not fully supinate to
start).
Strength:
* Left Upper Extremity: 5 throughout Delt, Biceps, Triceps,
Wrist Ext, Wrist Flex, Finger Ext, Finger Flex
* Right Upper Extremity: 5 throughout Delt, Biceps, Triceps,
Wrist Ext, Wrist Flex, Finger Ext, Finger Flex
* Left Lower Extremity: 5 throughout Iliopsoas, Quad, Ham, Tib
Ant, Gastroc, Ext Hollucis Longis
* Right Lower Extremity: 5 throughout Iliopsoas, Quad, Ham, Tib
Ant, Gastroc, Ext Hollucis Longis
Reflexes:
* Left: 2+ throughout Biceps, Triceps, Bracheoradialis, unable
to obtain Patella, Achilles
* Right: 2+ throughout Biceps, Triceps, Bracheoradialis, unable
to obtain Patella, Achilles
* Babinski: extensor on right, flexor on left
Sensation:
* Light Touch: intact bilaterally in lower extremities, upper
extremities, trunk, face
* Pinprick: intact bilaterally intact bilaterally in lower
extremities, upper extremities, trunk, face
* Temperature: altered sensation of cold on right upper, lower
extremity (seems warmer), intact to cold in left limbs,
bilateral
face
* Vibration: intact bilaterally at level of patella
* Proprioception: unable to detect subtle excursions of great
toe, intact at ankle bilaterally
* Extinction: No extinction to double simultaneous stimulation
Coordination
* Finger-to-nose: intact bilaterally with intention tremor L>R
Pertinent Results:
[**2159-8-14**] 06:30AM URINE BLOOD-LG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-SM
[**2159-8-14**] 06:30AM URINE RBC-21-50* WBC-[**12-8**]* BACTERIA-MANY
YEAST-NONE EPI-[**3-23**]
[**2159-8-14**] 05:45AM cTropnT-0.02*
[**2159-8-14**] 05:45AM proBNP-6468*
Brief Hospital Course:
Ms [**Known lastname 915**] is a RHF with a past medical history of HTN,
Hyperlipidemia, COPD using 3L O2, TIA's and s/p pacemaker. Who
presented to [**Hospital6 **] for language difficulties.
Initial workup there revealed HTN, language difficulties and a
left thalamic hemorrhage. The patient was then transferred here
[**Hospital1 18**] for further workup. Upon evaluation here the patient was
noted to have language difficiulties. Notable for disorientation
to time, date, anommia, paraphasic errors and poor short term
memory. Initially there was decreased temperture and pinprick
sensation on the right side both upper and lower extremities
that had noramalized by the time of the discharge. The patient
was initially taken to the ICU for closer observation. There was
no acute events during ICU evaluation and observation. A repeat
CT head did not show expansion of the hemorrhage. The patients
blood pressure was then stabalized with amlodipine 5mg daily.
The patient was then transferred to the floor for further
evaluationand observation. the patient did not have any acute
events on the general neurology unit. She was evaluated by
physical therapy and the decision was made that she would
benefit from rehabilitation. She was discharged in stable good
condition to the rehab unit with specific speech rehabilitaion
for thalamic type aphasia.
Medications on Admission:
Unknown. She does tno take any medications with any regualr
frequency. And more specifically does not take lasix as
prescribed.
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constip.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for temp > 100.4, pain.
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Hold if SBP < 105.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] [**Hospital1 189**]
Discharge Diagnosis:
- Left thalamic hemorrhagic stroke
- acute renal insult
- hypertension
- hyperlipidemia
- CAD, s/p MI, s/p CABG, Pacemaker
- CHF (EF unknown)
- COPD, on 3 L suppl O2 at baseline
- TIA - details of events unknown
- reports of DM denied by patient and family
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair and requires assistance or aid (walker or cane) for
ambulation.
Discharge Instructions:
You were transferred from [**Hospital6 204**]. You were
noted to have a Left thalamic hemorrhage and transfered to [**Hospital1 18**]
ICU. You were observed in the ICU with no significant change in
your neurological status. You had a CT scan which showed no
significant change in your stroke. You did not get an MRI
because you had a pacemaker. You had a noted elevated blood
pressure. You were also found to have a UTI with e.coli that was
pan-sensitive. You were treated with 2 days of levaquin
500mg/day and 1 day of SS bactrim. You were noted to have
increased Cr from your baseline of 1.1 to 1.4. Your ACEI and
your Levaquin was discontinued becasue of this and you were
given 1.25 liters of normal saline. You were then started on
norvasc 5mg which controlled your blood pressure. You had a
repeat chemistry panel which showed a lower Cr level at 1.3.
Your oxygen saturation remained stable on your home oxygen
requirements of 3L per NC.
Followup Instructions:
[**Hospital 4038**] Clinic: [**Last Name (LF) **], [**Name8 (MD) 2530**] MD. date/time: Monday [**9-17**]
1:30pm phone #([**Telephone/Fax (1) 7394**]
PCP: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]: Please make an immediate appointment
to be seen next week. Office opens on Monday [**8-20**] Phone #
[**Telephone/Fax (1) 87598**]
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2159-8-21**]
ICD9 Codes: 431, 5849, 5990, 4280, 4019, 2724, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1385
} | Medical Text: Admission Date: [**2158-12-7**] Discharge Date: [**2158-12-12**]
Date of Birth: [**2113-11-25**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 45 year old
female, being anticoagulated with Coumadin, status post
mitral valve replacement, #27 Carbomedics in [**2151**]. She
presented to the Emergency Department with one day history of
abdominal pain and bright red blood per rectum. The patient
usually takes 7 mg of Coumadin during the week days and 9 mg
of Coumadin on the weekends, as per husband who administers
her medications. Reportedly, she had an INR of 3.2 ten days
prior to admission. One day prior to admission, the patient
started having crampy abdominal pain, mostly in the left
lower quadrant. Pain was non radiating but progressively
worsened in intensity. Since the beginning of the abdominal
pain, the patient reports having passed three bloody bowel
movements with visible clots in the toilet. The patient
denies fevers, chills, sweats or any other systemic symptoms.
PAST MEDICAL HISTORY: Rheumatic heart disease with mitral
stenosis and mitral regurgitation, status post mitral valve
replacement in [**2151**], with 27 mm Carbomedics mitral valve
(mechanical). Asthma. Hypercholesterolemia. Anxiety. Panic
disorder. History of poly substance abuse, including alcohol
and cocaine. [**Location (un) 15587**] disease.
PAST SURGICAL HISTORY: Mitral valve replacement in [**2151**] as
mentioned above. Tubal ligation.
ALLERGIES: The patient reports allergic reaction to
Penicillin and aspirin.
MEDICATIONS AT HOME:
Lipitor 20 mg p.o. q. day.
Coumadin regular home regimen of 7 mg on week days and 9 mg
p.o. q. day on weekends, although the history is not clear
whether the patient had been taking mostly 9 mg p.o. q. day
prior to admission.
Zyprexa 5 mg p.o. q h.s.
Clonidine 0.1 mg p.o. q h.s.
Trazodone 150 mg q h.s.
Proventil MDI inhaled twice a day.
Calcium, Vitamin D and Vitamin C.
SOCIAL HISTORY: Significant for prior abuse of cocaine and
alcohol. The patient reports continuing one pack per day
history of smoking.
PHYSICAL EXAMINATION: Temperature of 98.4; heart rate of 94;
blood pressure of 105/86; respiratory rate of 16; 96% on room
air. The patient was alert and oriented times three and not
in apparent distress. HEAD, EYES, EARS, NOSE AND THROAT:
Within normal limits. Cardiovascular examination: Regular
rate and rhythm with S1 and S2, 3/6 systolic murmur,
consistent with history of mitral valve replacement.
Respiratory examination: Clear to auscultation bilaterally.
Abdominal examination with bowel sounds soft, diffusely
tender. Abdomen with worse pain and tenderness in the left
lower quadrant with rebound and guarding. There was no
rigidity. Extremities were warm and well perfused without
edema.
LABORATORY DATA: White blood cell count of 10.2; hematocrit
of 41.9; platelets of 202. PT was 100; PTT was 82.3 with INR
of 112.3. Chemistries were 143, potassium of 3.6; chloride
105; C02 of 27; BUN of 10 and creatinine of 0.6; glucose of
125. AST was 59; ALT was 28; alkaline phosphatase was 83;
Total bilirubin was 0.4; amylase 71 and lipase of 37.
Urinalysis showed large amounts of blood in the urine.
CT scan of the abdomen showed a 10 cm segment of the proximal
sigmoid colon with low attenuation signal within the sigmoid
wall. There were also several small diverticula noted within
the sigmoid colon. There was minimal stranding in the
adjacent fat and trace amount of free fluid within the
pelvis. These readings were consistent with intramural
hemorrhage of the sigmoid colon.
HOSPITAL COURSE: Because of the significantly elevated INR
of 112.3, the patient was urgently given two units of FFP, 10
mg of Vitamin K p.o., and one dose of Factor VII, (2,400
units) while in the Emergency Department. The patient was
followed closely with serial hematocrit checks and serial INR
checks. The gastrointestinal service and the surgery service
were called for urgent consultation. It was decided that the
patient should be admitted to the surgical Intensive Care
Unit for management of the anticoagulation.
Within a span of six hours of the treatment for the elevated
INR while in the Emergency Department, the patient's INR came
down to a level of 2.2 and, in the next two hours, the INR
dropped down to 0.6. Given the mechanical valve, the patient
was urgently started on heparin drip without a loading bolus.
The patient was started on 18 units per kg per hour which
translates to 800 units per hour, with a goal PTT of 60 to
80. However, the patient's PTT rose up to 120 after six
hours of treatment on heparin drip at 800 units per hour and
the heparin was held for one hour and restarted at 700 units
per hour. Serial check of the PT, PTT and hematocrit with
subsequent adjustment in the heparin drip stabilized the
patient at an acceptable PTT level, within the goal of 60 to
80 and the hematocrit remained stable. (It should be noted
that while the patient had a hematocrit of 41.9 on admission,
recheck of the hematocrit nine hours later showed hematocrit
of 34.8 and, with proper resuscitation, the patient's
hematocrit dropped to 30.5 on hospital day number two and
this was monitored in the Intensive Care Unit and the
hematocrit remained stable and increased slightly while being
observed in the Intensive Care Unit. Thus, the hematocrit
was deemed to be stable and there were no suspicions that the
patient was continuing to bleed.)
At the end of hospital day number two, with documented
evidence of stable hematocrit as explained above, and proper
anticoagulation on heparin drip, the patient was transferred
to the floor. While on the floor, the patient was maintained
n.p.o. because she had not passed flatus during the two days
of her hospital stay to that point. There was a question
whether or not the sigmoid intramural hematoma may be causing
an obstruction. It was thought to possibly be causing an
obstruction.
The patient underwent a Hypaque enema on hospital day number
five to rule out obstruction and the Hypaque enema did not
show any obstructing lesion. Given the stable nature of the
patient, the patient was started on p.o. which she tolerated
without any difficulty and without any episode of bright red
blood per rectum. The patient's Coumadin had been held for
three days by hospital day number five and, in discussion
with the patient's primary care physician, [**Name10 (NameIs) **] the
[**Hospital3 **] at which the patient is followed up,
the patient was restarted on Coumadin of 7 mg. The patient's
INR which had drifted down to 0.6 with the quick reversal at
the Emergency Department on the day of admission, slowly
increased with the depletion of the Factor VII infusion which
had been given on hospital day number one. On the day of
discharge, on hospital day number six, the INR was 2.5. The
patient was discharged home with Coumadin schedule of 7 mg
p.o. q h.s. during week days and the weekends. The patient
was instructed to follow-up on the day after discharge at the
[**Hospital3 **] for check of the INR. On the day of
discharge, the patient was tolerating a regular diet, without
any difficulty, without any episodes of bright red blood per
rectum.
DISCHARGE CONDITION: Discharged to home.
DISCHARGE DIAGNOSES:
Sigmoid hematoma, secondary to over anticoagulation, status
post mitral valve replacement.
DISCHARGE MEDICATIONS:
The patient is to continue all her preadmission medications
as ordered by her primary care physician, [**Name10 (NameIs) 151**] the exception
of Coumadin and the patient is to take 7 mg p.o. q h.s.
daily.
FOLLOW-UP: The patient is to be seen at the [**Hospital1 346**] [**Hospital3 **] on the day
after discharge, on [**2158-12-13**] for check of her INR.
The patient is to see Dr. [**First Name (STitle) 452**], gastroenterologist in four
weeks for sigmoidoscopy and is to call for an appointment
date and time. The patient is to see Dr. [**Last Name (STitle) 1888**] of
Gastrointestinal surgery in six weeks for surgical consult
and will call his office for appointment date and time. The
patient needs to see her primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **],
within the next one or two weeks. The patient can follow-up
with Dr. [**Last Name (STitle) **] as needed.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 8275**]
Dictated By:[**Last Name (NamePattern1) 10201**]
MEDQUIST36
D: [**2158-12-13**] 08:24
T: [**2158-12-13**] 20:29
JOB#: [**Job Number 15588**]
ICD9 Codes: 5789, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1386
} | Medical Text: Admission Date: [**2120-5-5**] [**Month/Day/Year **] Date: [**2120-5-28**]
Date of Birth: [**2091-7-18**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
Right chest tube placement [**2120-5-5**]
Exploratory lap, splenectomy [**5-5**]
ORIF right radial fracture [**5-6**]
History of Present Illness:
28 yo female unrestrained driver s/p high speed MVC vs tree;
prolonged extrication Medflighted from referring hospital with
significant injuries.
Past Medical History:
IVDA
Bipolar
Manic Depression
Social History:
H/o IVDA
Family History:
Noncontributory
Physical Exam:
VS upon admission: HR 100 BP 118/112 T 98.6 O2 Sat 95%
Gen: paralyzed; Intubated
HEENT: facial abrasions
Neck: cervical collar in place
Chest: ecchymosis, equal BS
Cor: tACHY
Abd: soft, FAST positive
Extr: right wrist deformity with 2+ radial pulse present;
ecchymosis left hip
Pertinent Results:
[**2120-5-5**] 10:08PM TYPE-ART TEMP-37.3 PO2-181* PCO2-41 PH-7.42
TOTAL CO2-28 BASE XS-2
[**2120-5-5**] 10:08PM LACTATE-2.6*
[**2120-5-5**] 07:41PM GLUCOSE-131* LACTATE-2.6*
[**2120-5-5**] 07:22PM URINE UCG-NEG
[**2120-5-5**] 07:09PM MAGNESIUM-1.9
[**2120-5-5**] 07:09PM PLT COUNT-108*
[**2120-5-5**] 07:09PM PT-12.5 PTT-24.7 INR(PT)-1.1
[**2120-5-5**] 05:56PM GLUCOSE-135* NA+-143 K+-4.3
[**2120-5-5**] 03:06PM ALT(SGPT)-178* AST(SGOT)-353* CK(CPK)-3114*
ALK PHOS-65 AMYLASE-29 TOT BILI-0.9
[**2120-5-5**] 11:13AM HGB-13.2 calcHCT-40
[**2120-5-5**] 09:15AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
WRIST, AP & LAT VIEWS BILAT PORT [**2120-5-5**] 5:49 PM
WRIST, AP & LAT VIEWS BILAT PO
Reason: ?injury
[**Hospital 93**] MEDICAL CONDITION:
40 year old woman s/p mvc
REASON FOR THIS EXAMINATION:
?injury
EXAM ORDER: Bilateral wrists.
HISTORY: Trauma.
Right wrist: Two views show distal radius fracture with
approximately 4-mm stepoff at the articular surface of the
radius. The articular surface of the radius appears to be
dorsally tilted, however, the lateral view is suboptimal. There
is also ulnar styloid fracture.
Left wrist: Two views show no evidence of a distal radius
fracture.
CT HEAD W/O CONTRAST [**2120-5-5**] 9:15 AM
CT HEAD W/O CONTRAST
Reason: ?injury
[**Hospital 93**] MEDICAL CONDITION:
40 year old woman s/p high speed mvc
REASON FOR THIS EXAMINATION:
?injury
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 40-year-old female status post high speed motor
vehicle accident.
No comparison studies.
CT HEAD NON-CONTRAST:
No definite intracranial hemorrhage is seen. The [**Doctor Last Name 352**]-white
differentiation is slightly less defined and normal. There is no
evidence of mass effect. There is no evidence of hydrocephalus.
Along the right temporal and frontal aspect of the skull, there
is a large extracranial soft tissue density likely representing
hematoma and swelling.
IMPRESSION: No evidence of intracranial hemorrhage. Slight
blurring of the [**Doctor Last Name 352**]-white matter differentiation. Large right
extra-axial hematoma.
CT ABDOMEN W/CONTRAST [**2120-5-5**] 9:16 AM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
Reason: ?injury
Field of view: 40 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
40 year old woman s/p high speed mvc
REASON FOR THIS EXAMINATION:
?injury
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 40-year-old female status post high-speed motor
vehicle accident.
No comparison studies.
TECHNIQUE: MDCT acquired axial images of the chest, abdomen and
pelvis were performed with IV contrast. Delayed scan and
thin-sliced reconstructions were performed.
CT CHEST: The mediastinum and great vessels are unremarkable.
Lung windows demonstrate partial collapse of the right greater
than left upper lobes. Within the left middle lung field, there
is a focal linear area of opacity, which may represent a small
contusion. There is a moderate-sized right pleural effusion of
high attenuation likely representing hematoma. There is no
evidence of pneumothorax, or pericardial effusion.
CT ABDOMEN: The liver is surrounded by moderate hematoma. Within
the liver parenchyma, there is a moderate-sized area of low
attenuation, likely representing laceration/contusion of
predominantly segment 7 and segment 8. No active extravasation
is seen within the liver--Grade III. Within the spleen, there
are multiple areas of low attenuation that are linear likely
representing laceration. Approximately 30% appears involved.
Adjacent to the spleen, there is a large hematoma with an area
of high attenuation very concerning for active extravasation. On
delayed images, this area is more diffusely spread consistent
with active extravasation. On delayed images, there also appears
to be increased volume of hematoma within the pericolic gutters.
The kidneys and adrenal glands are unremarkable. No gross small
or large bowel abnormalities are noted. There is a small amount
of free fluid seen within the mesentery. No oral contrast was
provided in this examination. The retroperitoneum is
unremarkable.
CT PELVIS: Free fluid likely representing blood is seen within
the pelvis. The urinary bladder, uterus, rectum are
unremarkable.
BONES: At the level of T7, there is a fracture through the the
vertebral body extending through the pedicles, left and right
lamina the right transverse process and the spinous process.
Included within this fracture plane are a fracture through the
superior end plate of T8. There is also an avulsion fracture of
the spinous process of T6. This distribution is unstable and is
consistent with a hyperflexion injury. No fragments are seen
within the spinal canal. There are also small right transverse
process fractures seen in T8 and T9.
IMPRESSION:
1. Moderate right hemothorax. Small left middle lung field
contusion.
2. Right greater than left upper lobe partial collapse.
3. Moderate-sized liver laceration in segment 7 and segment 8
with no evidence of active extravasation. Grade III. Moderate
perihepatic hematoma.
4. Moderate-sized splenic laceration. Moderate perisplenic
hematoma with marked active extravasation. Surgical team was
notified of these findings immediately after conclusion of the
exam and patient brought to the OR for splenectomy.
5. Unstable fractures of T7 and probably stable fracture of T8
vertebral bodies. Also avulsion fracture of T6 spinous process.
These likely were due to hyperflexion injury. Additional T8 and
T9 right transverse process fractures.
C-SPINE TRAUMA W/FLEX & EXT 5 VIEWS [**2120-5-21**] 5:10 PM
C-SPINE TRAUMA W/FLEX & EXT 5
Reason: ligamentous injury? Requested by ortho-spine. thank you.
[**Hospital 93**] MEDICAL CONDITION:
28 year old woman with MVC and difficulty clearing clinically.
REASON FOR THIS EXAMINATION:
ligamentous injury? Requested by ortho-spine. thank you.
INDICATION: 28-year-old woman with status post MVC with
difficulty clearing secretions, evaluate for ligamentous injury.
CERVICAL SPINE SERIES: Series consists of five radiographs
consisting of neutral, flex, and extension views, AP and open
mouth views. C1 through the superior endplate of C6 are
visualized. There is no evidence of acute fracture. No evidence
of reduced listhesis or instability on the flexion or extension
views. Orogastric feeding tube seen coursing anteriorly.
Thoracic paravertebral stabilization rods noted.
IMPRESSION: No evidence of ligamentous injury; C1 through the
superior endplate of C6 evaluated.
Brief Hospital Course:
Patient admitted to the trauma service. FAST exam was positive
in the trauma bay; patient was immediately taken to the
operating room for exploratory lap and splenectomy. Her serial
Hct's were followed closely, her most recent Hct was 30.4.
Plastic surgery consulted for chin/lip laceration which was
sutured. Orthopedic surgery consulted because of her wrist
injuries, she was taken to the OR on [**5-6**] for ORIF of her wrist
fracture. Vascular surgery consulted to rule out any vascular
injury to RUE; angiogram not indicated given stable exam.
Orthopedic Spine surgery consulted because of the thoracic
fractures, no operative intervention. Patient was custom fitted
for a TLSO brace which she will need to wear when ambulating.
She was started on Levofloxacin for a positive sputum culture
with H. Flu. Total 21 day course; she has 9 more days to
complete this course.
Pain control was an issue early during her hospital course, she
was eventually transitioned from PCA to oral Dilaudid which has
been effective in relieving her pain.
Physical and Occupational therapy were consulted early during
her hospitalization and have recommended short rehab stay.
Social work was consulted because of her psychiatric and
substance abuse history, her home meds, Seroquel and Methadone
were restarted.
Medications on Admission:
Seroquel
Methadone
[**Month/Year (2) **] Medications:
1. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed) as needed for dry eyes.
2. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed for constipation.
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
4. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Risperidone 2 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Methadone 10 mg Tablet Sig: Five (5) Tablet PO BID (2 times a
day).
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for wheezing.
8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
12. Hydromorphone 2 mg Tablet Sig: 2-3 Tablets PO Q4H (every 4
hours) as needed for pain.
13. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for anxiety.
14. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 9 days.
[**Hospital1 **] Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
[**Location (un) **] Diagnosis:
s/ Motor Vehicle Crash
T7 T8 fracture
Grade III spleniclaceration
Grade IV liver laceration
Right radial fracture
Nasal bone fracture
[**Location (un) **] Condition:
Stable
[**Location (un) **] Instructions:
You must wear your TLSO brace when ambulating.
Follow up with Orthopedics in 2 weeks.
Follow up with Orthopedic Spine in 4 weeks.
Follow up in Trauma Clinic in 2 weeks.
Follow up with your primary doctor [**First Name (Titles) **] [**Last Name (Titles) **] from rehab.
Take all of your medications as prescribed.
Followup Instructions:
Call [**Telephone/Fax (1) 1228**] for follow up appointment with Orthopedics in
2 weeks.
Call [**Telephone/Fax (1) 3573**] for a follow up appointment with Orthopedics
in 4 weeks.
Call [**Telephone/Fax (1) 6439**] for an appointment with Trauma Clinic in 2
weeks.
Call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from rehab for an
appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2120-5-28**]
ICD9 Codes: 5185, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1387
} | Medical Text: Admission Date: [**2109-5-29**] [**Month/Day/Year **] Date: [**2109-6-14**]
Date of Birth: [**2063-4-22**] Sex: F
Service: MEDICINE
Allergies:
Trazodone
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
Overdose, found unresponsive
Major Surgical or Invasive Procedure:
# Intubation, Extubation
# Arctic Sun cool protocol
History of Present Illness:
47yoF physician with depression and prior overdose suicide
attempts presents unresponsive with rigidity, hyperthermia,
hemodynamic instability. The patient was reportedly doing well,
per husband, from a depression standpoint and had gone on a hike
with her son and saw her psychiatrist the previous day without
reporting any difficulties. The patient does have an extensive
psychiatric history with history of overdoses and suicide
attempts and felt anxious the morning of presentation. The
patient's psychiatrist was called, who recommended taking an
extra dose of her Clonazepam which the patient did with
improvement of her anxiety. The husband reports he left her
alone for one hour and found her laying face down on the floor,
rigid and diaphoretic. He reports he moved her to the bed and
she was minimally responsive to his questions, then became
unresponsive and was twitching her arms and legs. She was
brought to the ED by within 1-2 hours of being found
unresponsive and was noted to be tremulous, rigid, diaphoretic,
hot to touch with fixed, dilated pupils.
.
In the ED, initial VS: 134/118 159 108.5 28 100%RA. Labs were
grossly abnormal, as described below, and EKGs showed peaked T
waves. Toxicology was consulted. Initial concern was for
serotonin syndrome from MAOI OD vs thyroid storm from
Levothyroxine overdose vs NMS. Toxicology determined the patient
was having MAOI toxicity and recommended continuing supportive
care with IVF, airway management, aggressive external cooling,
BZD +/- paralytic to decrease rigidity, serial EGK's, CBC,
lytes, coags, CE's. The patient had an episode of hypotension to
63/24 in the setting of receiving Fentanyl 50mcg, Lidocaine
100mg IV, Ativan 2mg, Rocuronium 100mg, Etomidate 20mg, and ice
for cooling. Levophed was initiated at 0.06-0.3mcg/hr, and she
was started on arctic sun to be cooled for her hyperthermia. She
was empirically given Ceftriaxone 2gm IV x1 and 3L NS, and was
transferred to the MICU for further management. Access was
central line (IJ), PIV 20 gauge x2, 18 gauge x1, and transfer
vitals were levophed (0.45) -> 144/67 on Levophed 0.45, HR 160,
on vent settings of 124, TV 0.5, peep 5, FIO2 98%.
.
On arrival to the MICU, the patient was unresponsive,
ventilated, on the arctic sun machine with cool extremities.
.
ROS: As per HPI. Per husband, no recent fevers/chills, cough,
abdominal pain, diarrhea, dysuria. Had headache 2 days ago which
resolved subsequently and has not occurred.
Past Medical History:
- Depression/Anxiety with multiple prior suicide attempts
(recent hospitalization at [**Hospital3 **] Psychiatry Unit in
[**7-/2108**])
- Chronic EtOH Dependence; h/o alcoholism years ago, per husband
- Prescription drug abuse (abuse of Ativan and Soma in the past)
***Note: patient denies h/o hypothyroidism and states she was
taking levothyroxine to augment a psychiatric medication
Social History:
- Tobacco: No current tobacco use.
- EtOH: Prior alcoholism history, husband reports she has not
had problems with alcohol abuse in years.
- Illicit Drugs: Per husband, denies known history of illicit
drug abuse. However has h/o prescription medication abuse,
including benzodiazepines and soma.
OB/GYN physician at [**Hospital1 2177**]. Married with 2 kids, lives with husband
at home.
Family History:
Noncontributory
Physical Exam:
Vitals: 37.1 105 178/95 22 100% on ventilator (see below for
vent settings)
General: Unresponsive, ventilated, no acute distress
HEENT: Pupils fixed and dilated at ~7mm, unresponsive, sclera
anicteric
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi anteriorly
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
Ext: Cool to touch, no clubbing, edema, cyanosis of toes b/l,
mild mottling of fingers b/l, 2+ DP pulses b/l
Neuro: Absence corneal reflexes b/l. Negative doll's eye
maneuver. Fixed, dilated pupils ~7mm. Does not follow commands
or respond to verbal or tactile stimuli. Flaccid tone, depressed
reflexes b/l, mild clonus.
[**Hospital1 **] Exam:
Gen: Middle aged woman in NAD
HEENT: NCAT PERRL MMMs OP clear
CVS: RRR, no m/r/g, S1, S2
Pulm: Decreased breath sounds at lung bases bilaterally, about
1/4 up lung field, with crackles superiorly
Ab: soft, NT, ND, normoactive BS
Ext: No edema in feet, trace edema over sacrum. 2+ pulses
Neuro: CN2-12 intact, AAOx3, no asterixis
Pscyh: Affect still somewhat flat but much improved. Denies
suicidal ideation
Pertinent Results:
Admission Labs:
[**2109-5-29**] 07:35PM FIBRINOGE-328
[**2109-5-29**] 07:35PM PLT COUNT-412
[**2109-5-29**] 07:35PM PT-13.0 PTT-18.2* INR(PT)-1.1
[**2109-5-29**] 07:35PM WBC-12.2* RBC-5.05 HGB-13.7 HCT-42.3 MCV-84
MCH-27.2 MCHC-32.5 RDW-12.8
[**2109-5-29**] 07:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2109-5-29**] 07:35PM CALCIUM-9.7 PHOSPHATE-4.2 MAGNESIUM-2.1
[**2109-5-29**] 07:35PM cTropnT-0.04*
[**2109-5-29**] 07:35PM CK-MB-2
[**2109-5-29**] 07:35PM LIPASE-41
[**2109-5-29**] 07:35PM ALT(SGPT)-19 AST(SGOT)-24 CK(CPK)-97 ALK
PHOS-89 TOT BILI-0.3
[**2109-5-29**] 07:35PM estGFR-Using this
[**2109-5-29**] 07:35PM GLUCOSE-68* UREA N-22* CREAT-2.2* SODIUM-155*
POTASSIUM-6.2* CHLORIDE-115* TOTAL CO2-21* ANION GAP-25*
[**2109-5-29**] 07:43PM freeCa-1.12
[**2109-5-29**] 07:43PM HGB-14.1 calcHCT-42
[**2109-5-29**] 07:43PM GLUCOSE-65* LACTATE-5.4* NA+-154* K+-5.6*
CL--114*
[**2109-5-29**] 07:43PM PO2-51* PCO2-53* PH-7.18* TOTAL CO2-21 BASE
XS--8 COMMENTS-GREEN TOP
[**2109-5-29**] 08:00PM URINE MUCOUS-MOD
[**2109-5-29**] 08:00PM URINE AMORPH-OCC
[**2109-5-29**] 08:00PM URINE HYALINE-3*
[**2109-5-29**] 08:00PM URINE RBC-0 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
[**2109-5-29**] 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2109-5-29**] 08:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.018
[**2109-5-29**] 08:00PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2109-5-29**] 08:00PM URINE UCG-NEGATIVE
[**2109-5-29**] 08:00PM URINE HOURS-RANDOM
[**2109-5-29**] 08:46PM TYPE-ART PO2-490* PCO2-40 PH-7.19* TOTAL
CO2-16* BASE XS--12 INTUBATED-INTUBATED VENT-CONTROLLED
[**2109-5-29**] 09:00PM TSH-0.042*
[**2109-5-29**] 09:00PM ALBUMIN-3.8 CALCIUM-7.0* PHOSPHATE-2.2*#
MAGNESIUM-2.1
[**2109-5-29**] 09:00PM CK-MB-21* MB INDX-1.3 cTropnT-0.10*
[**2109-5-29**] 09:00PM LIPASE-41
[**2109-5-29**] 09:00PM ALT(SGPT)-75* AST(SGOT)-86* CK(CPK)-1576* ALK
PHOS-71 TOT BILI-0.2
[**2109-5-29**] 09:00PM GLUCOSE-149* UREA N-20 CREAT-2.2* SODIUM-152*
POTASSIUM-4.9 CHLORIDE-124* TOTAL CO2-17* ANION GAP-16
[**2109-5-29**] 09:07PM LACTATE-1.8 K+-4.8
[**Month/Day/Year **] Labs:
[**2109-6-14**] 01:35PM BLOOD WBC-8.1 RBC-2.97* Hgb-8.0* Hct-23.8*
MCV-80* MCH-26.9* MCHC-33.6 RDW-21.6* Plt Ct-297
[**2109-6-14**] 01:35PM BLOOD Plt Ct-297
[**2109-6-14**] 01:35PM BLOOD
[**2109-6-14**] 01:35PM BLOOD Glucose-120* UreaN-69* Creat-8.7*# Na-137
K-4.3 Cl-99 HCO3-24 AnGap-18
[**2109-6-14**] 01:35PM BLOOD Calcium-8.5 Phos-5.4* Mg-2.2
Brief Hospital Course:
46yoF with hypothyroidism, depression with multiple prior
suicide attempts, called out from MICU after MAOI toxicity, now
with improving rhabdomyolysis, ATN.
.
ICU Course:
46yoF with hypothyroidism, depression with multiple prior
suicide attempts, now presenting with toxic ingestion.
#. Ingestion: Pt initially presented status post multiple med
ingestion (though pt denies suicide attempt) and presenting with
classic MAOI overdose symptoms including rigidity, hyperthermia
108.7, diaphoresis, labile BP's, lactate 5.4, multiple
electrolyte abnormalities following ingestion of what is
believed to be her home parnate (MAOI). Toxicology was consulted
in the ED, who followed the patient closely in the acute
setting. The patient was intubated and cooled by arctic sun
protocol. She was ruled out for MI after transient ST
depressions in the precordial and inferior leads, which were
attributed to demand ischemia. Serial labs showed marked
rhabdomyolysis, [**Last Name (un) **], and toxic liver damage. She received
aggressive fluid resuscitation. Renal consulted and diagnosed
ATN secondary to rhabdomyolysis, after which the goal was keep
her I/O even daily and follow kidney function. She was then
called out the floor in stable condition on no supplemental
oxygen.
.
Floor Course:
.
# Rhabdomyolysis: CK showed a reassuring trend toward
normalization without further IVF given on the floor; on [**2109-6-8**]
her last CK was 2035 and consistent with the previous downward
trend.
.
# ATN: Renal continued to follow. Cr peaked at 15.0 and was 8.7
on [**Date Range **], BUN peaked at 99 and was 69 on [**Date Range **]. HD was
deferred. When she began diuresing, she put out an average of
[**2-17**] liters of fluid per day for several days. She was monitored
for post-ATN diuresis with [**Hospital1 **] lyte checks, but she did not
require electrolyte repletion. She was, however, treated with
bicarb for metabolic acidosis and sevelemer for
hyperphosphatemia secondary to her ATN. Upon [**Hospital1 **], her
metabolic acidosis had resolved and she did not have an anion
gap, and her phosphate was trending down. Her phosphate was 5.4
upon [**Hospital1 **] so she was continued on sevelemer.
.
# Toxic Liver Failure: Presumed secondary to toxic damage.
AST/ALT/LDH showed a trend toward normalization and AST/ALT were
81/169 when last checked on [**2109-6-8**].
.
# Danger to Self: The patient continued to deny suicidal
ideation. A 1:1 sitter was maintained until psychiatry cleared
the patient. Home psychiatry medications other than low dose prn
lorazepam, oxycodone for pain, and zolpidem were held in keeping
with toxicology and psychiatry recommendations. The patient
will follow up with her outpatient social worker (known well to
the pt) within one week because her psychiatrist was not
available during that time period.
.
# Thrombocytopenia: On call-out to the floor, there was initial
concern for hemolytic anemia, but hemolysis labs were
reassuring; the working diagnosis was Parnate side effects.
Platelets rebounded spontaneously.
.
TRANSITIONAL ISSUES:
-Pt to see outpatient Social Worker in one week.
-Pt to get repeat bloodwork within one week and see PCP (CBC,
CHEM-7, Ca, Mg, Phos)
-Pt to follow up with [**Hospital1 18**] nephrology in [**2-15**] weeks.
Medications on Admission:
Medications at home:
- Provigil (modafinil) 200mg daily
- Parnate (tranylcypromine) 20mg [**Hospital1 **] (per OMR)
- Levothyroxine
- Cloanzepam 0.5mg [**Hospital1 **] prn
- Clonidine 0.2mg po qhs
- Rozerem 8mg qhs
- Zolpidem
- Ambien
- Amlodipine 5mg daily?
- Loestrin [**1-3**] (21) 1-20 mg-mcg Tablet po daily
- Gabapentin 300mg tid
.
Meds on transfer:
- Levophed 0.45
- 3rd liter of NS
[**Month/Year (2) **] Medications:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*12 Tablet(s)* Refills:*0*
2. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
Disp:*12 Tablet(s)* Refills:*0*
3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
4. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
5. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*60 Tablet(s)* Refills:*2*
[**Month/Year (2) **] Disposition:
Home
[**Month/Year (2) **] Diagnosis:
PRIMARY:
-MAOI overdose
-Rhabdomyolysis
-Acute tubular necrosis
-Toxic liver injury
-Major Depression
SECONDARY:
-Hypothyroid
[**Month/Year (2) **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
[**Month/Year (2) **] Instructions:
It has been a privilege to take care of you at [**Hospital1 18**].
.
You were hospitalized because you had an overdose, which we
suspect was an overdose of your parnate according to our
toxicology physicians.
.
As a result of the overdose, you had to be intubated and cooled
in the ICU because of a temperature of 107F and rigidity. You
suffered from rhabdomyolysis, which caused acute tubular
necrosis with associated decline in kidney function. The
decision was made by the renal physicians to defer dialysis with
the expectation that your kidney function should recover on its
own over time.
You also sustained liver injury from the overdose. Your liver
enzymes have shown a trend toward normalization.
No changes were made to your medications other than as detailed
below.
# STOP: Parnate
Please see your psychiatrist as scheduled.
Followup Instructions:
You have an appointment with Social Worker [**First Name8 (NamePattern2) 32569**] [**Last Name (NamePattern1) 32570**] on
Tuesday [**6-18**] at 11:30am. Her phone number is [**Telephone/Fax (1) 32571**].
At some point on Tuesday [**6-18**], you should see your PCP and get
your blood drawn (CBC, CHEM-7, Ca, Mg, Phos). You can come in
any time for the blood draw, but you must call your PCP to
schedule the appointment.
Name: [**Last Name (LF) **],[**First Name3 (LF) **] H.
Address: [**Location (un) **], [**Hospital Unit Name **], [**Location (un) **],MA,
Phone: [**Telephone/Fax (1) 32572**]
Fax: [**Telephone/Fax (1) 32573**]
Please follow up with Nephrology at [**Hospital1 18**] (Dr. [**Last Name (STitle) 21402**] and Dr.
[**Last Name (STitle) **] in [**2-15**] weeks.
ICD9 Codes: 5845, 2762, 2875, 2767, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1388
} | Medical Text: Admission Date: [**2152-5-17**] Discharge Date: [**2152-5-26**]
Date of Birth: [**2102-2-1**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Alcohol withdrawl
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a 50 year old man with a past medical history for
alcohol dependence and hypertension who presented from the
[**Hospital1 **] facility/[**Hospital3 **] for alcohol withdrawl. Per
[**Hospital1 **] records, patient tried to enter a detox center in
[**2150**], but left against medical advice. At that time, he endorsed
hallucinations after one day of abstinence, but no history of
seizures. Prior to the transfer to [**Hospital1 18**], patient last drank on
[**Last Name (LF) 1017**], [**5-14**] and was in "florid alcohol withdrawl" at
[**Hospital1 **]. He developed hallucinations on Monday and was then
transferred to [**Hospital1 **], where he received ativan, but became
quite aggressive. Due to this aggression, he was transferred to
[**Hospital1 18**].
In the ED, patient was agitated and delirious, placed in 4-point
restraints, and started on benzodiazepines, in addition to
receiving thiamine and multivitamins. His was afebrile at 98.1,
HR 124, BP 164/98, RR 16, and oxygen saturation was 99% on
ambient air. He received 70mg IV valium, 1 liter normal saline,
100mg thiamine, 10mg multivitamins, and 0.2mg folic acid. There
were no signs of trauma, so patient was transferred to the ICU.
ALT 104 and AST 114.
.
In the ICU, he was treated with large doses of valium (~ 2 gm in
total) and clonidine. He was started on haldol on the evening of
[**5-18**] for intermittent agitation. He developed a superficial
thrombophlebitis/cellulitis from an IV site and was started on a
short course of keflex.
.
Currently, he feels well. He is happy about being sober and
hopes that his family will accept him back since his wife had
given him an ultimatium about his drinking problem. [**Name (NI) **] feels
unsteady on his feet. Otherwise, has no complaints.
Past Medical History:
HTN
EtOH abuse
Social History:
Patient endorses drinking two six packs of beer and [**5-12**] nips or
one pint of whiskey daily, with his last drink occurring three
days prior to admission ([**Month/Day (3) 1017**] [**2152-5-14**]). Began drinking alcohol
at the age of 15. Smokes cigarettes, but denies any IV drug use.
Lives with his wife [**Name (NI) 6409**]. Two children, aged 20 and 17.
One son recently diagnosed with benign brain tumor. Works in
construction, but recently lost his job.
Family History:
Extensive family history of alcoholism. Brother alcoholic
Physical Exam:
:99.4 BP:105/74 HR:96 RR:18 O2saturation:99% on room air (on
admit to floor)
Gen: NAD. skin ruburous
HEENT: No scleral icterus.
NECK: No cervical lymphadenopathy.
CV: Regular. Normal S1 and S2, + s4
LUNGS: CTAB
ABD: soft, NT, ND. no HSM
EXT: Warm and well perfused. No lower extremity edema,
bilaterally. 2+ dorsalis pedis and radial pulses, bilaterally.
No palmar erythema. + tremor, difficult to tell if asterixis
present ot is tremor
NEURO: Alert. Oriented to person, [**Location (un) 86**], and year [**2151**]. When
asked the president, he said [**Doctor Last Name 16590**], then [**Doctor Last Name **], then said he
was kidding and knew it was [**Last Name (un) 2450**]. He was able to provide his
history fluently. Moving all 4's. strenght and sensastion [**4-8**]
thoughout extremities. FTN was very abnormal with both arms. He
declined a gait test because he felt unsteady on his feet.
Pertinent Results:
[**2152-5-17**] 06:06PM BLOOD HCV Ab-NEGATIVE
[**2152-5-17**] 09:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS Barbitr-NEG Tricycl-NEG
[**2152-5-17**] 06:06PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2152-5-18**] 03:18AM BLOOD CK-MB-7 cTropnT-<0.01
[**2152-5-17**] 09:00AM BLOOD ALT-104* AST-114* AlkPhos-71 Amylase-39
TotBili-0.7
[**2152-5-22**] 07:05AM BLOOD ALT-49* AST-50* LD(LDH)-233 CK(CPK)-225*
AlkPhos-77 TotBili-0.5
[**2152-5-17**] 09:00AM BLOOD Glucose-100 UreaN-10 Creat-0.7 Na-142
K-3.5 Cl-107 HCO3-24 AnGap-15
[**2152-5-22**] 07:05AM BLOOD Glucose-126* UreaN-5* Creat-0.7 Na-140
K-4.1 Cl-105 HCO3-23 AnGap-16
[**2152-5-17**] 09:00AM BLOOD WBC-5.3 RBC-3.98* Hgb-13.9* Hct-40.3
MCV-101* MCH-34.9* MCHC-34.4 RDW-13.0 Plt Ct-128*
[**2152-5-22**] 07:05AM BLOOD WBC-7.9 RBC-3.85* Hgb-13.8* Hct-39.6*
MCV-103* MCH-35.9* MCHC-34.9 RDW-12.6 Plt Ct-306
[**2152-5-17**] 11:40AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009
[**2152-5-17**] 11:40AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2152-5-17**] 11:40AM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
CXR: IMPRESSION: No acute cardiopulmonary process.
.
CT Head: FINDINGS: There is no evidence of hemorrhage, edema,
masses, mass effect, or infarction. The ventricles and the sulci
are normal in caliber and configuration. No osseous
abnormalities are noted.
.
[**2152-5-17**] 06:06PM BLOOD ALT-102* AST-138* LD(LDH)-244
CK(CPK)-1334* AlkPhos-71 Amylase-35 TotBili-0.7
[**2152-5-18**] 03:18AM BLOOD ALT-92* AST-127* LD(LDH)-305*
CK(CPK)-1678* AlkPhos-67 Amylase-30 TotBili-0.8
[**2152-5-18**] 05:01PM BLOOD CK(CPK)-1549*
[**2152-5-19**] 03:15AM BLOOD ALT-72* AST-80* LD(LDH)-340*
CK(CPK)-1067* AlkPhos-64 TotBili-0.9
[**2152-5-22**] 07:05AM BLOOD ALT-49* AST-50* LD(LDH)-233 CK(CPK)-225*
AlkPhos-77 TotBili-0.5
Brief Hospital Course:
EtOH abuse/withdrawl: required massive doses of benzodiazepens
(~ 2 gm) to control symptoms, but ultimatley pts withdrawl was
controlled. Called out to floor and benzos subsequently d/c'd
as pt appeared intoxicated on benzos. Intoxication improved
with discontinuation of benzos. Continued on MVN, Thiamine and
folate.
.
Elevated CK, ?secondary to EtOH: resolved with IVF
.
Left Arm Thromboplebitis, resolved: treated with short course of
Keflex
.
Gait instability, likely secondary to benzodiazepenes. Head CT
normal. Remainder of Neuro exam nl. For this reason, pt would
benefit from short term rehab for gait training.
Medications on Admission:
[**Last Name (un) **] 2/240 qAM
Discharge Medications:
1. [**Last Name (un) **] 2-240 mg Tab, Multiphasic Release 24 hr Sig: One (1)
Tab, Multiphasic Release 24 hr PO once a day.
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
presentation Manor
Discharge Diagnosis:
Primary Diagnoses
EtOH abuse/withdrawl
Elevated CK, ?secondary to EtOH
Left Arm Thromboplebitis, resolved
Gait instability, likely secondary to benzodiazepenes
Secondary Diagnoses
Hypertension
Discharge Condition:
stable
Discharge Instructions:
Please refrain from drinking Alcohol. Please return to the
Emergency Room should you develop fevers, chills, sweats,
nausea, vomiting, diarrhea, or any other complaints.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 35275**] within 2 weeks.
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1389
} | Medical Text: Admission Date: [**2187-2-21**] Discharge Date: [**2187-2-24**]
Date of Birth: [**2122-9-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
MI MVRepair on [**2187-2-21**]
History of Present Illness:
DOE found to have severe mitral regirgitation, flail leaflet.
Past Medical History:
Ulcerative colitis
HTN
s/p c-section X2
s/p hand surgery
Social History:
married, lives w/husband
works as OR nurse
no tobacco or ETOH use
Family History:
non contributory
Physical Exam:
unremarkable pre-op
Pertinent Results:
[**2187-2-22**] 01:44AM BLOOD WBC-10.7# RBC-3.34* Hgb-11.1* Hct-32.2*
MCV-96 MCH-33.4* MCHC-34.7 RDW-15.0 Plt Ct-136*
[**2187-2-22**] 01:44AM BLOOD PT-12.4 PTT-30.8 INR(PT)-1.0
[**2187-2-22**] 01:44AM BLOOD Glucose-160* UreaN-10 Creat-0.6 Na-136
Cl-106 HCO3-24
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA. All four pulmonary veins
identified and enter the left atrium.
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 and cavity
size. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Focal calcifications in aortic root. Simple atheroma in
ascending aorta. Simple atheroma in aortic arch. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Partial
mitral leaflet flail. Mild mitral annular calcification.
Eccentric MR jet. Moderate to severe (3+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
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
PRE CPB 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. 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 normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. 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. 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 a flail P2 segment of
the posterior mitral leaflet, resulting in an eccentric,
anteriorly directed jet of moderate to severe (3+) mitral
regurgitation. Dr. [**Last Name (STitle) **] was notified in person of the results
in the operating room at the time of the study.
POST CPB Normal biventricular systolic function. A mitral valve
annuloplasty ring is seen in situ. It is well seated. The mitral
valve is status-post repair. No mitral regurgitation is seen.
The mean pressure across the mitral valve is 4 mm Hg. The mitral
valve area is about 2.2 cm2. No other changes from pre-CPB
study.
Brief Hospital Course:
Admitted day of surgery, taken to OR. Underwent minimally
invasive mitral valve repair (please see operative note for
details of procedure). Post-op she went to the ICU in stable
condition. She was noted to have had a small apical
pneumothorax. The pneumothorax remained unchanged with the tube
off suction, so it was removed on POD # 2. She progressed well
with ambulation, and has remained hemodynamically stable & is
ready for discharge to home on POD # 3.
Medications on Admission:
Atenolol 25"
Diovan 80"
HCTZ 25'
KCl 20'
Asacol 400"
Zantac 75"
Fosamax 35 weekly
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
Disp:*180 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 4 weeks: then may take prn .
Disp:*90 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] homecare
Discharge Diagnosis:
Mitral regurgitation.
HTN
Ulcerative colitis.
Discharge Condition:
good
Discharge Instructions:
[**Month (only) 116**] shower, no creams, lotion or powders to any incisions.
Followup Instructions:
with Dr. [**First Name (STitle) 39190**] in [**2-4**] weeks
with Dr. [**Last Name (STitle) 8098**] in [**2-4**] weeks
with Dr. [**Last Name (STitle) **] in [**4-7**] weeks
Completed by:[**2187-2-24**]
ICD9 Codes: 4240, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1390
} | Medical Text: Admission Date: [**2180-11-2**] Discharge Date: [**2180-11-5**]
Date of Birth: [**2126-4-10**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
elective admit
Major Surgical or Invasive Procedure:
[**11-2**]: Transphenoidal pituitary adenoma resection
History of Present Illness:
s is a 54 year old Chinese gentleman with three episodes of
unprovoked LOC that led to a neurologic work up. He reports [**3-31**]
headaches per month that are bitemporal. He has had a [**5-2**] lb
weight loss over the course of ca one month. He had relatively
normal visual field studies and a slightly elevated
prolactin level with a full endocrinology evaluation. He was
prescribed Androgel but this was not covered by insurance and
hence he does not take it.
Past Medical History:
HTN, CHOL, BPH, right renal cyst
Social History:
He is right handed. He ia an unemployed restaurant worker. He
denies tobacco or ETOH use.
Family History:
NC
Physical Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:4=3mm EOMs intact
RRR
CTA
NTTP; ND
Extrem: Warm and well-perfused.
Neuro:Mental status: Awake and alert, cooperative with exam,
normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3mm
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-1**] throughout. No pronator drift
Sensation: Intact to light touch
Discharge: Intact
Pertinent Results:
[**11-2**] IMPRESSION: No evidence of hemorrhage status post resection
of macroadenoma. Air is seen in the post surgical bed in the
sella, but there is no evidence of hemorrhage.
[**2180-11-3**] 03:50AM BLOOD WBC-10.6# RBC-4.52* Hgb-12.5* Hct-39.3*
MCV-87 MCH-27.7 MCHC-31.7 RDW-13.6 Plt Ct-230
[**2180-11-3**] 03:50AM BLOOD Glucose-139* UreaN-15 Creat-0.8 Na-138
K-3.6 Cl-102 HCO3-29 AnGap-11
[**2180-11-3**] 03:50AM BLOOD Calcium-8.2* Phos-3.1 Mg-2.0
[**2180-11-3**] 03:50AM BLOOD Osmolal-292
[**2180-11-3**] 03:50AM BLOOD T4-6.2 calcTBG-0.95 TUptake-1.05
T4Index-6.5 Free T4-1.2
[**2180-11-3**] 03:50AM BLOOD Cortsol-32.0* - On Hydrocortisone for
this lab draw
[**2180-11-3**] 03:50AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.024
[**2180-11-3**] 03:50AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
Brief Hospital Course:
Pt electively presented and underwent a transphenoidal pituitary
adenoma resection. Surgery was without complication. Endocrine
was consulted for post operative evaluation and management.
Urine output as well as Urine specific gravity, urine osm, Serum
Sodium and Serum Osm were monitered closely for signs of
Diabetes Insipidus. Postoperatively the patient was started on
a rapid Hydrocortisone taper to prednisone. He was maintained
on strict sinus precautions throughout his hospital stay.
Throughout postoperative day 1 the patient's urine output and
labs remained stable without signs of DI. His nasal trumpet and
nasal packing were removed in the afternoon on [**11-3**].
On the day of discharge the patient had stable labs, stable
urine output and no signs of CSF rhinorrhea. He is tolerating a
regular diet, ambulating without difficulty, afebrile with
stable vital signs.
He was followed by endocrine during his hospital stay. he had
no signs of DI or CSF leak. His steroids were tapered. His
sodium remained stable
Medications on Admission:
Simvastatin, terazosin
Discharge Medications:
1. Outpatient Lab Work
[**2180-11-20**]
AM cortisol level
Serum Na
diagnosis: s/p transphenoidal excision of pituitary adenoma
call Endocrinology for results: [**Telephone/Fax (1) 1803**]
2. prednisone 5 mg Tablet Sig: One (1) Tablet PO once a day:
Take 1 tab on Sunday [**11-5**], 1 tab on Monday [**11-6**], then hold on
Tuesday Morning [**11-7**] for your lab tests. Resume prednisone
AFTER your lab test on Tuesday [**11-7**].
3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for HA, pain.
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): take while on prednisone.
Disp:*60 Tablet(s)* Refills:*2*
7. terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
Discharge Disposition:
Home
Discharge Diagnosis:
Pituitary Macroadenoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? 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.
?????? Continue Sinus Precautions for an additional two weeks. This
means, no use of straws, forceful blowing of your nose, or use
of your incentive spirometer.
?????? You have been discharged on Prednisone, take it as prescribed.
?????? You are required to take Prednisone, an oral steroid, make
sure you are taking a medication to protect your stomach
(Prilosec, Protonix, or Pepcid), as this medication can cause
stomach irritation. Prednisone should also be taken with a
glass of milk or with a meal.
Followup Instructions:
Follow-Up Appointment Instructions
?????? Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with
your surgeon, Dr. [**Last Name (STitle) **] , to be seen in two months. You will
need an MRI of the brain with and without contrast prior to your
appointment.
?????? Please call ([**Telephone/Fax (1) 9072**] to schedule an appointment with
your endocrinologist, Dr. [**Last Name (STitle) **] to be seen within the next
two weeks.
?????? Please call ([**Telephone/Fax (1) 5120**] to schedule Formal Visual Field
Testing to be done before you are seen in follow-up with your
surgeon. The Ophthalmology department is located on the [**Hospital Ward Name **] in the [**Hospital Ward Name 23**] building, [**Location (un) 442**].
- Follow up with Endocrinology within 2 weeks. Call
[**Telephone/Fax (1) 1803**]
to schedule an appointment with Dr. [**Last Name (STitle) **]. You will need
blood work that morning including a cortisol level - DO NOT take
your prednisone the morning of your appointment.
Completed by:[**2180-11-5**]
ICD9 Codes: 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1391
} | Medical Text: Admission Date: [**2110-12-12**] Discharge Date: [**2110-12-22**]
Date of Birth: [**2045-12-30**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
64yoM s/p OP CABGx4 on [**11-20**] discharged to rehab on [**12-11**].
Returned to Emergency prior to scheduled dialysis complaining of
shortness of breath. While in the emergency room the patient was
found to be anemic with a Hct of 20. He was admitted to the
cardiac surgery ICU and transfused with several units of PRBC's.
Additionally a GI bleed workup was initiated including a consult
to the GI service. His Hct increased appropriately to the packed
cells and a source for his bleeding was never identified. His
stools remained guiac negative throughout the hospitalization.
Past Medical History:
Coronary artery disease
s/p off pump cabg x4
[**2110-4-9**] - BMS (Driver) to OM1
[**2110-7-24**] - 95% in-stent thrombosis of OM1, tx with 2 DES (Xience)
in the proximal OM1 extending to the circumflex with no residual
stenosis; distal L Cx occluded
- per cath report, left main without significant disease
- LAD with 30-40% plaque after large septal branch
- known RCA occlusion with collateral flow
Dyslipidemia
ESRD on HD M/W/F
COPD
s/p CVA L MCA [**3-16**]
s/p CVA R MCA [**3-18**]
secondary hyperparathyroidism
Social History:
-Tobacco history: + [**12-12**] ppd
-ETOH: none recently, but + history
-Illicit drugs: pt denies
Family History:
No hx of CAD, MI, DM per daughter.
Physical Exam:
Discharge
VS T 98.4 BP 109/61 HR 76SR RR 20 O2sat 93%-RA Wt 102.7K
Gen NAD
Neuro A&Ox3, nonfocal exam
CV RRR, sternum stable. Incision CDI
Pulm diminished bilat @ bases
Abdm soft, NT/+BS
Ext warm, extensive scar tissue bilat. Old wound left knee, with
some necrotic and fibrinous tissue. Small amount of
sero-purulent drainage.
Pertinent Results:
[**2110-12-12**] 11:35PM PLT COUNT-281
[**2110-12-12**] 11:35PM PT-16.1* PTT-28.2 INR(PT)-1.4*
[**2110-12-12**] 07:50PM GLUCOSE-93 UREA N-22* CREAT-3.2*# SODIUM-148*
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-38* ANION GAP-11
[**2110-12-12**] 07:50PM CK(CPK)-54
[**2110-12-12**] 07:50PM cTropnT-0.12*
[**2110-12-12**] 07:50PM WBC-9.8 RBC-2.26* HGB-6.9* HCT-20.2* MCV-89
MCH-30.5 MCHC-34.1 RDW-17.2*
[**2110-12-22**] 08:20AM BLOOD WBC-6.6 RBC-3.27* Hgb-9.8* Hct-29.8*
MCV-91 MCH-30.1 MCHC-33.0 RDW-16.4* Plt Ct-257
[**2110-12-22**] 08:20AM BLOOD Plt Ct-257
[**2110-12-15**] 03:10AM BLOOD PT-16.5* PTT-29.7 INR(PT)-1.5*
[**2110-12-22**] 08:20AM BLOOD Glucose-82 UreaN-33* Creat-7.5*# Na-139
K-4.6 Cl-102 HCO3-29 AnGap-13
[**2110-12-13**] 08:19PM BLOOD Hapto-147
[**2110-12-16**] 10:09AM BLOOD PTH-1008*
[**2110-12-22**] 08:20AM BLOOD Vanco-20.1*
[**2110-12-12**] 8:00 pm BLOOD CULTURE #2/FEMORAL.
**FINAL REPORT [**2110-12-20**]**
Blood Culture, Routine (Final [**2110-12-20**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
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.
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
2ND MORPHOLOGY FINAL SENSITIVITIES.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
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 ([**6-/2408**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). FINAL
SENSITIVITIES.
Sensitivity testing performed by Sensititre.
ERYTHROMYCIN = Resistant AT >4 MCG/ML.
GENTAMICIN = Resistant AT 16 MCG/ML.
Penicillin = Resistant AT 8 MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
CORYNEBACTERIUM SPECIES (DI
| | |
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R =>8 R R
GENTAMICIN------------ =>16 R 8 I R
LEVOFLOXACIN---------- =>8 R =>8 R
OXACILLIN------------- =>4 R =>4 R
PENICILLIN G---------- =>0.5 R =>0.5 R R
RIFAMPIN-------------- <=0.5 S <=0.5 S
TETRACYCLINE---------- 2 S <=1 S
VANCOMYCIN------------ 2 S 2 S <=1 S
Aerobic Bottle Gram Stain (Final [**2110-12-13**]):
REPORTED BY PHONE TO [**Doctor First Name **] OVERLAND @ 7PM [**2110-12-13**].
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2110-12-14**]):
GRAM POSITIVE COCCI IN CLUSTERS.
=
=
=
=
=
=
=
=
=
=
=
================================================================
[**Known lastname **],[**Known firstname **] [**Medical Record Number 66637**] M 64 [**2045-12-30**]
Radiology Report CHEST (PA & LAT) Study Date of [**2110-12-21**] 9:34 AM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2110-12-21**] SCHED
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 66639**]
Reason: eval for pleural effusions
Final Report
HISTORY: Status post CABG. Evaluate pleural effusions.
CHEST, TWO VIEWS.
A right IJ central line is present, tip over mid SVC. No
pneumothorax is
detected.
The patient is status post sternotomy. There is mild prominence
of the
cardiomediastinal silhouette, unchanged compared with [**2110-12-16**].
There is a
small left effusion and patchy increased retrocardiac density,
essentially
unchanged. There is minimal pleural thickening along the right
chest wall and blunting of the right costophrenic angle. This is
more apparent on today's exam, but not clearly changed. No CHF.
Probable background hyperinflation.
IMPRESSION: Small bilateral pleural effusions, unchanged on the
left and
probably unchanged on the right, though thelatter is better seen
on today's examination.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4343**]
Approved: [**First Name8 (NamePattern2) **] [**2110-12-21**] 3:53 PM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 66640**]TTE (Complete)
Done [**2110-12-15**] at 3:28:57 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
Division of Cardiothoracic [**Doctor First Name **]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2045-12-30**]
Age (years): 64 M Hgt (in): 70
BP (mm Hg): 88/49 Wgt (lb): 190
HR (bpm): 73 BSA (m2): 2.04 m2
Indication: R/o Endocarditis , s/p CABG.
ICD-9 Codes: 424.90, 424.1, 424.0, 424.2
Test Information
Date/Time: [**2110-12-15**] at 15:28 Interpret MD: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**],
MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 18401**]
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Suboptimal
Tape #: 2009W004-0:57 Machine: Vivid [**6-17**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.3 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.7 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 4.9 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.7 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 5.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 30% to 35% >= 55%
Left Ventricle - Stroke Volume: 87 ml/beat
Left Ventricle - Cardiac Output: 6.38 L/min
Left Ventricle - Cardiac Index: 3.13 >= 2.0 L/min/M2
Aorta - Sinus Level: *4.2 cm <= 3.6 cm
Aorta - Ascending: *3.7 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.8 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 23
Aortic Valve - LVOT diam: 2.2 cm
Mitral Valve - E Wave: 0.9 m/sec
Mitral Valve - A Wave: 0.9 m/sec
Mitral Valve - E/A ratio: 1.00
Mitral Valve - E Wave deceleration time: 206 ms 140-250 ms
TR Gradient (+ RA = PASP): 22 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2110-11-10**].
LEFT ATRIUM: Normal LA and RA cavity sizes.
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
Moderate regional LV systolic dysfunction. Trabeculated LV apex.
Estimated cardiac index is normal (>=2.5L/min/m2). No resting
LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Moderately dilated aortic sinus. Mildly dilated ascending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. [**Male First Name (un) **] of the mitral chordae (normal
variant). No resting LVOT gradient. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA systolic pressure.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is moderate regional left ventricular systolic dysfunction with
severe hypokinesis of the distal half of the septum and anterior
walls and distal inferior wall. The apex is akinetic and mildly
aneurysmal. No definite thrombus is identified (cannot exclude
due to suboptimal views). . The estimated cardiac index is
normal (>=2.5L/min/m2). 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 leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2110-11-10**],
left ventricular systolic function is slightly improved and the
estimated pulmonary artery systolic pressure is reduced.
CLINICAL IMPLICATIONS:
Based on [**2108**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2110-12-15**] 17:54
[**Known lastname **],[**Known firstname **] [**Medical Record Number 66637**] M 64 [**2045-12-30**]
Radiology Report CT ABDOMEN W/O CONTRAST Study Date of [**2110-12-13**]
10:29 AM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG CSRU [**2110-12-13**] SCHED
CT CHEST W/O CONTRAST; CT ABDOMEN W/O CONTRAST; CT PELVIS W/O
CONTRAST Clip # [**Clip Number (Radiology) 66641**]
Reason: source of bleeding**with and without contrast
[**Hospital 93**] MEDICAL CONDITION:
64 year old man acute anemia
REASON FOR THIS EXAMINATION:
source of bleeding**with and without contrast
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
CT TORSO WITHOUT INTRAVENOUS CONTRAST
INDICATION: 64-year-old man with acute anemia, evaluate for
source of
bleeding.
COMPARISON: [**2110-12-9**] and [**2110-11-12**].
TECHNIQUE: MDCT axial images of the torso were obtained without
administration of oral or intravenous contrast. Coronal and
sagittal
reformatted images were obtained.
CT CHEST WITHOUT INTRAVENOUS CONTRAST: Bilateral large pleural
effusions are present, the left is slightly increased in size,
when compared with the prior study. The density values of the
effusions are still low to suggest presence of a hemorrhage.
There is adjacent compression atelectasis bilaterally. Again
note is made of aortic arch calcifications. The ascending aorta
measures approximately 4.2 cm maximum dimension. There is a
small amount of pericardial fluid. No significant mediastinal,
hilar or axillary lymphadenopathy is noted.
CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Re-demonstrated is a
small
diaphragmatic node, measuring now 8 mm in the short axis
diameter.
Low attenuation splenic collection measures 8.9 x 7.1 cm, better
imaged than on the prior study.
There is cholelithiasis, no evidence of acute cholecystitis. The
kidneys are atrophic. Non-contrast evaluation of the pancreas,
adrenal glands, abdominal loops of large and small bowel is
unremarkable. There are dense vascular calcifications. There is
no free air and no free fluid in the abdomen.
CT PELVIS WITHOUT INTRAVENOUS CONTRAST: The prostate contains
coarse central calcifications. The seminal vesicles, rectum,
sigmoid colon are unremarkable. There is no free pelvic fluid,
no pathologically enlarged pelvic or inguinal lymph nodes. There
is no evidence of retroperitoneal hematoma.
Soft tissues demonstrates diffuse stranding, compatible with
total body edema.
BONE WINDOWS: Demonstrate multilevel degenerative changes, there
is
heterogeneous appearance of the osseous structures, compatible
with renal
osteodystrophy. Remote fracture of the left inferior and
superior pubic rami are again seen.
IMPRESSION:
1. 9 cm splenic collection, not entirely characterized in the
absence of IV contrast, could represent a subacute hematoma,
infected collection cannot be excluded.
2. Low attenuation bilateral left greater than right effusions
with
compression atelectasis. The density values of the effusions
argue against
hemorrhage, however this could be confirmed with thoracentesis.
3. Dilated ascending aorta, extensive vascular and coronary
artery
calcifications and right common iliac artery aneurysm measuring
18 mm.
4. Cholelithiasis, no evidence of acute cholecystitis.
The study and the report were reviewed by the staff
radiologist.
DR. [**First Name (STitle) **] [**Name (STitle) **]
DR. [**First Name (STitle) 5432**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Approved: MON [**2110-12-15**] 12:48 PM
Brief Hospital Course:
Mr [**Known lastname 7518**] was admitted the the cardiac surgery service and
transfused with several units of packed red blood cells. He had
a gasteroenterolgy and general surgery consult, they did not
feel there was any indication to scope the patient at this time
as he was guiac negative and his hematocrit rose predictably and
remained stable.
The patient also had blood cultures checked, it was positive for
Cornybacterium and he was started on a 2 week course of
Vancomycin. All lines were changed.
He was also relatively hypotensive with a SBP that frequently
was in the 85-95 range despite being off all antihypertensives.
He was started on Midodrine and his systolic blood pressure rose
and remined stable in the 100-110 range.
On hospital day 11 it was decided he was stable and ready for
transfer to rehabilitation.
Medications on Admission:
Epo
Plavix
ASA
Simvastatin
protonix
albuterol
Atrovent
Percocet Cinacalet
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment
Inhalation Q6H (every 6 hours) as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) treatment Inhalation Q6H (every 6
hours) as needed.
9. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
10. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
11. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
12. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gm Intravenous HD PROTOCOL (HD Protochol) for 5 days: thru [**12-27**].
13. Epoetin Alfa 10,000 unit/mL Solution Sig: 4400 (4400) units
Injection Q HD.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location (un) 64102**]
Discharge Diagnosis:
CAD s/p OP CABG X4([**11-20**]), ESRD(HD), ^cholesterol, Secondary
hyperparathyroidism, COPD, CVA, s/p GI bleed
Discharge Condition:
stable
Discharge Instructions:
keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds.
Followup Instructions:
Dr [**Last Name (STitle) 7772**] in [**1-13**] weeks
Dr [**First Name4 (NamePattern1) 13740**] [**Last Name (NamePattern1) **] in [**1-13**] weeks
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2110-12-22**]
ICD9 Codes: 5789, 5856, 2851, 7907, 5849, 5119, 496, 2724, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1392
} | Medical Text: Admission Date: [**2191-2-18**] Discharge Date: [**2191-2-24**]
Date of Birth: [**2113-1-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 18988**]
Chief Complaint:
"Increased parkinsonian symptoms", dyspnea on exertion
Major Surgical or Invasive Procedure:
ERCP with stent placed in common bile duct
History of Present Illness:
78yo M with Parkinson's disease, AF on warfarin, and ? sleep
disorder, sent into the ED by PCP for concern that patient is
failing at home. He reports worsening of his Parkinson's
symptoms over the last month, including rigidity, instability,
more frequent falls, and memory difficulties. Denies difficulty
speaking or swallowing, or new weakness in extremities. He
administers his own medications, and his wife and PCP are
concerned that he is no longer able to do so accurately. He has
had 2 falls over the last 2 weeks, both with no head injury and
no LOC, resulting from balance difficulties while walking. He
has also had increasing dyspnea on exertion recently, over last
2-4 weeks, with associated worsening lower extremity edema.
.
He currently feels well. He has some mild hip pain which he has
had since his fall earlier this week. He denies SOB at rest, he
has not been walking around in the ED so is unable to assess
DOE. Denies CP, headache, N/V, diarrhea.
Past Medical History:
1. Atrial fibrillation- on Coumadin, followed by Dr. [**Last Name (STitle) 73**],
planning for DCCV
2. Parkinson's disease- on Sinemet and mirapex, followed by Dr.
[**Last Name (STitle) **] of Neurology
3. Prostate cancer- s/p XRT
4. L hip replacement
5. ?Sleep disorder
6. LE edema
7. Cervical myelopathy- to wear C-collar
8. Myasthenia [**Last Name (un) 2902**]- diplopia, on pyridostigmine
Social History:
Lives with his wife at home with wife. no EtOH, drugs. no
tobacco.
Family History:
Father died of esophageal ca (cigar smoker), Mother with
[**Name (NI) 2481**], Brother died of CVA
Physical Exam:
95.7 75 122/66 18 98% RA
General- elderly man sitting up in bed, appears somnolent but
easily arousable, Ox3, pleasant, NAD
HEENT- eyes closed for most of the exam and interview, sclerae
anicteric, moist MM
Neck- supple, no bruits
Lungs- CTAB, ? decreased breath sounds at L base
Heart- irregularly irregular, no murmur
Abd- soft, NT, ND, NABS
Ext- [**11-29**]+ pitting LE edema b/l, abrasions on knees b/l, +tremor
in hands b/l
Pertinent Results:
Labs on admission:
[**2191-2-18**] 12:40PM PT-17.9* INR(PT)-1.7*
[**2191-2-18**] 03:40PM BLOOD WBC-6.8 RBC-3.99* Hgb-11.9* Hct-35.7*
MCV-90 MCH-29.8 MCHC-33.3 RDW-16.9* Plt Ct-167
[**2191-2-18**] 03:40PM BLOOD Neuts-82.1* Lymphs-10.7* Monos-4.8
Eos-1.7 Baso-0.8
[**2191-2-18**] 12:40PM BLOOD PT-17.9* INR(PT)-1.7*
[**2191-2-18**] 03:40PM BLOOD Glucose-131* UreaN-31* Creat-1.1 Na-142
K-4.2 Cl-107 HCO3-25 AnGap-14
[**2191-2-19**] 12:40AM BLOOD CK(CPK)-74
[**2191-2-20**] 01:28AM BLOOD Lipase-17
[**2191-2-18**] 03:40PM BLOOD CK-MB-7 cTropnT-0.03* proBNP-3834*
[**2191-2-18**] 03:40PM BLOOD Calcium-9.4 Phos-3.0 Mg-2.1
[**2191-2-20**] 06:04AM BLOOD Type-ART pO2-69* pCO2-32* pH-7.48*
calHCO3-25 Base XS-0
[**2191-2-20**] 01:38AM BLOOD Lactate-2.1*
[**2191-2-20**] 11:14PM BLOOD Lactate-1.3
.
Pertinent labs during hospital course (LFTs, etc):
[**2191-2-20**] 01:28AM BLOOD ALT-151* AST-799* LD(LDH)-733*
AlkPhos-361* TotBili-3.5*
[**2191-2-20**] 09:00AM BLOOD ALT-186* AST-879* LD(LDH)-626*
AlkPhos-294* TotBili-5.0* DirBili-4.3* IndBili-0.7
[**2191-2-20**] 04:50PM BLOOD ALT-88* AST-629* AlkPhos-262*
TotBili-4.9*
[**2191-2-20**] 09:10PM BLOOD ALT-165* AST-468* AlkPhos-234* Amylase-35
TotBili-4.5*
[**2191-2-21**] 06:28AM BLOOD ALT-140* AST-362* AlkPhos-238*
TotBili-5.1* DirBili-4.6* IndBili-0.5
[**2191-2-22**] 04:03AM BLOOD ALT-191* AST-166* AlkPhos-167*
TotBili-4.4*
[**2191-2-23**] 05:05AM BLOOD ALT-140* AST-106* LD(LDH)-215
AlkPhos-161* TotBili-3.3*
[**2191-2-24**] 05:27AM BLOOD ALT-72* AST-60* AlkPhos-165* TotBili-2.2*
[**2191-2-20**] 09:00AM BLOOD GGT-486*
[**2191-2-20**] 09:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-POSITIVE
[**2191-2-20**] 04:50PM BLOOD IgM HAV-NEGATIVE
[**2191-2-20**] 09:00AM BLOOD Acetmnp-NEG
[**2191-2-20**] 09:00AM BLOOD HCV Ab-NEGATIVE
.
Labs on discharge:
[**2191-2-24**] 05:27AM BLOOD WBC-6.8 RBC-3.85* Hgb-10.9* Hct-34.0*
MCV-88 MCH-28.2 MCHC-32.0 RDW-16.8* Plt Ct-107*
[**2191-2-24**] 05:27AM BLOOD PT-17.2* PTT-28.3 INR(PT)-1.6*
[**2191-2-24**] 05:27AM BLOOD Glucose-104 UreaN-21* Creat-0.9 Na-141
K-3.5 Cl-107 HCO3-24 AnGap-14
[**2191-2-24**] 05:27AM BLOOD Calcium-8.9 Phos-2.2* Mg-1.9
.
Microbiology:
Blood culture [**2191-2-20**]: 4/4 bottles E. coli, 3/4 bottles
KLEBSIELLA OXYTOCA, pan sensitive
Urine culture [**2191-2-20**]: Negative
HCV viral load [**2191-2-20**]: Negative
Blood culture [**2191-2-21**]: NGTD
Blood culture [**2191-2-23**]: NGTD
.
CXR [**2191-2-18**]: increased pulmonary markings c/w CHF
.
CT head [**2191-2-18**]: no acute ICH, no mass effect
.
Hip films [**2191-2-18**]: IMPRESSION: No evidence of acute fracture.
.
RUQ U/S [**2191-2-20**]: IMPRESSION: Status post cholecystectomy without
evidence for intrahepatic or extrahepatic biliary ductal
dilatation.
.
CTA Chest [**2191-2-20**]:
IMPRESSION:
1. No evidence for pulmonary embolus.
2. Large bilateral pleural effusions with bilateral air space
opacities at the lung bases representing atelectasis versus
consolidation.
3. Small pericardial effusion.
.
CXR [**2191-2-20**]:
IMPRESSION:
1. Persistent congestive heart failure with interstitial edema.
2. New retrocardiac opacities, which may relate to dependent
edema. Aspiration pneumonia should also be considered.
3. Small left pleural effusion.
.
KUB [**2191-2-20**]: There is a nonobstructive bowel gas pattern
visualized, with air and stool within nondistended colon and air
within nondistended loops of small bowel. If there is clinical
suspicion for free intraperitoneal air, dedicated upright or
left lateral decubitus view would be recommended.
.
ERCP [**2191-2-21**]: Report pending
.
CXR [**2191-2-23**]: IMPRESSION: Improving mild pulmonary edema and
small bilateral effusions.
.
ECHO [**2191-2-24**]:
Conclusions:
EF 35-40%. The left atrium is moderately dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity size is top
normal/borderline dilated. Overall left ventricular systolic
function is
moderately depressed. Resting regional wall motion abnormalities
include
inferior akinesis/hypokinesis and inferolateral hypokinesis and
mild to
moderate global hypokinesis. The aortic valve leaflets are
mildly thickened. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is mild pulmonary artery systolic hypertension.
There is a small pericardial effusion.
Brief Hospital Course:
Patient is a 78 year old man with Parkinson's disease, Atrial
Fibrillation on anticoagulation (coumadin), with recent
worsening in Parkinson's symptoms suspected due to improper
administration of his own meds, and recent dyspnea on exersion.
.
# Parkinson's disease: He was maintained on his outpatient
Sinemet and Mirapex. His presentation included worsening
rigidity and gait difficulties resulting in falls. His PCP and
wife were suspicious that he is no longer able to administer his
own medications accurately. A Neurology consult was obtained to
comment on the possible etiologies of his gait difficulties, and
whether they could be explained by medication nonadherence.
They felt his gait difficulties were likely multifactorial, with
Parkinson's disease, cervical myelopathy, and possible [**Last Name (un) 309**] body
dementia contributing, as well as improper administration of his
parkinson's medications. He has a history of significant
worsening of his symptoms with nonadherence to medications and
his cervical collar. Therefore he was maintained on his
outpatient parkinson's medications and discharged on these
medications. He was discharged to rehab for improved
administration of these medications, and if patient returns
home, his wife will likely need to take over administration of
his medications.
.
# Cholangitis: Patient was noted to have abdominal pain and
fever on [**2191-2-20**], work up included LFTs which were noted to be
elevated in a hepatitis/obstructive pattern. Blood cultures
were sent which ended up growing 4/4 bottles pan sensitive e.
coli and Klebsiella. He was initially empirically started on
Zosyn. RUQ U/S demonstrated no dilation of the common bile
duct, but given clinical picture, there was suspicion of
obstruction. Therefore patient underwent ERCP on [**2191-2-21**] that
noted partial obstruction of common bile duct with 3 stones,
stones unable to be removed, but stent placed for pus drainage
noticed. Immediately following ERCP, patient went to the ICU
for closer monitering, but came back to the regular floor the
following day without complication. His fevers resolved, he
became more hemodynamically stable, his symptoms improved. His
diet was advanced to regular without complication. He was
maintained on Zosyn throughout hospital course, but given the
pan-sensitive bacteria, he was switched to levofloxacin on
discharge to complete a 14 day course of antibiotics. He will
need follow up with ERCP in 1- 2 months time for likely repeat
ERCP. They will contact him for scheduling.
.
# DOE: He presented with increasing dyspnea on exertion over the
last month, most notably on the day of admission when he was
trying to put on his compression stockings. While his pulmonary
exam was initially without rales, he had CHF on CXR, LE edema
greater than baseline, and he had a markedly elevated BNP. His
last TTE was in [**2186**] and showed an EF of 45-50%. He had no
infiltrates or clinical history for pneumonia. He had excellent
O2 saturations on room air, so he was maintained on his
outpatient dose of furosemide. He then had some tenuos
respiratory issues around the same time as his noted
cholangitis, requiring nasal cannula oxygen for a short time
period. This was thought secondary to trans-abdominal fluid
movement from his abdominal process. As the cholangitis was
treated as above, his respiratory issues and Oxygen requirement
resolved and the patient no longer required supplemental oxygen.
His outpatient lasix of 20mg PO QD was held during the above
infectious period of his hospital course, but was restarted
prior to discharge, and the patient had continued (but improved)
lower extremity edema. He also had a repeat ECHO prior to
discharge, which demonstrated EF=35-40%. Medication adjustments
on discharge included restarting the patient's cozaar at 25mg
QD, continuing lasix 20mg QD, adding spironolactone 25mg QD,
discontinuing the patient's beta blocker (metoprolol 25mg [**Hospital1 **])
and continuing his amiodarone 200mg QD. He was kept on his
aspirin dose 325mg QD.
.
# Atrial Fibrillation: The patient is on amiodarone and Coumadin
as an outpatient. He and his cardiologist (Dr. [**Last Name (STitle) 10241**] were
planning for DCCV but his INR has been difficult to manage, and
he has consistently been subtherapeutic on his coumadin. The
patient reached therapeutic values of his coumadin during
hospital course, but then had his coumadin held and received FFP
prior to his ERCP. Coumadin remained held following the ERCP
and discussions ensued regarding risk vs benefit of this patient
being on coumadin for his atrial fibrillation given his fall
risk. Dr. [**Last Name (STitle) 73**] wanted an ECHO to assess heart function
prior to making a decision of patient remaining on coumadin or
not. Given ECHO results above, it was decided to continue
coumadin 4mg qhs, as patient will be in a controlled environment
at rehab. Long term coumadin administration will be addressed
at a later time. He otherwise had his amiodarone held during
his acute LFT elevation, but this was restarted upon resolution
of his cholangitis. Per Dr. [**Last Name (STitle) 73**], there is continued
consideration of cardioversion in the future, once patient has a
documented therapeutic INR for 1 month's time.
.
# Left shoulder pain: Noted following ERCP. Per patient,
positional, and worse with deep breathing. Likely
musculoskeletal from lying in bed, ?positioning during ERCP.
Therefore patient discharged with oxycodone PRN, with thoughts
that shoulder pain will improve with time and physical therapy.
.
# Cervical myelopathy: His myelopathy results in left leg
weakness, contributing to his gait disturbances. His cervical
collar improves his symptoms.
.
# Prostate ca: Patient is status-post radiation therapy. He was
maintained on his outpatient oxybutynin and tamsulosin
.
# Code status: FULL
Medications on Admission:
Sinemet 25/100 tid
Mirapex 0.5 tid
Zoloft 100 qd
ASA 81 qd
Lasix 20 qd
Warfarin 2.5 qTWFSaSu, 1.25 qMTh
Tamsulosin 0.4 qhs
Oxybutynin 5 tid
Amiodarone 200mg qd
Pyridostigmine
Discharge Medications:
1. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
3. Pramipexole 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
4. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
9. Pyridostigmine Bromide 60 mg Tablet Sig: One (1) Tablet PO
Q8H (every 8 hours).
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Lactulose 10 g/15 mL Syrup Sig: 30-60 MLs PO Q6H (every 6
hours) as needed.
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 9 days.
18. Cozaar 25 mg Tablet Sig: One (1) Tablet PO once a day.
19. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
20. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
21. Coumadin 4 mg Tablet Sig: One (1) Tablet PO at bedtime:
Please moniter INR for goal of [**12-31**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2732**] & Retirement Home - [**Location (un) 55**]
Discharge Diagnosis:
Cholangitis
Parkinson's disease
Cervical myelopathy
Myasthenia [**Last Name (un) 2902**]
Atrial fibrillation
Hypertension
Discharge Condition:
Stable. Patient afebrile, stable blood pressure and heart rate,
good oxygen saturation, feeling better.
Discharge Instructions:
Please take all of your medications as prescribed.
.
If you experience falls, worsening instability, worsening
abdominal pain, fevers/chills, or other concerning symptoms,
please call your doctor or go to the ER.
.
Please follow up with appointments as directed.
Followup Instructions:
- Please call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] [**Location (un) 1683**] ([**Telephone/Fax (1) 29962**], to
schedule a follow up appointment within the next 7-10 days.
- Cardiology: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**] ([**Telephone/Fax (1) 12468**] - please follow
up in [**12-31**] weeks
- You will need to return in [**11-29**] months for follow up ERCP. The
office will notify you with an appointment time.
- Neurology: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**],
[**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 541**] Date/Time:[**2191-6-14**] 12:00
ICD9 Codes: 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1393
} | Medical Text: Admission Date: [**2137-12-10**] Discharge Date: [**2138-1-2**]
Date of Birth: [**2087-10-22**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 19157**]
Chief Complaint:
SOB, dizziness
Major Surgical or Invasive Procedure:
Dialysis catheter placement
peg placement
tunnled line placement
peritoneal dialysis catheter
trachestomy
History of Present Illness:
Pt is 50 yo M with ESRD-PD(daily at night), HTN, DM, CAD s/p
NSTEMI and CHF with EF20% who presents to OSH with SOB, fatigue
and with c/o feeling dizzy X 2days. He was found to be
hypotensive to 80/20 and transferred to [**Hospital1 18**]. Overall has not
been feeling well for about 3 days. Has developed progressive
SOB, orthopnea. Unable to lay flat at this point. States edema
unchanged. Had episode of chest pain last week and earlier
yesterday that radiated down his left arm, now resolved. Denies
anynausea, vomiting, diaphoresis. Denies any fevers, chills,
dysuria. Minimal urine output which is his baseline. Denies
any recent episodes of confusion.
.
In the ED found to have trop of 3.04 so he was started on
heparin which was then d/c per cardiology recommendation. He
also have further hypotensive to 60s, given gental ivf initially
with BP going up to 80s, then started on dopamine infusion with
BP's going to 110's. Also given Levofloxacin and flagyl in ED.
Also got 2 units of PRBC's
Past Medical History:
-Hypertension.
-CHF with an EF equal to 20% in [**2133-2-5**].
-Mild pulmonary hypertension.
-Diabetes mellitus for greater than 20 years.
-ESRD on PD
-History of upper GI bleed secondary to gastritis.
-Asthma.
-Right below the knee amputation in [**2127**].
-Left eye blindness.
-Coronary artery disease, status post non ST wave MI
([**2132**]),status post catheterization showing 50% D1
stenosis,pulmonary hypertension, increased right and left
filling pressures, pulmonary artery pressure 70/35/51, wedge
equal to29.
-h/o pneumonia
-Anemia.
-Left elbow septic joint.
-Peripheral neuropathy.
-Hand/elbow arthritis.
Social History:
No alcohol, tobacco, or drugs. Lives in [**Location 3146**] with wife and
kids.
.
Family History:
Noncontributory.
Physical Exam:
T 97.9 BP 103/43 HR 78 RR 16 O2sats 94% 2L NC
Gen- Obese, A&O times 3, mild respiratory distress
HEENT- Blind in left eye, Rt eye reactive pupil, Rt eye EOMI,
anicteric, dry mmm
Neck- Unable to assess JVD given obesity
Chest- Decreased breath sounds at bases
CV- Distant heart sounds, regular, unable to appreciate any
murmur
Abd- Distended, obese, + BS, NT, + PD catheter, pannus pitting
edema
Ext- Rt BKA, Lt leg with edema, chronic venous stasis changes, +
erythema
Neuro- Grossly intact
Pertinent Results:
[**2137-12-9**] 08:45PM WBC-13.5* RBC-2.58*# HGB-7.6* HCT-23.3*#
MCV-90# MCH-29.6# MCHC-32.8 RDW-16.1*
[**2137-12-9**] 08:45PM NEUTS-85.0* LYMPHS-10.5* MONOS-3.4 EOS-1.0
BASOS-0.1
[**2137-12-9**] 08:45PM PLT COUNT-275
[**2137-12-9**] 08:45PM PT-15.6* PTT-29.1 INR(PT)-1.7
[**2137-12-9**] 08:45PM CK-MB-16* MB INDX-13.0*
[**2137-12-9**] 08:45PM cTropnT-3.07*
[**2137-12-9**] 08:45PM CK(CPK)-123
[**2137-12-9**] 09:03PM GLUCOSE-179* K+-5.2
[**2137-12-10**] 01:45AM ASCITES WBC-415* RBC-783* POLYS-52* LYMPHS-8*
MONOS-31* MESOTHELI-3* MACROPHAG-6*
.
Imaging:
DATA:
Echo [**2-5**] - Mildly dilated LA, Mild LVH, moderately dilated LV,
LVEF <20%, moderate pulm artery systolic hypertension.
.
Cath [**9-7**]- no flow limiting disease, RA 27 PCWP 29, LVEDP 32.
.
Stress MIBI [**12-10**] - no perfusion defect however only 50% target
HR achieved.
Brief Hospital Course:
A/P: 50yo man with ESRD on PD, DM, CAD s/p NSTEMI, CHF with EF
20%, and HT, admitted with hypotension and acute on chronic
renal failure, worsening acidosis.
.
Patient was admitted with hypotension and acute renal failure.
Given high WBC count in peritoneal fluid concern for peritoneal
infection was high and pt was started on ceftaz. He remained
hypotensive and on and off dopamine for most of the
hospitilaztion. Renal sevice followed pt and dialyzed pt with
CCVH while he was hypotensive. Pt was intubated for respiratory
distress and attempts to wean the went were unsuccessful. He
underwent Tracheostomy, PEG placement, removal of peritoneal
dialysis catheter and tunnled line for dialysis placement with
surgery. He was weaned off all pressors. His respirattory
status was stable and he was finally able to sit up in a chair.
He was noted to be in a wide complex tachycardia on tele. He
was unresponsive with no pulse and CPR was initiated. A code
was run and after ~45-50 minutes of unsuccessful efforts to
maintain a pulse of a viable rhythm after discussion with family
code was stopped and pt expired.
Medications on Admission:
Medications:
Calcium Acetate 667 mg, Two (2) Tablet PO TID W/MEALS
Polysaccharide Iron Complex 150 mg PO DAILY
B-Complex with Vitamin C. (1) Tablet PO DAILY.
Folic Acid 1 mg Tablet (1) Tablet PO DAILY.
Pravastatin Sodium 40 mg PO daily.
Percocet 1 tablet q12 hours PRN.
Lasix 80 mg po bid.
Metolazone 2.5 mg po daily
Losartan 50 mg po daily
Metoprolol 100mg po daily
Imdur 120 mg po daily
Coumadin 2.5 mg po qhs
Protonix 40 E.C. daily
NPH 84 qam, 70 qpm
RISS 10 u qAM
Fosrenal 250 mg po qAC.
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2138-1-6**]
ICD9 Codes: 0389, 4275, 4280, 5856, 5849, 412, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1394
} | Medical Text: Admission Date: [**2109-6-24**] Discharge Date: [**2109-7-28**]
Date of Birth: [**2054-9-11**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: Ms [**Known lastname **] is a 54 year old
Caucasian woman who presented to [**Hospital6 649**] Emergency Department on [**2109-6-24**] for
presumed subarachnoid hemorrhage. She had been in her usual
state of health up until four hours prior to presentation
when she was witnessed to have had a sudden onset of nausea,
vomiting and disorientation and brief episodes of loss of
consciousness. On presentation to the Emergency Department,
she was noted to be pleasant and cooperative in no acute
distress.
PHYSICAL EXAMINATION: Physical examination revealed the
patient to be alert and oriented times three. Her pupils
were equal and reactive to light and her eyes showed full
extraocular movement. Cardiac examination showed regular
rate and rhythm without any evidence of murmur, rubs or
gallops. Pulmonary examination showed lungs to be clear to
auscultation bilaterally. Abdominal examination was soft and
nontender in all four quadrants. Cranial nerve examination
showed cranial nerves II through XII to be grossly intact.
Pupils were equal and reactive to light with 4 to 3 mm
constriction. Extraocular motion was noted to be full
bilaterally. Tongue was protruding in central. Palate was
midline. There was no evidence of pronator drift. Upper
extremity strength showed [**5-6**] bilaterally in her deltoids,
biceps and triceps and grips were full. Lower extremity
strength was [**5-6**] in iliopsoas, anterior tibial and
gastrocnemius. Reflexes were 2+ in the patellar ligaments.
Computerized tomography scan performed at that time showed a
significant amount of free blood in the subarachnoid space
but without any evidence of midline shift.
At that time the decision was made to admit the patient to
the Intensive Care Unit for q. one hour neurological checks.
The systolic blood pressure was maintained below 140 via
Nipride drip. She was started on Decadron 2 mg q. 8,
Amlodipine 60 mg q. 4.
ADMISSION MEDICATIONS: On admission the patient's
medications included Estrogen, Vitamin C and Vitamin E.
ALLERGIES: On admission allergies were noted to be only
Darvon.
LABORATORY DATA: Admission laboratory data included a white
count of 23.5, hematocrit 36.6 and platelets of 263. Chem-7
was sodium 136, potassium 2.7, chloride 98, carbon dioxide
26, BUN 17, creatinine .7, glucose 112. Coagulation
laboratory data were PT of 12.9, PTT 12.3 and INR of 1.1.
HOSPITAL COURSE: On presentation to the Intensive Care Unit
the patient was noted to be alert and oriented times three,
sleepy but arousable. Extraocular motion was intact and her
systolic blood pressure continued to be maintained below 130.
Late in the afternoon on [**2109-6-24**], decision was made to
place an extraventricular drain. This was performed under
sterile conditions and inserted to 7 cm. Cerebrospinal fluid
was immediately obtained and pressures greater than 20 cm H2O
was noted. Prophylactic antibiotics were started and the
patient continued with q one hour neurological checks. On
the morning of [**2109-6-25**], the patient's neurological
examination was again noted to be unchanged and decision was
made to schedule her for operative clipping of aneurysm.
This surgery was completed late in the evening on the 24th
and an anterior communicating and right MCA aneurysm
preoperative diagnosis was confirmed. During the procedure,
craniotomy was performed for clipping of an anterior
communicating and right MCA aneurysm. Surgery was performed
by Dr. [**Last Name (STitle) 1132**] with assistance by Dr. [**Last Name (STitle) 48090**]. Estimated
blood loss under 1 liter. Over the postoperative days 1 and 2,
the patient's vital signs remained stable with an intracranial
pressure of 4 and a cerebral perfusion pressure of 87.
Neurological examination remained nonfocal. Repeat head
computerized tomography scan on [**2109-6-27**] showed evidence of
increasing edema within the right frontal lobe and some
falcine herniation to a minor degree which was thought to be
mostly related to the surgery. Based on the evidence of
increasing swelling the decision was made late in the day of
[**6-27**] to return to the Operating Room and perform a right
frontotemporal parietal craniectomy. Bone flap was placed in
the subcutaneous fat within the abdomen and a soft skin flap
was left over the brain. In the following days, the patient
continued to have increased intracranial pressures ranging as
high as 32 with cerebral perfusion pressure ranging from 86
to 122. She was maintained on Triple-H therapy and frequent
interval computerized tomography scans likewise showed
evidence of cerebral edema. On [**2109-7-1**], it was noted
that there was a decline of the patient's overall
neurological examination. While she had continued to move
her upper extremities spontaneously she was no longer
localizing. There was a slight withdrawal in the left upper
extremity but minimal withdrawal in the right upper
extremity. On [**2109-7-1**], late in the afternoon due to
concerns of possible vasospasm, the patient was taken to the
Neurointerventional Suite and a bilateral ACA vasospasm was
recognized. Intraarterial superselective infusion of Papaverine
was performed in both A1 segments of the ACAs with good
results. On [**2109-7-2**], examination was mostly unchanged
with the patient opening eyes to stimulation, however, mostly
obtunded. She continued on Triple-H therapy maintaining
systolic blood pressure greater than 200. Intensive Care
Unit where she was including multiple febrile episodes and
appearance of hyponatremia. Following several days in the
Intensive Care Unit the patient continued to have febrile
temperatures and white counts size 20.5, repeated
cerebrospinal fluid, blood and sputum cultures revealed no
source of this infection. The patient continued to be
treated empirically. Low sodium was treated with sodium
supplementation. On [**2109-7-12**], the patient was consented
for a tracheostomy and percutaneous endoscopic gastrostomy
tube placement, both of which were performed without
complications.
Over the following week, the patient's neurological
examination continued with her unable to follow commands and
only vaguely localizing to stimulation.
On [**2109-7-18**], the first signs of an improvement in her
examination were seen with her beginning to open her eyes to
voice and becoming somewhat attentive to the examiner. This
progress in the neurological examination was paralleled with
success at weaning her off of the ventilator. She continued
to make progress in maintaining herself on CPAP during the
day and returning to the ventilator at night. On [**2109-7-19**], the decision was made to return to the operation and
replace her bone flap. This was performed without incident.
It was felt that it was not necessary at that time to place
any sort of ventriculoperitoneal shunt. Interval
computerized tomography scans following replacement of the
bone flap showed continued decrease in swelling. The
patient's neurological examination likewise continued to
improve. On [**2109-7-25**], the patient had improved to the
point where planning for possible placement in a
rehabilitation facility began. At that time, her
neurological examination had continued to improve where she
was attentive to the examiner, mouthed some words and
responded appropriately to family members. Upon evaluation
for placement in a rehabilitation facility, the patient was
being fed through a percutaneous endoscopic gastrostomy tube,
had maintained 72 hours off of the ventilator and had shown
improving neurological examinations.
DISPOSITION/MEDICATIONS: On [**2109-7-28**] when being
evaluated for transfer to a rehabilitation facility the
patient's medications included:
1. Zantac 20 mg p.o. b.i.d.
2. Calcium carbonate 1 gm p.o. q. 6
3. Sodium chloride 1 gm p.o. t.i.d., hold for sodium greater
than 140
4. Lopressor 100 mg p.o. t.i.d., hold for heartrate less
than 55 or systolic blood pressure less than 110
5. Captopril 12.5 mg p.o. t.i.d.
6. Albuterol Ipratropium 1 to 2 puffs inhaled q. 6 hours prn
congestion
7. Insulin sliding scale
8. Hydralazine 20 mg p.o. q. 4, hold for systolic blood
pressure less than 140, heartrate greater than 100
9. Heparin 5000 units subcutaneously q. 12
10. Epogen 40,000 units subcutaneously one time a week
11. Dilantin suspension 100 mg via tube b.i.d.
FOLLOW UP: The patient's plan is to be placed in a intensive
rehabilitation facility for ongoing neurological
rehabilitation, as appropriate she will follow up with Dr.
[**Last Name (STitle) 1132**] at [**Hospital6 256**]. Her EVD was
removed after intracranial pressures while clamped did not
exceed 20cm water.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 6825**]
MEDQUIST36
D: [**2109-7-28**] 17:00
T: [**2109-7-28**] 17:26
JOB#: [**Job Number 27938**]
ICD9 Codes: 5185 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1395
} | Medical Text: Admission Date: [**2147-1-27**] Discharge Date: [**2147-2-1**]
Date of Birth: [**2062-6-18**] Sex: F
Service: NEUROLOGY
Allergies:
Pineapple
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Sudden onset hearing loss, diplopia, and weakness.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 86448**] is an 84-year-old right-handed woman with history
of hypertension who now presents with a sudden onset of hearing
loss, diplopia, and weakness, found to have a basal pontine
hemorrhage. The patient was in the
shower and experienced the sudden onset of the above symptoms,
yelled to her son who noted that she is having trouble getting
some of her words out, stuttering at times and she was
immediately to [**Hospital6 2561**]. At that time, her
examination was unclear; however, she clearly had the new onset
of hearing loss. Non-contrast head CT revealed a pontomedullary
junction hemorrhage. She was transferred to [**Hospital1 18**] for further
care.
Past Medical History:
Hypertension
Cataracts
s/p thyroidectomy
Social History:
Lives with her son and sister. [**Name (NI) **] 2 children. Independent,
denies smoking, ethanol or
Family History:
Non-contributory
Physical Exam:
O: T: AF BP: 171/68 HR: 90s R 16 100% O2Sats
Gen: WD/WN, comfortable, NAD.
Lungs:Coarse B/L, no wheezing
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2mm
bilaterally yet sluggish with caratacts. Visual fields are full
to confrontation.
B/L: CNIII with limited up, down and medial gaze, CNVI with
lateral gaze palsy,
VII: Right Facial droop
VIII: Bilateral tinnitus with "loud noise"
IX, X: Poor palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor:
D B T WE WF IP Q H AT [**Last Name (un) 938**] G
R 5 5 5 5 5 5 5 5 5 5 5
L 5- 5- 5- 5- 5- 5- 5- 5- 5- 5- 5-
Sensation: Left hemisensory decreased sensation
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
Pertinent Results:
[**2147-1-27**] 08:15PM
URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2
BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG
COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.034
[**2147-1-27**] 08:15PM PT-12.5 PTT-24.4 INR(PT)-1.1
[**2147-1-27**] 08:15PM PLT COUNT-256
[**2147-1-27**] 08:15PM NEUTS-82.5* LYMPHS-13.1* MONOS-3.9 EOS-0.3
BASOS-0.1
[**2147-1-27**] 08:15PM WBC-8.9 RBC-4.37 HGB-13.2 HCT-38.3 MCV-88
MCH-30.2 MCHC-34.5 RDW-13.7
[**2147-1-27**] 08:15PM CK-MB-NotDone
[**2147-1-27**] 08:15PM cTropnT-<0.01
[**2147-1-27**] 08:15PM CK(CPK)-78
[**2147-1-27**] 08:15PM
GLUCOSE-124* UREA N-17 CREAT-1.0 SODIUM-138 POTASSIUM-3.8
CHLORIDE-99
TOTAL CO2-28 ANION GAP-15
[**2147-1-28**] 02:19AM BLOOD ALT-11 AST-23 LD(LDH)-193 AlkPhos-74
TotBili-0.5
ECG Study Date of [**2147-1-27**] 8:05:06 PM
Sinus rhythm. Normal tracing. No previous tracing available for
comparison.
CT HEAD W/O CONTRAST Study Date of [**2147-1-27**] 8:39 PM
IMPRESSION: Pontomedullary junction hemorrhage (17 x 9 mm).
CT HEAD W/O CONTRAST Study Date of [**2147-1-29**] 9:02 AM
NON-CONTRAST HEAD CT: Previous 1.7 x 0.9 cm pontomedullary
junction
hemorrhage (2:7) is grosssly unchanged in size accounting for
differences in technique. Minimal apparent change in shape may
represent evolution of bleed or difference in slice selection.
There is no new area of intracranial hemorrhage. There is no
intraventricular or subarachnoid extension of hemorrhage. There
is no mass effect, or territorial infarction. Partially
visualized maxillary sinuses demonstrate almost complete
opacification of the right maxillary sinus. Expansion of the
left temporal bone just posterior to the left mastoid air cells
with internal ground-glass matrix is stable and most compatible
with fibrous dysplasia (2:9).
IMPRESSION:
1. Grossly stable pontomedullary junction hemorrhage.
2. Mucosal sinus disease.
3. Left temporal bone fibrous dysplasia.
Brief Hospital Course:
Ms. [**Known lastname 86448**] was admitted as a transferr from [**Hospital3 **] for evaluation of a pontine hemorrhage.
The patient initially presented with complaints of bilateral
hearing loss, weakness and diplopia. CT on arrival to the ED
confirmed the presence of a hemorrhagic infarct at the
pontomedullary junction. She was initially admitted to the ICU
for close monitoring. She remained stable both neurologically
and hemodynamically, and was transferred to the floor.
Hypertension was initially controlled with hydralazine, but her
home antihypertensive regimine was resumed prior to discharge.
Her neurologic exam at the time of discharge was notable for
continued bilateral hearing impairment (although improved),
dysphonia, bilateral 6th nerve palsies and sensory ataxia of the
left upper extremity. An eye patch was used to eliminate
diplopia.
It is felt that this hemorrhage was secondary to hypertension
and thus, the patient should continue to be monitored and
medications adjusted as needed to maintain SBP <130.
Medications on Admission:
1. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Avapro 300 mg Tablet Sig: One (1) Tablet PO once a day.
3. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
6. Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO once
a day.
7. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: One (1) Tablet
PO once a day. Tablet(s)
Discharge Medications:
1. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Avapro 300 mg Tablet Sig: One (1) Tablet PO once a day.
3. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
5. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
6. Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO
once a day.
7. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: One (1) Tablet
PO once a day. Tablet(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] - Rehab and SCI
Discharge Diagnosis:
Intracranial hemorrhage at the pontomedullary junction.
Discharge Condition:
The patient continued to have bilaeral hearing impairment
(although improved, L loss greater than R), dysphonia, bilateral
6th nerve palsies and sensory ataxia of the left upper
extremity.
Discharge Instructions:
You were admitted for evaluation and treatment of a stroke
caused by a hemorrhage in your brainstem. This was most likely
caused by high blood pressure. You have improved but will
continue to require therapy for your neurologic deficits. You
are being discharged to rehab.
You have scheduled you for follow up in the stroke clinic with
Dr. [**Last Name (STitle) **]. You will need to call the registration line prior
to this appointment ([**Telephone/Fax (1) 10676**])
Followup Instructions:
[**3-11**], 1pm with Dr. [**Last Name (STitle) **]. [**Hospital Ward Name 23**] clinical building, [**Location (un) **].
Completed by:[**2147-2-1**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1396
} | Medical Text: Admission Date: [**2146-1-4**] Discharge Date: [**2146-1-10**]
Date of Birth: [**2066-11-3**] Sex: M
Service: SURGERY
Allergies:
Iodine-Iodine Containing / Ceftriaxone / Azithromycin
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
Right lower extremity claudication and intermittent rest pain
Major Surgical or Invasive Procedure:
Right femoral to below knee popliteal artery bypass with GSV
History of Present Illness:
Mr. [**Known lastname 174**] is a 79 year old gentleman with extensive peripheral
vascular disease with history noted for distant aorto-bifemoral
bypass graft now presenting with increased claudication symptoms
in his right lower extremity as well as intermittent rest pain.
He recently underwent a CT scan with demonstrated his graft to
be patent, but with complete occlusion of his right SFA with
reconstitution of the distal popliteal artery; his left SFA was
found to also be severely diseased. He therefore presents for
elective right femoral to popliteal artery bypass.
Past Medical History:
PMH: PVD, carotid disease s/p L CEA, history of CAD,? MI, s/p
CABG x 3, hx of PNA, PUD, chronic back pain, anemia,
dyslipidemia
PSH: axillo-bifemoral bypass, L CEA with take back to OR for
hematoma evacuation, CABG X 3 ([**2137**]), catheterization ([**2141**] with
stenosed grafts), angiogram ([**2142**]) with occluded R SFA, disease
L SFA
Social History:
retired law enforcement officer; divorced and lives alone. Acive
smoker, tobacco: 1ppd x 60+ yrs. Regular alcohol consumption.
4-6 beers daily.
Family History:
Brother: MI in 70s
Physical Exam:
Upon discharge:
VS: Tm 97.2 Tc 97.2 HR 81 BP 133/58 RR 24-26 O2sat 90-95% RA
General: in no acute distress
HEENT: no perioral cyanosis, mucus membranes moist, nares clear,
trachea at midline
CV:regular rate, rhythm. No appreciable murmurs, rubs, gallops
Pulm: slightly diminished at bases, but otherwise clear
Abd: soft, non tender, nondistended
MSK: palpable R and L groin pulses. Some induration lateral
aspect of left anterior thigh, lateral to incision, about 4-5cm;
non-cellulitic, not fluctuant. Incision otherwise clean, dry,
intact. Dopplerable right DP, palpable right PT; palpable graft
pulse. Dopplerable left DP and PT pulses.
Neuro: alert, oriented to person, place, time.
Pertinent Results:
[**2146-1-4**] 11:35AM BLOOD Hgb-11.8*# Hct-33.4*# Plt Ct-173
[**2146-1-5**] 05:28AM BLOOD WBC-9.1 Hgb-10.0* Hct-28.2* Plt Ct-141*
[**2146-1-5**] 07:06PM BLOOD Hct-24.9*
[**2146-1-10**] 06:50AM BLOOD WBC-6.8 RBC-3.25* Hgb-10.6* Hct-31.3*
MCV-96 MCH-32.7* MCHC-34.0 RDW-15.4 Plt Ct-283
[**2146-1-4**] 11:35AM BLOOD PT-11.9 PTT-33.8 INR(PT)-1.1
[**2146-1-4**] 11:35AM BLOOD Glucose-116* UreaN-12 Creat-1.2 Na-134
K-4.1 Cl-100 HCO3-26 AnGap-12
[**2146-1-10**] 06:50AM BLOOD Glucose-97 UreaN-18 Creat-1.3* Na-139
K-3.8 Cl-101 HCO3-24 AnGap-18
[**2146-1-4**] 11:35AM BLOOD ALT-22 AST-24 AlkPhos-13*
[**2146-1-4**] 11:35AM BLOOD CK-MB-3 cTropnT-<0.01
[**2146-1-5**] 07:06PM BLOOD CK-MB-6 cTropnT-0.06*
[**2146-1-6**] 12:03AM BLOOD CK-MB-6 cTropnT-0.06*
[**2146-1-6**] 02:58AM BLOOD CK-MB-6 cTropnT-0.08*
[**2146-1-6**] 08:27PM BLOOD CK-MB-6 cTropnT-0.13*
[**2146-1-7**] 01:07AM BLOOD CK-MB-5 cTropnT-0.13*
[**2146-1-4**] 11:35AM BLOOD Calcium-8.0* Phos-5.1* Mg-1.8
[**2146-1-10**] 06:50AM BLOOD Calcium-9.2 Phos-3.9 Mg-1.9
Imaging:
[**2146-1-4**]: CXR: Interval development of mild asymmetric
interstitial pulmonary edema.
[**2146-1-5**]: TTE: There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with hypokinesis of the basal
to mid inferior and inferolateral walls. The remaining segments
contract normally (LVEF = 45 %). The aortic root is mildly
dilated at the sinus level. 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. There is trivial
mitral regurgitation. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
[**2146-1-9**]: CXR: mild interstitial edema. More focal opacity at the
left base with associated layering fluid is seen suggestive of
compressive
atelectasis.
Brief Hospital Course:
The patient was admitted to the vascular surgery service on
[**2146-1-4**] and had undergone appropriate pre-operative evaluation
for an elective right femoral to below knee popliteal bypass
with saphenous vein graft. The patient's immediate hospital
course was complicated by frequent, intermittent episodes of
angina on HD#1, POD#0. Cardiology was initially consulted, with
no attempt at catheterization given that his cardiac bypass
grafts had stenosed according to catheterization report in [**2141**].
The patient also demonstrated an increased oxygen requirement
while on the floor, and was transferred to the CVICU on POD#1
for aggressive diuresis, close monitoring and pulmonary toilet.
Once stable the patient was transferred to the unit on POD#3
with continued physical therapy, chest physiotherapy, and
titration with beta-blockade and isosorbide nitrate. During the
next few days of his admission, he was weaned off of nebulizing
treatments, transitioned to inhalers and his cardiovascular
medications titrated appropriately. By system,
Neuro: Post-operatively, the patient received Dilaudid IV with
good effect and adequate pain control. When tolerating oral
intake, the patient was transitioned to oral pain medications.
CV: As noted above, the patient experienced increased episodes
of angina not dissimilar to his episodes at home. The patient
stated he could have 'a few' episodes of chest pain per day,
always relieved by SL nitroglyerin or with time. During this
admission, the patient was noted to have chest pain with
increased anxiety or with mild exertion. Given his history (CABG
x3, catheterization upwards of 4 years ago demonstrating
stenosed bypass grafts), cardiology was consulted for
recommendations on further management. The initial thought was
for catheterization with potential intervention, and so the
patient was placed on heparin drip on POD#0. This plan was
abandoned the next day, with the decision to pursue conservative
medical management and up-titrate his beta-blockade and
isosorbide nitrate.
An intial set of troponins and CK fractions were negative, and
the second set showed 0.6-0.8-.13-.13 which was likely secondary
to demand ischemia. The patient was continued on his increased
Toprol XL dose of 300mg once daily, imdur 30mg [**Hospital1 **], ranolazine
500mg [**Hospital1 **] and po furosemide 20mg once daily with marked decrease
in symptoms to about 1-3 episodes per day. He did not require SL
nitroglycerin prior to discharge, and his heart rate remained
consistent in the 70-80 range, SBP stable at 110s-120s mmHg.
Pulmonary: The patient is known to have significant history of
COPD, but does not require additional oxygen at home. As noted
above during this admission, the patient demonstrated
de-saturations to the low 80s despite being on face-mask with
increasing oxygen requirement. Given his worsening respiratory
status, he was transferred overnight on HD#1 to the CVICU for
closer monitoring. He was aggressively diuresed as he had
received one unit of blood and close to 5 liters of crystalloid
intraoperatively. His oxygen saturations improved, and his UOP
was well maintained and monitored with foley catheter in place.
Once achieving O2sats at 95-100% on 5lNC, the patient was
subsequently transferred from the CVICU to the floor on POD#3
and continued to have standing nebulizer treatments, chest
physiotherapy, and continuous O2 monitoring. He was resumed on
his spiriva inhaler, and advair was also implemented with good
effect. He did not require standing nebulizer treatments and was
attaining O2saturations in the low 90s to mid 90s prior to
discharge without O2 requirement. He may benefit from
intermittent O2 by nasal cannula (at most at 2L) while at his
rehabilitation facility.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. His diet was advanced on POD#1, which
was tolerated well. He was also started on a bowel regimen to
encourage bowel movement. Foley was removed on POD#3. Intake and
output were closely monitored.
ID: Pre-operatively, the patient received IV vancomycin and
cefazolin. The patient's temperature was closely watched for
signs of infection.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge on POD#6, the patient was afebrile,
with good blood pressure and heart rate control, tolerating a
diet, ambulating with some assistance, and having regular bowel
movements and voiding without assistance.
Medications on Admission:
asa 81mg daily, plavix 75mg daily, toprol 50mg [**Hospital1 **],
lasix 20mg daily, lisinopril 20mg daily, imdur 30mg [**Hospital1 **], crestor
20mg daily, NTG PRN, pantoprazole 40mg daily, tamsulosin 0.4mg
daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
6. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO BID (2 times a
day).
8. ranolazine 500 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO BID (2 times a day).
Disp:*60 Tablet Extended Release 12 hr(s)* Refills:*2*
9. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
Pt home dose is 40mg, increase appropriately when creatinine
back to baseline 1.1.
10. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: Three (3) Tablet Extended Release 24 hr PO DAILY (Daily).
11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
14. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain for 7 days.
Disp:*45 Tablet(s)* Refills:*0*
15. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
16. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
17. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
18. lisinopril 20mg once daily (HELD for elevated creatinine 1.3
from baseline 1.1).
Discharge Disposition:
Extended Care
Facility:
Country Rehabilitation and Nursing Center - [**Location (un) 5028**]
Discharge Diagnosis:
Peripheral vascular disease, right lower extremity claudication
with intermittent rest pain
Discharge Condition:
Mental status: alert, oriented to person, place, time.
Cooperative with plan of care
Ambulatory status: walking with 1 person assist
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**3-11**]
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
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? 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:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1391**] in 2 weeks; call his office
at([**Telephone/Fax (1) 4852**] to schedule an appointment or if you have any
questions.
Completed by:[**2146-1-10**]
ICD9 Codes: 4111, 5180, 412, 2724, 3051, 496, 4589, 5859, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1397
} | Medical Text: Admission Date: [**2133-11-11**] Discharge Date: [**2133-11-15**]
Service: NEUROSURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Unsteady gate
Major Surgical or Invasive Procedure:
None
History of Present Illness:
84y/o gentleman transferred from outside hospital for initial
complaint of disorientation and unsteady gate, a Ct scan of the
head there revealed a acute on Chronic SDH bilaterally, but
greater on the left. On questioning here in the ED, the pt.
denies history of falls. He expresses that he has been having
difficulty with gate and balance for about a month and had
difficulty standing this morning. Pt. is on Coumadin for DVTs
and presented with an INR of 3.0, he was given one unit of FFP
at the outside facility.
Past Medical History:
- coronary artery disease s/p MI and CABG [**44**] yrs ago
- lower extremity DVT in [**8-/2133**] (now off anticoagulation due
to SDH; bliateral LENIs earlier this month show no clot)
- colon cancer (stage, therapy, status otherwise unknown)
- hyperlipidemia
- hypertension
- chronic kidney disease, stage II with baseline creatinine 1.2
Social History:
Lives with son
Family History:
NC
Physical Exam:
BP:208 / 80 HR: 60 R O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:pinpoint bilaterally EOMs: intact
Neck: Rigid collar in place
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Cranial Nerves:
I: Not tested
II: Pupils equally round, pinpoint, flicker reactivity. 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.
Sligth Right pronator drift
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-13**] throughout.
Sensation: Intact to light touch,
Reflexes: B T Br Pa Ac
Right 2+-------------
Left 2--------------
Toes upgoing bilaterally
Coordination: slight R finger to nose dysmetria
Upon Discharge:
Denies HA, ROS negative
A&O [**1-11**], has baseline dementia, sl. R pronator drift, face/smile
symmetric. MAE, Full strength.
Pertinent Results:
[**2133-11-11**] GLUCOSE-87 UREA N-27* CREAT-1.4* SODIUM-135
POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-27 ANION GAP-13
[**2133-11-11**] WBC-14.3*# RBC-3.88* HGB-11.8* HCT-34.2* MCV-88
MCH-30.5 MCHC-34.6 RDW-13.5
[**2133-11-11**] PT-23.2* PTT-29.1 INR(PT)-2.2*
[**2133-11-13**] BLOOD WBC-7.7 RBC-3.41* Hgb-10.2* Hct-29.7* MCV-87
MCH-29.8 MCHC-34.1 RDW-13.5 Plt Ct-212
[**2133-11-13**] 07:15AM BLOOD PT-13.4 PTT-24.8 INR(PT)-1.2*
[**2133-11-13**] 07:15AM BLOOD Glucose-108* UreaN-22* Creat-1.4* Na-130*
K-3.8 Cl-97 HCO3-24 AnGap-13
Head CT [**11-11**] 11a:Acute on chronic left basal frontal subdural
hematoma with 5 mm of midline shift as detailed above. Scattered
foci of subdural hematoma along the basal right frontal lobe and
right temporal lobe as well. No skull fracture identified.
Head CT [**11-11**] 7p: Little change to acute on chronic subdural
hematomas. There is no evidence of new intracranial herniation.
Head CT [**11-12**] 8p:Little change to the acute-on-chronic bilateral
subdural
hematomas. No evidence for new intracranial hemorrhage or
herniation.
Brief Hospital Course:
84M admitted the ICU for observation of Bilat. Acute on Chronic
SDH. He was on Coumadin for a DVT which has since now resolved
based on recent U/S of BLE. His INR was reversed and pt had
subsequent stable head CTs and stable neurologic exams. He was
transferred to the SDU where he remained stable and was seen by
PT and OT who recommended home therapy. On [**11-13**] his foley was
d/c'd and he was tolerating Reg diet. His Sodium dropped from
135 to 130 the day prior and he was placed on free water
restrictiion and Sodium was monitored. He was placed on a fulid
restriction and salt tabs and his sodium came up to 132 on the
day of discharge. He was sent home with a fluid restricion and
direction to follow up with his pcp for additional lab work and
follow up Na level within a week of his discharge date. He will
follow up with Dr. [**Last Name (STitle) **] for schedualing of elective drainage
of his subdurals on an elective basis.
Medications on Admission:
Provigil
Coumadin
Folic acid
Triamterene-Hydrochlorothiazid
Doxazosin
Donepezil
Discharge Medications:
1. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
2. Memantine 5 mg Tablet Sig: Two (2) 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. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
6. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
7. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed.
10. Multivitamins Tablet, Chewable Sig: One (1) Tablet PO
DAILY (Daily).
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
13. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
14. Sodium Chloride 1 gram Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 3894**] Health VNA
Discharge Diagnosis:
Bilateral Acute on Chronic SDH
Discharge Condition:
Neurologically stable
Discharge Instructions:
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
. You may return to your day program.
. Please Make an appointment to see your PCP by Wed of this week
for blood work, your Sodium level has been low here in the
hospital and you were placed on fluid restriction with a max
intake of water of 1000 ml, and you have been perscribed Salt
tabs. Please have your PCP check your Sodium level again this
week.
You can increase your intake of salt and drink V8 or Gateraid
when possible.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks to discuss surgical options.
??????You will need a CT scan of the brain without contrast prior to
your visit, our office will arrange this for you, just be sure
to mention that you need a CT when you call for your
appointment.
Completed by:[**2134-2-7**]
ICD9 Codes: 2761, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1398
} | Medical Text: Admission Date: [**2174-6-6**] Discharge Date: [**2174-6-15**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
s/p fall, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 61875**] is an 82 year old Portugese-speaking man admitted
on [**2174-6-6**] with shortness of breath and abdominal pain. He was
transferred here intubated and was found to have a WBC of 194k
and have hyperkalemia. He had a fever to 101.4 and was extubated
on [**6-8**]. CTA to assess for PE was negative.
.
Translated by the [**Hospital1 18**] portugese translator, he says that he
feels much better. He says that he originally fell while he was
trying to walk, but that he doesn??????t walk very much because he
gets ??????lightheaded?????? or ??????dizzy?????? but he could not clarify further.
He kept referring to ??????bronchitis?????? and that he worked in a plant
with a lot of dust exposure. Today he feels that he is not
having trouble breathing. His right arm swelling is new for him.
He expects his daughter to arrive soon who can explain more.
Past Medical History:
COPD
Parkinson's
HTN
R cataract [**Doctor First Name **]
Social History:
Portugese speaking man, had occupational exposure to large
amounts of dust- many coworkers have died of lung diseases. He
lives at home and is mostly sedentary for the past 3 years. He
denies alcohol or drug use.
Family History:
Noncontributory
Physical Exam:
PE: 66, 122/50, 14, 100% on FiO2 1.0
intubated, sedated, anasarca
Chest: diff bilat crackles, no weezing
CV: RRR, distant HS
Abd: protruding, large R sided round mass mid abdomen,
large/diffuse ecchymoses ([**2-24**] abdomen), +BS
Ext: 2=3+ pitting edema+ woody edema LE, no LAD
ECG: sinus, no ischemic changes
Pertinent Results:
ADMISSION LABS:
[**2174-6-6**] 02:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2174-6-6**] 02:45PM calTIBC-303 HAPTOGLOB-191 FERRITIN-119
TRF-233
[**2174-6-6**] 07:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2174-6-6**] 02:45PM WBC-172.6* RBC-2.49* HGB-7.2* HCT-21.6*
MCV-87 MCH-28.7 MCHC-33.1 RDW-14.4
[**2174-6-6**] 02:45PM NEUTS-10* BANDS-1 LYMPHS-86* MONOS-2 EOS-0
BASOS-0 ATYPS-1* METAS-0 MYELOS-0 OTHER-0
[**2174-6-6**] 02:45PM HYPOCHROM-1+ ANISOCYT-OCCASIONAL
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-OCCASIONAL SPHEROCYT-OCCASIONAL OVALOCYT-OCCASIONAL
[**2174-6-6**] 02:45PM PLT SMR-NORMAL PLT COUNT-171
[**2174-6-6**] 02:45PM RET AUT-4.2*
[**6-8**] CTA of Chest:
1) No pulmonary embolism.
2) Bilateral pleural effusions with atelectasis of the right
upper and both lower lobes. Mediastinal and left hilar
lymphadenopathy.
3) Splenomegaly, with small amount of adjacent free fluid.
Echo [**6-7**]:
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
Right ventricular chamber size is mildly dilated with mild
free wall hypokinesis. 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 structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is a small circumferential pericardial effusion without
evidence of hemodynamic compromise.
IMPRESSION: Preserved global and regional biventricular systolic
function. Pulmonary artery systolic hypertension. Mild right
ventricular cavity enlargement with free wall hypokinesis.
Small circumferential pericardial effusion without hemodynamic
compromise.
Based on [**2166**] 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.
[**2174-6-12**]: Abdominal/Pelvis CT:
1. No evidence of lymphoma recurrence within the abdomen and
pelvis.
2. Enlarged lymph, in the part of cardiac region, large
bilateral pleural effusions, right greater than left with
compressive atelectasis again seen. These are unchanged from
prior CTA obtained [**2174-6-8**].
3. 11.3 x 5.1 cm rectus sheath hematoma.
4. Splenomegaly.
5. Bilateral inguinal hernias.
ECG: Atrial fibrillation
Multifocal atrial rhythm
Since previous tracing of [**2174-6-7**], irregular supraventricular
rhythm seen
[**2174-6-13**] Cytology PLEURAL FLUID pending
CXR [**6-14**]: Compared with [**2174-6-13**] there is considerable interval
clearing of the pulmonary edema and the pulmonary vascular
engorgement. Residual right pleural effusion is seen causing
haziness at the right base. The lungs are better aerated.
Flow cytometry on peripheral blood:
The following tests (antibodies) were performed: HLA-DR, FMC-7,
Kappa, Lambda, and CD antigens 3, 5, 10, 19, 20, 23, 45.
RESULTS:
Three-color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.
Abnormal/lymphoma cells comprise 90% of total gated events.
B-cells demonstrate a monoclonal kappa light chain restricted
population. They co-express pan-B cell markers CD19, 20
(bright) along with CD 23 and FMC7. They do not express any
other characteristic antigens including CD10 or CD5.
T-cells express mature lineage antigens.
INTERPRETATION Immunophenotypic findings consistent with
involvement by: a kappa-restricted B-cell lymphoproliferative
disorder.
Cytogenetics (pending).
Brief Hospital Course:
82 year old man with CLL, COPD, HTN admitted s/p fall 3 days
prior to admission
1) Pulmonary: pt arrived from OSH intubated for tachypnea ?lung
collapse and airway protection per ED physician who evaluated pt
at [**Hospital3 15402**]. Pt has been fluid overloaded with anasarca and
right pleural effusion. Thoracentesis done [**6-13**] around 2pm
which showed a transudative process consistent with CHF. After
diuresis and thoracentesis, patient's respiratory status much
improved.
2) ID: s/p 10days of ceftriaxone/azithro/clinda for pneumonia.
Started on keflex for possible right wound infection, although
superficial wound culture was negative. Pt still occasionally
spikes fevers but blood, urine and pleural fluid cultures have
been negative. We feel that his intermittent fevers are due to
his leukemia.
3) Onc: Pt has chronic lymphocytic leukemia with extremely
elevated white blood count. Pt was temporarily started on
allopurinol for possible tumor lysis, but this was discontinued.
The patient is noted to have an enlarged spleen. Heme onc was
consulted, but they felt no acute interventions were indicated.
Abd/pelvis ct was performed for staging. Will f/u with Dr.
[**First Name (STitle) 1557**] as outpt on [**7-18**].
4) Cardiovascular:
a) rhythm: intermittently tachycardic, EP curbside suggested
resolving systemic issues. We considered adding beta-blockade
although there is some quetion of whether he also is in
wenckebach [**Date range (1) 61876**] although official ekg read as afib w/
multifocal atrial rhythm.
b) pump: echo shows normal ef, decreased E/A ratio == dialstolic
heart failure, pulmonary hypertension. Pulm effusions may in
part be due to CHF.
5) Neuro: history of parkinsons disease, continue cinemet.
6) F/E/N: Continue cardiac/salt-restricted diet. Creatinine is
1-1.1 at baseline.
We restarted home dose of lasix 40mg for [**6-14**] AM but increased
it to 60mg qd. This should be decreased as an outpatient.
Please keep him in/out even, increase lasix as needed.
7) PPX: pneumoboots, heparin sc.
Medications on Admission:
Laix 40
protonix
carbidopa 25'
iron 325 [**Hospital1 **]
naprosyn 375 [**Hospital1 **]
alprazolam 0.5 tid
celexa 20
lisinopril 20
terazosin 5'
advair
Discharge Medications:
1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) units Injection TID (3 times a day).
2. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
4. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours).
8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
11. Neomycin-Bacitracin-Polymyxin Ointment Sig: One (1) Appl
Topical TID (3 times a day) for 5 days: to right arm abrasion.
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
14. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
15. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days: day 1=[**6-14**].
16. Furosemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
17. Insulin Regular Human 100 unit/mL Solution Sig: ASDIR
Injection ASDIR (AS DIRECTED): sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 3894**] Nursing & Rehabilitation Center - [**Location (un) 5503**]
Discharge Diagnosis:
Chronic lymphocytic leukemia
Congestive heart failure
Pleural effusion
Discharge Condition:
Stable.
Discharge Instructions:
Please seek medical attention for fevers>101.4, for chest pain,
or for anything else medically concerning.
Please take your medications as directed.
Followup Instructions:
1) Please see your PCP [**Name Initial (PRE) 176**] 1-2 weeks following discharge from
rehab. (daughter has information on new PCP.
2) Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], MD Where: [**Hospital6 29**]
HEMATOLOGY/BMT Phone:[**Telephone/Fax (1) 3237**] Date/Time:[**2174-7-18**] 12:00
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
ICD9 Codes: 4280, 5119, 486, 496, 2761, 2767, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1399
} | Medical Text: Admission Date: [**2112-7-28**] Discharge Date: [**2112-8-4**]
Date of Birth: [**2034-8-12**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 10370**]
Chief Complaint:
chest pain, atrial fibrillation, fever, mental status changes,
hypotension, dyspnea
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
77 year old man with history of atrial fibrillation during a
previous hospitalization which was converted to NSR and was
followed up with a good performance on a stress test who
presented to the ED [**2112-7-28**] with chest pain. He was in his
usual state of health until two days prior to admission when he
developed a "cold" consisting of a dry cough and fevers to 37.8
in addition to chest pain. He described the chest pain as a
[**5-7**], dull and intermittent located in his mid-chest and
radiating to his right shoulder. He also noted loss of appetite
and diaphoresis. He reports that he gets this same combination
of fever, chest pain, and diaphoresis every Fall.
No recent fatigue, no dysuria, no diarrhea. No recent travel, no
leg swelling. No recent weight loss. In the ED he was noted to
have a temperature of 101 and hypotension to 83/53 which
improved with 2 L IVF.
Past Medical History:
-hypertension
-hyperlipidemia
-atypical chest pain (ETT and stress test [**8-31**] normal)
-anxiety
-s/p fall with multiple facial fractures ([**2107**])
-s/p removal infected mandibular hardware ([**2108**])
-remote h/o afib controlled with amiodarone; d/c by cards([**2107**])
-hemorrhoids
-colonic polyps (colonoscopy [**2107**])
-glaucoma
Social History:
Moved from [**Country 532**] about 14 years ago, traveled 3 years ago to
[**Country **] but no other travel. H/o tobacco in [**2045**], none recently.
Uses EtOH socially on weekends ([**1-1**] drinks/week); denies IVDU.
Lives with his wife.
Family History:
No CAD.
Physical Exam:
VS: 97.3; BP: 146/82; P:97; RR: 22, labored; O2 Sat: 100% on 2L
GEN: resting in bed watching TV, labored breathing using
accessory muscles but NAD, able to speak in full sentences, RR
of 22, patient is very uncooperative and refuses to be
interviewed
HEENT: PERL
NECK- supple, no cervical or supraclavicular LAD. No bruits. No
JVD.
CV- Irregular, tachycardic, no murmur appreciated.
CHEST- expiratory wheezes noted bilaterally
ABD- taut, possibly distended, non-tender, no masses, no
organomegaly
EXT: warm, well perfused, no edema
Neuro: limited exam, seems to have no focal findings
Pertinent Results:
[**2112-7-28**] 10:18PM CK-MB-3 cTropnT-<0.01
[**2112-7-28**] 10:18PM CK(CPK)-194*
[**2112-7-28**] 08:53PM LACTATE-2.8*
[**2112-7-28**] 04:55PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.029
[**2112-7-28**] 04:55PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2112-7-28**] 04:55PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2112-7-28**] 04:10PM GLUCOSE-151* UREA N-19 CREAT-1.2 SODIUM-132*
POTASSIUM-3.8 CHLORIDE-96 TOTAL CO2-24 ANION GAP-16
[**2112-7-28**] 04:10PM cTropnT-<0.01
[**2112-7-28**] 04:10PM CK(CPK)-104
[**2112-7-28**] 04:10PM CK-MB-2 proBNP-1598*
[**2112-7-28**] 04:10PM WBC-16.0*# RBC-4.85 HGB-13.4* HCT-38.7*
MCV-80* MCH-27.7 MCHC-34.8 RDW-14.3
[**2112-7-28**] 04:10PM NEUTS-95.0* BANDS-0 LYMPHS-2.9* MONOS-1.9*
EOS-0 BASOS-0.1
[**2112-7-28**] 04:10PM HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-NORMAL MICROCYT-3+
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2112-7-28**] 04:10PM PLT SMR-NORMAL PLT COUNT-174
[**2112-7-28**] 04:10PM PT-13.5* INR(PT)-1.2*
Brief Hospital Course:
He was admitted to CC7. On the medicine floor, he was ruled out
for myocardial infarction with serial enzymes. He was
orthostatic and his hypotension initially improved with fluid
rehydration. A fever work up including UA, cultures, CXR, and LP
was started and has so far been inconclusive. Serum tox screen
negative. He had a head CT without any obvious intracranial
bleed or mass; some maxiallary sinus mucosal thickening was
noted. He was started on antibiotics the evening of [**2112-7-29**], when
he was spiking fevers with altered MS; he was started
empirically on vanco/levo/flagyl. His WBC had trended down and
his fevers were intermittent (Tmx: 102). He developed atrial
fibrillation with RVR on the floor; his rate was controlled with
lopressor, at the expense of his BP. He also became more
tachypnic, breathing 40/min while sleeping, with ABG 7.41/29/91
on 3L nc.
He was transferred to the MICU. A work up for his change in
mental status resulted in a repeat negative head CT, an abnormal
EEG which showed changes consistent with metabolic
abnormalities, infection, ischemia or anxiety, an unrevealing
second LP, a negative RPR, B12 of 289 and TSH of 1.0. He was
treated with Zyprexa and Ativan for agitation and placed on the
CIWA protocol. His Atrial Fibrillation was treated with
Lopressor, Amiodarone, and Heparin and Warfarin. An
Echocardiogram showed no vegetations. Due to increased wheezing,
he was started on albuterol nebs and inhaled fluticasone with an
improvement in his tachypnea and wheezing. His WBC continued to
trend downwards and his blood pressure stabilized. Antibiotics
were continued.
On [**2112-8-2**] he was transferred to [**Hospital Ward Name 121**] 7 for further
management.
1. ATRIAL FIBRILLATION
The patient's atrial fibrillation with RVR has remained stable
with HR ranging from 90-125. He was started on Amiodarone HCl
400 mg PO starting [**2112-8-1**], and his home dose of Metoprolol was
increased from 25 mg [**Hospital1 **] to 75 mg [**Hospital1 **]. Heparin on and sliding
scale and Warfarin 2.5 mg PO were begun [**2112-8-2**] with an
increase in Warfarin to 5 mg PO daily on [**2112-8-4**] since the INR
remained low at 1.3. Lovenox 90 mg [**Hospital1 **] SC was begun [**2112-8-4**] at
6 PM and heparin discontinued in anticipation of discharge. INR
upon discharge 1.3. Home VNA will help administer Lovenox.
2. CHANGES IN MENTAL STATUS
A work up for his change in mental status resulted in a negative
head CT, an abnormal EEG which showed changes consistent with
metabolic abnormalities, infection, ischemia or anxiety, two
unrevealing LPs, a negative RPR, B12 of 289 and TSH of 1.0. He
was treated with Zyprexa and Ativan and placed on the CIWA
protocol for concerns about possible alcohol withdrawal. The
patient's mental status improved during his hospital stay with
more difficulties at night. He was fully alert and oriented
with a mini-mental status score of 27/30 with only some
difficulty on fine points of orientation including the floor of
the hospital he was on, the county we were in, and the date the
day before discharge.
3. FEVER OF UNKNOWN ORIGIN
At discharge, the patient was afebrile with a WBC of 9.4, down
from 16.0 upon admission. ID believes he had a viral infection
which has resolved. He was treated with Levofloxacin for 6 days,
and Vancomycin and Flagyll for 5 days during his
hospitalization.
4. DYSPNEA
The patient improved with a RR of 22, an oxygen saturation of
95% on room air, and lungs CTAB upon discharge. The dyspena is
believed to be due to COPD although the patient only has a
remote history of smoking. A Chest/Abdominal/Pelvic CT
concluded "1.Prominent mediastinal fat likely corresponds to the
widened appearance of the mediastinum on chest radiograph. On
this study limited by patient motion
artifact and suboptimal contrast bolus timing, there is no
evidence of aortic
dissection, aneurysm, or central pulmonary embolism. 2.
Posterior dependent atelectatic changes and minimal bilateral
pleural, effusions. 3. Right renal lesions incompletely
characterized, but likely cysts. 4. Prostatic enlargement. 3.8
cm cystic area of right prostate is of uncertain signficance and
clinical correlation is suggested."
During this hospitalization he was treated with Albuterol 0.083%
nebs every four hours, fluticasone propionate 110 mcg 4 puffs
inhaled [**Hospital1 **] and Albuterol 0.083% 1-2 nebs inhaled every [**1-30**]
hours PRN. He will be discharged on Spiriva, Combivent and
Albuterol for presumed COPD.
5. HYPOTENSION
The patient's blood pressure has remained stable since his
return to the medical floor.
6. HEMATURIA
The patient had one episode of blood tinged urine. A UA showed
only large amount of blood and RBC >1000. His Is and Os have
been excellent.
7. CHEST PAIN
His chest pain resolved soon upon admission. EKGs do not show
ischemic changes and his cardiac enzymes were negative x3.
Echocardiogram performed [**2112-8-2**] concluded: left ventricular
systolic function is low normal, mild to moderate ([**11-30**]+) mitral
regurgitation, Moderate [2+] tricuspid regurgitation is seen.
There is borderline pulmonary artery systolic hypertension.
8. MICROCYTIC ANEMIA
The patient had a microcytic anemia with a HCt in the low 30s
and an MCV of 79 which was not fully worked up. He was placed
on 1000 mcg of B12 due to a low normal B12 value, B12: 289.
At the time of discharge, pt had no further chest pain and was
rate-controlled. His systolic pressures were excellent and he
was discharged with followup plans discussed with his primary
care provider.
Medications on Admission:
fluoxetine 20mg daily
ativan 0.25mg tid prn
lipitor 10mg daily
metoprolol 25mg [**Hospital1 **]
Discharge Medications:
1. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Combivent 103-18 mcg/Actuation Aerosol Sig: 1-2 puffs
Inhalation four times a day.
Disp:*qs inhaler * Refills:*2*
6. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) cap Inhalation once a day.
Disp:*qs inhaler+caps* Refills:*2*
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
q4-6 hours PRN as needed for shortness of breath or wheezing.
Disp:*qs 1 inhaler* Refills:*0*
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
9. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous twice a day for 7 days.
Disp:*14 syringes* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
twice a day.
Disp:*180 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family and Children Services
Discharge Diagnosis:
1. Atrial fibrillation with Rapid Ventricular Response
2. Atypical chest pain
3. Hypertension
4. Hypercholesterolemia
5. Anxiety
6. Changes in mental status
7. Probable COPD
8. Probable Alcohol withdrawal
9. Acute on Chronic Renal Insufficiency
Discharge Condition:
Stable no further rapid ventricular response.
Discharge Instructions:
1. Please take your medications as prescribed.
2. Please return to the hospital or call your PCP if you develop
shortness of breath, chest pain, fevers or other worrisome
symptoms.
3. You will need to continue taking Enoxaparin (lovenox) for the
next 5 days. Also continue taking warfarin as directed by your
doctor's office. You have also been started on a number of new
medications for your breathing difficulty.
Followup Instructions:
Please followup with your primary care doctor: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10477**],
MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2112-8-10**] 11:30
Recommend pulmonary function tests as outpatient as baseline for
amiodarone therapy.
ICD9 Codes: 2761, 4240, 496, 5859, 2724, 4019 |
Subsets and Splits
No community queries yet
The top public SQL queries from the community will appear here once available.