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{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1400
} | Medical Text: Admission Date: [**2138-6-4**] Discharge Date: [**2138-6-7**]
Date of Birth: [**2072-6-6**] Sex: F
Service: NEUROSURGERY
Allergies:
Coumadin
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
meningioma
Major Surgical or Invasive Procedure:
R craniotomy for resection of meningioma
History of Present Illness:
Ms. [**Known lastname 92231**] is a 65 year-old right handed woman with a PMH
significant for hypertension, hyperlipidemia.
She was referred to us for evaluation of new
left leg weakness likely secondary to and a right para-saggital
lesion (likely meningioma). About [**4-7**], she first noticed that
her left leg seemed weaker than her right, when she had
particular difficulty rising from low heights and navigating
stairs. The left leg weakness has been associated with left leg
incoordination and she finds it difficult to lift the left leg
from the level of the hip. She does not recall a traumtic event.
There are no exacerbating or alleviating factors.
She denies other concurrent symptoms including seizureHA, N,
V,Dz, back pain, leg pain, falls, and incontinence.
Past Medical History:
Hypertension
hyperlipidemia
polycystic kidney disease
colonic polyp
Meningioma diagosed in [**Month (only) 956**] on dexamethasone and keppra
TAH/BSO
DVT dx: [**5-7**] on coumadin, completed lovenox injections [**5-15**]
Social History:
She is a professor of computer science at [**University/College 5130**]
[**Location (un) **]. She lives with her husband and does not have kids.
She does not smoke tobacco, drink alcohol, or use
illicit drugs.
Family History:
Her mother developed lung cancer in her 60s and died at age 85.
Her father has heart disease. Her sister had breast cancer
diagnosed at age 55 and her brother had metastatic kidney cancer
diagnosed in his 40s
Physical Exam:
Af vss
General: NAD.
Normocephalic
HEENT: supple neck
no LNN
Cardiac: RRR
Pulmonary: CTA and no SOB.
Abdomen: ND NTTP
Extremities: Warm, well-perfused
No discolourations
Mental Status:
She is alert and oriented to person, place, month, date, year,
and situation.
nl MS
[**First Name (Titles) **] [**Last Name (Titles) 92232**]:
The sense of smell is not tested, but she knows coffee
PERL; visual fields are full.
EOMI
Sensation on the face is intact to light touch.
Facial movements
are normal and symmetric.
Hearing is intact to finger snap
The tongue protrudes in the midline
Motor System:
Tone is normal in each of the limbs.
LUE: 0/5 at deltoid, [**3-31**] biceps, [**5-1**] grip strength
LLE: without active movement
RUE and RLE with good strength
Pertinent Results:
MR HEAD W/ CONTRAST [**2138-6-4**]
Pre-surgical planning images of the falx meningioma, with
slightly increased neighboring right frontal edema since the
[**2138-3-9**] reference MR examination.
CT HEAD W/O CONTRAST [**2138-6-4**]
1. Status post resection of a right frontal parafalcine
meningioma, with
small amount of hemorrhage and subdural fluid collection in the
post-surgical site
2. Vasogenic edema in the right frontal lobe, allowing for
differences in
technique, is stable since the preoperative MRI of [**2138-3-9**].
3. Large amount of pneumocephalus predominantly seen in the
bifrontal and
left temporal regions, with a small amount of air tracking along
the anterior interhemispheric fissure; displacement of cerebral
hemisphere- correlate clinically for ? tension though this can
be within normal limits post-op.
[**2138-6-5**] MRI Head
Small residual tumor remaining along the falx.
Brief Hospital Course:
65 y/o F presents for elective resection of parasagittal
meningioma. OR course was uncomplicated and she was transferred
to the ICU immediately post op for neuro exams. Post op head CT
showed post surgical changes. On exam, her LLE had no movement
to noxious stimuli and was 5-/5 on her R side. She has a history
of a DVT in that LE and lovenox was restarted on POD#2. Neuro
onc and rad onc were consulted. She was transferred to the
floor, her foley was removed and PT ordered. PT cleared her for
rehab facility. She started to regain movement in her LUE. She
progressed well on the floor, was tolerating a regular diet,
able to void, and her vital signs remained stable. On POD3 she
was deemed ready for discharge to rehab with the appropriate
discharge instructions and follow-up instructions.
Medications on Admission:
ATENOLOL 50 daily / DEXAMETHASONE - 4 mg [**Hospital1 **] / ESTERIFIED
ESTROGENS [MENEST] 1 Tablet(s) by mouth once a day /
LEVETIRACETAM - 750 [**Hospital1 **] / Furosemide 20 mg daily
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain fever.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours for 2 days: start on discharge.
Disp:*6 Tablet(s)* Refills:*0*
6. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours for 2 days: starting after completion of 4mg doses.
Disp:*6 Tablet(s)* Refills:*0*
7. dexamethasone 1 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours for 2 days: To start after the completion of the 2mg
doses.
Disp:*6 Tablet(s)* Refills:*0*
8. dexamethasone 1 mg Tablet Sig: One (1) Tablet PO once a day
for 1 days: To start after completion of 1mg q8hr doses.
Disp:*1 Tablet(s)* Refills:*0*
9. levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
10. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
11. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
12. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Parafalcine meningioma
Discharge Condition:
AOx3. Activity as tolerated.
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.
?????? Dressing may be removed on Day 2 after surgery.
?????? If you have dissolvable sutures you may wash your hair and get
your incision wet day 3 after surgery. You may shower before
this time using a shower cap to cover your head.
?????? If your wound was closed with staples or non-dissolvable
sutures then you must wait until after they are removed to wash
your hair. 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 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.
?????? You will be discharged on lovenox 80mg daily for
anticoagulation.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
You have a follow up scheduled in brain tumor clinic on [**6-16**] at
10:30 a.m. BTC is located in the [**Hospital Ward Name **] building on the [**Location (un) **] of the [**Hospital Ward Name **]. Please call [**Telephone/Fax (1) 13019**] for
questions.
ICD9 Codes: 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1401
} | Medical Text: Admission Date: [**2103-4-24**] Discharge Date: [**2103-5-2**]
Date of Birth: [**2061-2-9**] Sex: F
Service: SURGERY
Allergies:
Codeine
Attending:[**First Name3 (LF) 16769**]
Chief Complaint:
Presents with long standing diabetes for elective renal
transplant wi
Major Surgical or Invasive Procedure:
Living unrelated kidney transplant [**2103-4-24**]
History of Present Illness:
She has had no recent changes in her medical condition. Preop EF
60% and cardiac imaging shows no reversible defects. Preop labs
revealed recent hct 36.1. CMV status is negative to negative.
Past Medical History:
Type I DM
Hypothyroid
ESRD on peritoneal dialysis
Retinopathy
Left tib-fib fracture with internal fixation
Left breast lumpectomy
restless leg syndrome
Social History:
Lives with spouse. She works as office manager. Has two children
Family History:
Pertinent Results:
[**2103-4-24**] 09:21PM GLUCOSE-257* UREA N-70* CREAT-10.5*
SODIUM-134 POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-15* ANION GAP-20
[**2103-4-24**] 09:21PM HCT-33.1*
[**2103-4-24**] 02:53PM GLUCOSE-121* UREA N-68* CREAT-11.4*#
SODIUM-137 POTASSIUM-3.3 CHLORIDE-106 TOTAL CO2-17* ANION GAP-17
[**2103-4-24**] 02:53PM CALCIUM-8.2* PHOSPHATE-3.0 MAGNESIUM-1.9
[**2103-4-24**] 02:53PM WBC-8.4 RBC-3.44* HGB-10.8* HCT-33.0* MCV-96
MCH-31.5 MCHC-32.8 RDW-15.6*
[**2103-4-24**] 02:53PM PLT COUNT-223
[**2103-4-24**] 01:23PM GLUCOSE-63* K+-3.1*
[**2103-4-24**] 01:23PM HGB-9.7* calcHCT-29
[**2103-4-24**] 12:22PM TYPE-[**Last Name (un) **] PH-7.16*
[**2103-4-24**] 12:22PM GLUCOSE-152* K+-3.1*
[**2103-4-24**] 12:22PM HGB-10.2* calcHCT-31
[**2103-4-24**] 12:22PM freeCa-1.25
[**2103-4-24**] 11:30AM TYPE-[**Last Name (un) **] PH-7.14*
[**2103-4-24**] 11:30AM HGB-11.3* calcHCT-34
[**2103-4-24**] 11:30AM freeCa-1.28
[**2103-4-24**] 10:40AM TYPE-[**Last Name (un) **] PO2-85 PCO2-47* PH-7.19* TOTAL
CO2-19* BASE XS--10
[**2103-4-24**] 10:40AM GLUCOSE-365* K+-4.3
[**2103-4-24**] 10:40AM HGB-11.2* calcHCT-34
[**2103-4-24**] 10:40AM freeCa-1.25
Brief Hospital Course:
Taken to OR on [**2103-4-24**] for Left iliac fossa living unrelated
renal transplant. See operative note for details. Induction
immunosuppression was initiated intraoperatively using ATG,
Solumedrol and Cellcept. There was minimal EBL with good
perfusion intra op. BP ran 110/40-80/30 with heart rate of 80.
Neo and dopamine were initiated to keep SBP greater than 120.
Urine output was low postoperatively. She was transferred to the
SICU for administration of neosynephrine and dopamine. Urine
output picked up to 100cc/hour with pressor support keeping sbp
>120. Renal ultrasound on [**4-26**] revealed "no evidence of
perinephric fluid collections or hydronephrosis. There is flow
in the main renal artery and vein. There is no detectable
diastolic flow within the upper, mid, or lower poles." Prograf
was initiated on POD 1. One unit of PRBC was given for hct of
27.5 on POD 2. Repeat hct was 33.8. Urine output decreased to
36-40cc/hour. She was medicated with morphine sulfate pca for
pain with fair relief. Creatinine dropped from 11.8
preoperatively to 8.8 on POD 2.
Nephrology followed the patient closely and recommended IV
hydration with 1/2 saline and d/c of neosynephrine as urine
output was ~30ml/hour. Glucoses ran in the 300 range. This was
managed with an insulin drip. Glucoses improved to the low 100s.
The [**Last Name (un) **] attending was consulted and Lantus insulin was
initiated in addition to sliding scale humalog when the insulin
drip was stopped. She will follow up with [**Last Name (un) **] as an
outpatient for diabetes management.
She was transferred to the transplant unit on POD 3 after
neosynephrine and dopamine were stopped. BP was stable at
115-125/60. She was started on po bicarb for level of 15. WBC
dropped to 1.5 on POD 4. This was felt to be partially related
to cellcept. She received six doses of ATG. A repeat ultrasound
was done on [**2103-4-29**]. This demonstrated "a slight increase in
diastolic flow within the mid upper and mid pole compared to
[**2103-4-26**]. No diastolic flow is seen within the lower pole. A
normal venous waveform is seen within the renal vein. Resistive
indices in the upper pole and mid pole measure 0.82 in both
locations. Flow velocities appear similar to those on [**4-26**]".
Delayed graft function occurred for the remainder of the
hospital stay. Urine output averaged 1200-945ml/24 hours. She
was started on Lasix on [**4-29**] for significant edema. She denied
shortness of breath, nausea and vomiting. Peritoneal dialysis
was initiated via tenckhoff catheter at low volume dwells 1.5
liter 1.5% on [**4-30**] (POD 6). She did not tolerated these dwells
very well due to abdominal fullness and pain over LLQ. She was
unable to pull off fluid and was actually positive 250cc on POD
7. Leg edema decreased a small amount, but weight remained above
dry weight.
Physical therapy was consulted as she experienced difficulty
ambulating secondary to fluid retention. PT did not recommend
need for rehab and felt that she would be able to manage at home
with PT.
The wbc dropped on POD 6 to 1.7. She received neupogen 480mg sc
once and valcyte was decreased to every other day. WBC increased
to 12.9 after neupogen.
On POD 8 it was decided that patient could be discharged home
without peritoneal dialysis as she was not short of breath,
nauseated or so edematous that she couldn't ambulate. She was
tolerating a regular diet and moving her bowels. Pain was
moderately well controlled with oral dilaudid. Percocet were
ineffective. Dialysis was stopped secondary to leaking of clear
fluid from tenckhoff site and discomfort. JP was removed on pod
7.
In conjunction with nephrology, it was decided to discharge
[**Known firstname **] with follow up labs in 2 days. PT, PTT and INR was
ordered in anticipation of biopsy to rule out rejection versus
delayed graft function. A tranplant kidney biopsy was scheduled
for Monday [**5-7**] with labs ordered for Friday [**5-4**]. Labs on
discharge were as follows:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2103-5-2**] 06:00AM 11.5* 2.81* 8.5* 26.7* 95 30.5 32.0 16.1*
141*
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2103-5-2**] 06:00AM 141*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2103-5-2**] 06:00AM 102 92* 6.6*#1 139 3.2* 102 22 18
ADDED TSH [**2103-5-2**] 4:00PM
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2103-5-2**] 06:00AM 8.0* 5.6* 2.1
ADDED TSH [**2103-5-2**] 4:00PM
PITUITARY TSH
[**2103-5-2**] 06:00AM PND
ADDED TSH [**2103-5-2**] 4:00PM
TOXICOLOGY, SERUM AND OTHER DRUGS FK506
[**2103-5-2**] 06:00AM 9.51
1 TARGET 12-HR TROUGH (EARLY POST-TX): [**4-27**] [24-HR TROUGH 33-50%
LOWER]
She was discharged on lasix 100mg, prograf 4mg [**Hospital1 **] and cellcept
1 gram [**Hospital1 **]. She was set up to have VNA services as glargine
insulin was new and a home safety eval was recommended. She will
follow up with Dr. [**Last Name (STitle) 15473**] as an outpatient.
Medications on Admission:
levoxyl 137mcg po qam, renagel 1800mg with meals and snacks,
hecterol daily Monday thru Friday, zantac prn, Insulin Humulin
regular in dialysate 32-46 units, 4x/day. Humalog sliding scale.
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed: tylenol.
5. Levothyroxine Sodium 137 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed.
7. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-10**] Sprays Nasal
QID (4 times a day) as needed.
8. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
9. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO every [**3-14**]
hours as needed.
Disp:*30 Tablet(s)* Refills:*0*
10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12
hours).
11. Clotrimazole-Betamethasone 1-0.05 % Cream Sig: One (1) Appl
Topical HS (at bedtime) for 5 days.
Disp:*1 * Refills:*0*
12. Valganciclovir HCl 450 mg Tablet Sig: One (1) Tablet PO QOD
().
13. Insulin Glargine 100 unit/mL Solution Sig: Fourteen (14)
units Subcutaneous at bedtime.
14. Insulin Lispro (Human) 100 unit/mL Solution Sig: sliding
scale Subcutaneous every four (4) hours: follow sliding scale.
15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
16. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO BID (2
times a day).
17. Lasix 20mg tab: take 5 tabs every am for dose of 100mg qam.
Discharge Disposition:
Home With Service
Facility:
Community VNA, [**Location (un) 8545**]
Discharge Diagnosis:
Living unrelated kidney transplant [**2103-4-24**]
end stage renal failure [**1-10**] Type I Diabetes
Type I DM
Retinopathy
Hypothyroidism
Gerd
Discharge Condition:
stable
Discharge Instructions:
Call if fevers, chills, nausea, vomiting, inability to take
medications, increased abdominal pain, decreased urine output,
increased incisional or PD catheter site leaking. [**Telephone/Fax (1) 673**]
Labs on Friday [**5-4**] CBC, chem 7, calcium, phosphorus, ast,
t.bili, PT, PTT, INR, urinalysis and trough prograf level with
results fax'd to transplant office. THEN LABS as follows:
Labs every Monday & Thursday for cbc, chem 7, calcium,
phosphorus, ast, t.bili, urinalysis, and trough prograf level.
Labs to be fax'd immediately to transplant office [**Telephone/Fax (1) 697**]
No Peritoneal dialysis until notified by MD
No heavy lifting
No driving while taking pain medication
[**Month (only) 116**] shower
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15475**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2103-5-8**] 11:20
Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2103-5-18**] 11:10
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] TRANSPLANT SOCIAL WORK Where:
TRANSPLANT SOCIAL WORK Date/Time:[**2103-5-18**] 12:00
Follow up with [**Name8 (MD) **] MD: Walzcek. Call to schedule appointment
Completed by:[**2103-5-2**]
ICD9 Codes: 2761, 2762, 2449, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1402
} | Medical Text: Admission Date: [**2173-8-16**] Discharge Date: [**2173-8-27**]
Date of Birth: [**2098-6-13**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
pseudoaneurysm of LUE AVF
Major Surgical or Invasive Procedure:
[**2173-8-16**] excision of LUE AVF pseudoaneurysm
History of Present Illness:
Ms. [**Known lastname 103090**] is a 75 year-old Creole-speaking woman with history
of DM 2, ESRD on
HD, HTN, stroke with vascular dementia, and CHF who presented
with a spontaneous rupture of an aneurysm involving an AV
fistula. Patient is a poor historian, french creole speaking,
spoken to with french speaking ER staff. She was at dialysis
two days
prior without incident. She awoke with bleeding at her AV
fistula site of the LUE. She arrived via EMT with gross
saturation of her bandage.
On arrival she had an approximately 5 mm bleeding ulceration at
the midpoint of a large 5 cm by 3 cm aneurysm. This was
controlled with pressure dressing by ED staff.
Past Medical History:
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%. Echo
[**2170**].
-Osteoarthritis
-Cataracts
-insertion Left groin permcath [**2172-12-23**]
Social History:
SH: no tobacco, ETOH, illicit drug use, lives at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]
Daughter involved in care
Family History:
noncontributory
Physical Exam:
98.6 HR 84 BP: 215/120 RR: 20 O2SAT: 93% 2LNC
EXAM: Awake, alert, MAE, agitated
EXAM per ER staff WNL
LUE bleeding AV fistula pseudo aneurysm.
Pertinent Results:
[**2173-8-16**] 07:50AM PT-13.7* PTT-30.0 INR(PT)-1.2*
[**2173-8-16**] 07:50AM PLT COUNT-250
[**2173-8-16**] 07:50AM WBC-13.9*# RBC-3.15* HGB-10.6* HCT-31.2*
MCV-99* MCH-33.6* MCHC-33.9 RDW-14.1
[**2173-8-16**] 07:50AM CALCIUM-9.9 PHOSPHATE-4.8* MAGNESIUM-2.0
[**2173-8-16**] 07:50AM GLUCOSE-185* UREA N-43* CREAT-7.8* SODIUM-138
POTASSIUM-4.7 CHLORIDE-96 TOTAL CO2-27 ANION GAP-20
[**2173-8-27**] 06:55AM BLOOD WBC-11.1* RBC-2.95* Hgb-9.7* Hct-31.0*
MCV-105* MCH-32.9* MCHC-31.3 RDW-16.3* Plt Ct-416
[**2173-8-27**] 06:55AM BLOOD Plt Ct-416
[**2173-8-16**] 11:28AM BLOOD PT-14.5* PTT-32.6 INR(PT)-1.3*
[**2173-8-27**] 06:55AM BLOOD Glucose-389* UreaN-30* Creat-5.5*# Na-142
K-3.8 Cl-104 HCO3-25 AnGap-17
[**2173-8-27**] 06:55AM BLOOD Calcium-10.2 Phos-2.6* Mg-2.1
Brief Hospital Course:
On [**2173-8-16**] Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] performed an exploration of the
left upper arm
arteriovenous fistula, with excision of an aneurysm and
interposition graft placement for spontaneous rupture of an
arteriovenous fistula aneurysm. At the end of the case, she
became hypotensive to the 50 systolic range. This was
treated with multiple vasopressors with poor response. BP was
unreadable for ~ 8 min. Am intraoperative TEE was performed
which demonstrated a poor right ventricular flow consistent with
a possible pulmonary embolus. The patient was eventually
stabilized with epinephrine and taken to the PACU". A chest CT
was done and was negative for PE. In the PACU, she became
hypertensive with systolics in 200s. She was transferred to the
SICU intubated where she received a nitro drip and remained
sedated on a propofol drip while intubated. She spiked a
temperature to 101.4. Blood cultures and a sputum culture were
sent. She was dialyzed via a temporary hemodiaysis line. A unit
of PRBC was transfused for a hct of 24.4.
On [**8-17**] she had successful placement of an 19 cm tip to cuff 15.5
French tunneled
hemodialysis catheter through the right subclavian vein.
Occlusion of the lower right internal jugular vein.
Sedation was weaned and she was extubated, but she remained
unresponsive and was not breathing on her own. She was
reintubated. A CT scan of the head was done showing no bleed or
major vascular infarct. Sedatives were held. An EEG was done
showing mild to moderate
encephalopathy of toxic, metabolic, or anoxic etiology. No
evidence of
ongoing or potential epileptogenesis was seen. A neuro consult
was obtained. Recommendations included holding sedatives,
continuing antibiotics and keeping sbp greater than 140. An LP
was performed. This was negative. IV vanco, ceftriaxone and
acyclovir were given. All blood and urine cultures remained
negative. Neuro felt that her mental status was consisten with
watershed hypoperfusion of the MC and ACA territories
bilaterally related to the intraop hypotension. An MRI was
recommended. This was done and showed the following:
"No evidence of acute infarction. Stenosis of left A1,
multiple
areas of irregular narrowing in the MCA bilaterally, as well as
the posterior
circulation vessels. The left A1 segment stenosis may be worse,
when compared
to the prior study of [**2170-7-29**]."
She was extubated, but did experience some stridor requiring
re-intubation. A pulmonary consult was obtained and
recommendations included treating with dexamethasone. She had
good response to this and was successfully extubated by
bronchoscopy assistance by Dr. [**First Name (STitle) **] [**Name (STitle) **]. There was no
evidence of airway obstruction, edema, or compromise up to the
level of the vocal cords.
A postpyloric feeding tube was placed and she received tube
feedings until the tube was self-removed by the patient on [**8-26**].
The feeding tube was replaced on [**8-17**] and again this was removed
by the patient. A speech and swallow eval was obtained given
concerns for aspiration. Recommendations included PO diet:
pureed solids, nectar thick liquids. If meds to be given PO,
crushed in puree with f/u sips of nectar thick liquid to clear.
1:1 assist with all POs to maintain standard aspiration
precautions and to monitor for signs of aspiration. Please
alternate each bite of puree with a sip of nectar thick liquid.
Mental status gradually improved to baseline per daughter who
visited and spoke to the patient in Creole. She was transferred
out of the SICU and was safe to go back to [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] where
she resides. Dialysis was last done on [**8-26**]. She remained alert
and oriented to herself only. She was able to answer simple
questions. Vital signs remained stable. (afeb, hr ranged in mid
70s, BP 121/50s and O2 stats in mid 90s on room air. rr was 18).
The right chest tunnelled hemodialyis line site remained clean,
dry and intact. The Left upper arm incision line was clean, dry
and intact.
Of note, namenda, risperdal and celexa were held during this
hospitalization. This will need to be re-addressed by her PCP at
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **].
Medications on Admission:
phoslo 1334mg tid with meals on HD days, celexa 10mg qd,
amlodipine 10mg po at 5pm, hold for sbp <100 or HR <60, renal
caps 1 qd, colace 100mg [**Hospital1 **], labetalol 100mg [**Hospital1 **], hold for sbp
<100 or HR <60, simvastatin 40mg qd, diovan 40mg qd, procrit
10,000 units 3xwk at HD, novolin sliding scale, lisinopril 5mg
qd, hold for sbp <100, namenda 5mg at HS, risperdal 0.25mg at
HS, dulcolax 10mg pr prn nitorquick 0.3mg sl prn for chest pain,
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Labetalol 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
6. Insulin Regular Human 100 unit/mL Solution Sig: follow
sliding scale Injection four times a day.
7. PhosLo 667 mg Capsule Sig: Two (2) Capsule PO three times a
day: with meals.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **]
Discharge Diagnosis:
pseudoaneurysm of LUE AVF
ESRD
Dementia
Discharge Condition:
good
Discharge Instructions:
Please call Dr.[**Name (NI) 670**] Office [**Telephone/Fax (1) 673**] if fever, chills,
malfunction of right tunnelled Hemodialysis line or if LUE AVF
incision red/draining
Followup Instructions:
Call Dr.[**Name (NI) 670**] office [**Telephone/Fax (1) 673**] to schedule follow up
Completed by:[**2173-8-27**]
ICD9 Codes: 5856 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1403
} | Medical Text: Admission Date: [**2194-11-26**] Discharge Date: [**2194-11-28**]
Date of Birth: [**2129-7-19**] Sex: F
Service: NEUROSURGERY
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Cerebral Artery Stenosis
Major Surgical or Invasive Procedure:
Bilateral carotid artery stenting
History of Present Illness:
65 year old F with history of s/p left middle cerebral artery
infarct secondary to occlusive tandem stenotic lesions of the
left internal carotid artery in [**10/2194**] who is in the hospital
right now after stenting of her carotid lesions.
Neurology consult was called today for the management of her
neurological problems and [**Name2 (NI) **] pressure.
Her symptoms of right sided weakness have significantly improved
in rehabilitation after the stroke. Her speech has returned to
[**Location 213**]. She only reports difficulty writing with the right hand
and slight decrease in dexterity of the right hand. She also
indicates that her right knee tends to buckle every now and
then.
Review of symptoms and systems is otherwise all negative. She
denies any history of left-sided transient monocular blindness
or TIA/stroke prior to her recent symptoms. She denies neck
pain or headaches at the time of stroke onset.
Past Medical History:
non-insulin-dependent diabetes diagnosed approximately 10 years
ago and hyperlipidemia. She was recently diagnosed with acute
renal failure in [**Month (only) **], which was attributed to "bilateral renal
stones." She underwent bilateral renal artery stent placement.
Social History:
She lived alone until her recent stroke. She worked as a
part-time sales woman at a card store. She has three children.
She does not smoke nor consume alcohol.
Family History:
Her family history is noted for a father who had a stroke,
coronary artery disease, and diabetes.
Physical Exam:
Exam on Admission:
T- 98.0 BP- 140/84 HR- 67 RR- 18 O2Sat 100
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, says
[**Doctor Last Name 1841**] backwards. Speech is fluent with normal comprehension and
repetition; naming intact. No dysarthria. [**Location (un) **] and writing
intact. No right left confusion. No evidence of apraxia or
neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields are full to confrontation.
Extraocular
movements intact bilaterally, no nystagmus. Sensation intact
V1-V3. Facial movement symmetric. Hearing intact to finger rub
bilaterally. Palate elevation symmetrical. Sternocleidomastoid
and trapezius normal bilaterally. Tongue midline, movements
intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
No pronator drift
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, pinprick, vibration and
proprioception throughout except in lower extremities
bilaterally
where vibration and pinprick is decreased.
No extinction to DSS
Reflexes:
+2 and symmetric throughout.
Toes downgoing bilaterally
Coordination: finger-nose-finger normal, heel to shin not
checked.
Gait: not checked as patient is s/p post angio
Romberg: not checked.
Exam on Discharge:
Pertinent Results:
[**2194-11-26**] 12:18PM TYPE-ART PO2-224* PCO2-33* PH-7.57* TOTAL
CO2-31* BASE XS-8
[**2194-11-26**] 12:18PM GLUCOSE-273* LACTATE-2.8* NA+-136 K+-2.6*
CL--97*
[**2194-11-26**] 12:18PM HGB-8.3* calcHCT-25
[**2194-11-26**] 12:18PM freeCa-0.96*
[**2194-11-26**] 09:00AM UREA N-28* CREAT-1.4*
[**2194-11-27**] 02:55AM [**Month/Day/Year 3143**] WBC-6.3 RBC-2.50*# Hgb-7.2*# Hct-21.0*#
MCV-84 MCH-28.8 MCHC-34.3 RDW-15.2 Plt Ct-181
[**2194-11-27**] 02:55AM [**Month/Day/Year 3143**] Neuts-64.0 Lymphs-31.5 Monos-3.0 Eos-1.4
Baso-0.1
Brief Hospital Course:
65 year old female presenting with cerebral artery stenosis. The
patient underwent bilateral carotid stenting on [**11-26**]. Her
intraoperative [**Month/Year (2) **] loss was approximately 200cc, she was
admitted to the SICU post operatively to watch her after her
acute [**Month/Year (2) **] loss. Her hematocrit on POD 1 was 21.0, down from
her preop hematocrit of 35. She was transfused 2 units of packed
red [**Month/Year (2) **] cells while in the SICU. Her hematocrit post
transfusion improved, and her [**Month/Year (2) **] pressure was liberalized, as
well as her diet was advanced, and PT was consulted. She has
tolerated diet well, and PT recommended d/c home without
services. She is voiding without any difficulties, and she will
follow up with dr. [**Last Name (STitle) **] in one month with a carotid duplex, as
well as follow up with her PCP and Nephrologist. Pt was
discharged directly from SICU since there were no regular floor
beds available. Patient and familiy are aware and comfortable
with the plan.
Medications on Admission:
Aggrenox twice daily,
folic acid 1 mg once daily,
metoprolol 50 mg twice daily,
Prilosec 20 mg once daily,
Lantus 20 units at bedtime,
Lipitor 80 mg once daily,
ciprofloxacin 250 mg once daily for a recent urinary tract
infection.
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): TAKE FOR SIX MONTHS DAILY.
Disp:*30 Tablet(s)* Refills:*5*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*10*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): PLEASE USE WITH PAIN MEDICINE, IF DIARRHEA, STOP
THE MEDICINE.
Disp:*60 Capsule(s)* Refills:*2*
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
9. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every eight (8)
hours as needed for anxiety: PLEASE DISCUSS WITH YOUR PRIMARY
CARE PHYSICIAN THE USE OF LORAZEPAM FOR LONGER THAN 10 DAYS. DO
NOT DRIVE WHILE USING LORAZEPAM.
Disp:*30 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Discharge Disposition:
Home With Service
Facility:
all care vna of [**Location (un) **]
Discharge Diagnosis:
Left cerebral artery stenosis
Discharge Condition:
Good
Discharge Instructions:
?????? Have a family member monitor your mental status and headaches
if occur
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? If you use pain medicine, ncrease your intake of fluids and
fiber as pain medicine (narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
YOU WILL NEED A CAROTID DUPLEX PRIOR TO YOUR APPOINTMENT, PLEASE
CALL [**Telephone/Fax (1) 657**] TO HAVE IT SCHEDULED.
PLEASE FOLLOW UP WITH YOUR NEPHROLOGIST AND PRIMARY CARE
PHYSICIAN AS AN OUTPATIENT
YOU HAVE AN APPOINTMENT WITH DR. [**First Name (STitle) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) **]:[**Telephone/Fax (1) 657**] Date/Time:[**2194-12-23**] 3:30
Completed by:[**2194-11-28**]
ICD9 Codes: 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1404
} | Medical Text: Admission Date: [**2118-6-28**] Discharge Date: [**2118-7-7**]
Service: CSU
CHIEF COMPLAINT: ASPVD, dyspnea on exertion.
HISTORY OF PRESENT ILLNESS: An 87-year-old man with ASPVD,
dyspnea on exertion over the past year. He has had near
syncope 3 to 4 times. He is referred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **]
[**First Name (Titles) **] [**Last Name (Titles) **] for cardiac catheterization.
This 87-year-old man with dyspnea on exertion after 50 to 100
feet with known aortic stenosis undergoing cardiac
catheterization on the day of admission which revealed an
aortic valve area of 0.8 cm squared, as well as calcified
left main without stenosis, 95% LAD, 40% circumflex, after
the OM and osteostenosis of 50 to 60% with mid lesion of 99%.
PAST MEDICAL HISTORY: The patient's past medial history is
significant for permanent pacer done in [**2118-4-1**] for
syncope and bradycardia, abdominal aortic aneurysm repair in
[**2117-11-1**], left CEA in [**2112**], hypertension,
hypercholesterolemia, and peripheral vascular disease with
positive claudication.
FAMILY HISTORY: The patient's family history is negative for
coronary artery disease.
SOCIAL HISTORY: Retired dentist who has a remote tobacco
history. Last use was over 50 years ago. Social alcohol use
with 1 to 4 drinks per day.
ALLERGIES: No known drug allergies.
MEDICATIONS: Medications at home include:
1. Nifedipine.
2. Lipitor.
3. Lotensin.
4. Aspirin.
5. Toprol.
REVIEW OF SYMPTOMS: No angina. Positive gastroesophageal
reflux type epigastric pain. Positive orthopnea, positive
dyspnea on exertion and shortness of breath. No diabetes, no
CVA, no nausea, vomiting, diarrhea or constipation. No
melena. Productive cough with yellow to brown sputum x 2
weeks.
PHYSICAL EXAMINATION: He is in no acute distress lying flat
in bed.
CARDIOVASCULAR: Regular rate and rhythm S1 and S2 with a
holosystolic murmur at the base.
LUNGS: Bilateral wheezes.
EXTREMITIES: Warm and well perfused with no edema and no
varicosities. 2+ pulses throughout.
ABDOMEN: Soft, nontender, nondistended.
LABORATORY DATA: White blood cell 7.3, hematocrit 35,
platelet count 146, PT 12.5 with an INR of 1.0. Sodium 138,
potassium 3.7, chloride 106, CO2 23, BUN 17, creatinine 1.0,
glucose 158, ALT 12, AST 14, alkaline phosphatase 60, amylase
40, direct bilirubin 0.3. Carotid ultrasound from [**2117-9-1**] showed left sided stenosis with 40 to 60% LCA
stenosis and chronically occluded right internal carotid
artery. The patient was seen by the dental service and was
cleared by that service. On [**6-30**] he was brought to the
operating room. Please see the OR report for full details.
In summary, the patient had an AVL with 21 mm [**Last Name (un) 3843**]-
[**Doctor First Name 7624**] pericardial valve as well as coronary artery bypass
graft x 2 with left internal mammary artery to the LAD and
saphenous vein graft to the patent ductus arteriosus. His
bypass time was 122 minutes with cross-clamp time of 102
minutes. He tolerated the operation well and was transferred
from the operating room to the cardiothoracic intensive care
unit. At the time of transfer the patient was a paced at 100
beats per minute with mean arterial pressure of 60. He had
propofol at 20 mics/kg per minute as well as Levophed at 0.04
mics/kg per minute, epinephrine at 0.04 mics/ kg per minute
and milrinone at 0.25 mics/kg per minute.
The patient did well in the immediate postoperative period.
His anesthesia was reversed and he was successfully
extubated. He remained hemodynamically stable throughout the
day of the surgery. Over the course of the first
postoperative night, the patient was weaned from his
epinephrine drip and on postoperative day 2 he was weaned off
his milrinone as well as his Levophed infusions.
Additionally, the patient was slowly diuresed during that
period.
On postoperative day 3, the electrophysiology service was
called to interrogate the patient's permanent pacemaker. It
was noted that he was in atrial fibrillation at that time,
has an underlying rhythm below his pacemaker and amiodarone
was begun at that time following which the patient converted
back in sinus rhythm.
On postoperative day 4, it was decided that the patient was
stable and ready to be transferred to the floor for continued
postoperative care and cardiac rehabilitation. Once on the
floor the patient had an uneventful postoperative course. His
activity level was increased with the assistance of the
nursing staff as well as the physical therapy staff. His
medications were adjusted to maintain an adequate blood
pressure and keep him in the normal sinus rhythm as well as
to diurese effectively.
On postoperative day 6, it was decided that the following
day, the patient would be stable and ready to be transferred
to rehabilitation, with postoperative care. At the time of
this dictation the patient's physical examination is as
follows.
PHYSICAL EXAMINATION: VITAL SIGNS: Temperature 98.6, heart
rate 73 and in sinus rhythm, blood pressure 110/69,
respiratory rate 18, oxygen saturations 93% on room air.
NEUROLOGIC: Alert and oriented. Moves all extremities and
follows commands. Nonfocal examination.
PULMONARY: Bibasilar crackles, otherwise clear to
auscultation.
CARDIAC: Regular rate and rhythm S1 and S2 with no murmurs.
Sternum is stable. Incision is clean and dry without erythema
or drainage.
ABDOMEN: Soft and nontender, nondistended with normal active
bowel sounds.
EXTREMITIES: Warm and well perfused with trace edema. Left
lower extremity incision with Steri-Strips clean and dry.
LABORATORY DATA: White blood cell 8.1, hematocrit 32,
platelet count 189, sodium 139, potassium 4.3, chloride 100,
CO2 30, BUN 30, creatinine 1.3, glucose 107.
DISCHARGE DISPOSITION: The patient is to be discharged to
rehabilitation.
DISCHARGE DIAGNOSIS:
1. Status post AVL with No. 21 [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial
valve as well as coronary artery bypass graft x 2 with
left internal mammary artery to the LAD and saphenous vein
graft to the patent ductus arteriosus.
2. Hypertension.
3. Peripheral vascular disease.
4. Hypercholesterolemia.
5. Status post permanent pacemaker.
6. Status post abdominal aortic aneurysm repair.
J7. Status post left CEA.
The patient's condition at the time of discharge is good. He
is to have follow up with Dr. [**Last Name (STitle) 32017**] at the [**Hospital3 **]
[**Hospital **] Clinic in 1 to 2 weeks. Follow up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4469**], in 3 to 4 weeks and follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **],
in 4 weeks.
The patient's discharge medications include:
1. Lasix 40 mg q d x 2 weeks.
2. Potassium chloride 20 mEq q d x 2 weeks.
3. Colace 100 mg b.i.d.
4. Aspirin 81 mg q d.
5. Percocet 5/325 one to two tabs q 4 to 6 hours as needed
for pain.
6. Atorvastatin 40 mg q d.
7. Pantoprazole 40 mg q day.
8. Amiodarone 400 mg b.i.d. x 1 week, then 400 mg q day x 1
week, and then 200 mg q d.
9. Metoprolol 12.5 mg b.i.d.
10.
Atrovent 2 puffs b.i.d.
11. Captopril 12.5 mg t.i.d.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2118-7-6**] 23:29:30
T: [**2118-7-7**] 01:14:16
Job#: [**Job Number 32018**]
ICD9 Codes: 4241, 4168, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1405
} | Medical Text: Admission Date: [**2149-5-18**] Discharge Date: [**2149-5-24**]
Date of Birth: [**2073-9-6**] Sex: M
Service: MED
Allergies:
Lovenox / Zyprexa
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
hypotension and gait disturbance
Major Surgical or Invasive Procedure:
fluoroscopically guided lumbar puncture
History of Present Illness:
History per chart and patient. Pt is a 75 yo male with history
of recent left temporal lobe CVA, CAD, recent cardiac cath at
[**Hospital1 2025**] recently diagnosed hydrocephalus with a 3rd ventricle lipoma
who presented to [**Hospital6 4620**] for hypotension and
gait disturbances on [**4-30**]. There he was found to have bladder
cancer and an appointment was arranged for him to have a
definitive resection under Dr. [**Last Name (STitle) 986**] at [**Hospital3 **]. It
was during this time that the temporal lobe CVA and NQWMI
occurred. After the cardiac cath, [**Hospital1 2025**] Neurology treated him for
HSV encephalitis although it seems that HSV was never
successfully cultured from any spinal fluid. This treatment
with acyclovir, however, resulted in acute renal failure. He
was then discharged to a nursing home after this episode
resolved. On the evening of [**5-18**], he presented to the [**Hospital 55955**] again for hypotension and mental status
changes. After doing with lisinopril and lopressor, both of
which were apparently new medications prescribed during the
hospital course at [**Hospital1 2025**]. The patient was treated with dopamine
at NWH and then sent to [**Hospital1 18**] because no beds were available in
the ICU. In the [**Hospital1 18**] ICU, the patient responded to 4LNS with
improvement in mental status. Neurology saw the patient and
thought that hemodynamic issues were causing the mental status
changes and the frontal dementia was secondary to the front
infarct and hydrocephalus as demonstrated on another CT.
Neurosurgery was consult and they felt a shunt to be
unnecessary. The patient was then transferred to the floor for
further evaluation.
Past Medical History:
1) colelithiasis
2) bladder ca soon to be resected [**5-1**]
3) old left frontal stroke
4) corpus callosum lipoma with hydrocephalus
5) hospital HIT
6) ARF thought to be due to acyclovir
7) DJD of spine
8) osteoarthritis of knee
9) history of PUD status post GI bleed
Social History:
1) cigars 2) [**2-25**] shots of brandy per day 3) 11 children 4) wife
alive and speaks for him
Family History:
NC
Physical Exam:
On admission, the vitals:
GEN: lying in bed, no acute distress, appears stated age.
HEENT: pupils round and reactive to light bilaterally 2->1.5.
neck supple without lymphadenopathy. no JVD. THORAX: clear to
auscultation bilaterally. COR: RRR, no m/r/g. ABD: soft,
nontender, nondistended, positive bowel sounds. EXT: no edema,
no rashes. NEURO: II-XII grossly intact without focal lesions.
4/5 strength throughout, with particular weakness on the LUE and
LLL [**1-24**] (could not lift leg more than 4 inches off the bed). No
dysmetria on finger to nose. rapid finger tap normal
bilaterally as well as rapidly alternating movements.
Pertinent Results:
[**2149-5-23**] 07:00AM BLOOD WBC-9.3 RBC-3.81* Hgb-11.0* Hct-31.4*
MCV-83 MCH-28.9 MCHC-35.0 RDW-14.3 Plt Ct-374
[**2149-5-23**] 07:00AM BLOOD Plt Ct-374
[**2149-5-23**] 05:50PM BLOOD ESR-85*
[**2149-5-23**] 07:00AM BLOOD Glucose-87 UreaN-9 Creat-1.0 Na-144 K-3.6
Cl-108 HCO3-30* AnGap-10
[**2149-5-22**] 08:00AM BLOOD Calcium-8.9 Phos-4.5 Mg-1.8
[**2149-5-23**] 05:50PM BLOOD TSH-1.5
[**2149-5-23**] 05:50PM BLOOD Free T4-1.4
[**2149-5-23**] 05:50PM BLOOD CRP-6.39*
Brief Hospital Course:
1) Mental status changes/Gait disturbance: Neurology and
neurosurgery were immediately consulted and a head CT performed
on [**5-19**] which showed no intraparenchymal or extraaxial
hemorrhage, no shift of normally midline structures, and no mass
efect or hydrocephalus. Neurology felt the mental status
changes could be attributed to a combination of sequelae from
the previous CVA and was unsure of normal pressure
hydrocephalus. When the patient was transferred to the floor,
the patient's mental status seemed to have improved. He was
alert and oriented to person/place/date. Over the following
days, mental status continued to improve as he was able to
conduct a detailed conversation about his favorite sports teams,
the news, and his family. Of note, the patient has a baseline
personality which tends to be slightly aggressive, sarcastic,
and "frontally disinhibited". His wife says that his
personality is essentially unchanged s/p CVA but there very well
might be an aspect of post infarct personality change. On [**5-22**],
a head MRI was performed at the recommendation of neurosurgery
to assess whether the patient had NPH which was causing mental
status changes and gait disturbance. MRI showed a pericallosal
lipoma (which was seen on CT [**5-19**]) which extended into the
lateral ventricles bilaterally. Despite a patent aqueduct of
Sylvius, there seemed to be mild ventricular enlargement and
sulcal widening, both of which were noted to be possibly due to
atrophy. An old left frontal lobe infarction was present with
some T2 abnormalities in both cerebral hemispheres, likely
representing microvascular infarctions. No abnormal
intracranial enhancement is detected on the post-gadolinium
images. No diffusion weighted studies were performed.
Due to the mild hydrocephalus, neurosurgery remained
uncertain about the utility of shunt placement and recommended a
large volume lumbar puncture. Since it was reported that [**Hospital1 2025**]
Neurology was unable to perform the LP at the bedside and IR
guidance was necessary, fluoroscopically guided LP was pursued
at the [**Hospital1 **] as well. Fluoro-guided LP was performed on [**5-23**] at the
Pain Clinic without complication and CSF was sent for further
study. Results were largely unremarkable with respect to
chemistries. There were no WBC and 1 RBC. Opening pressure was
49 while sitting and the approximately 30cc's of CSF were
drained. Although the patient was sitting and opening pressures
are not necessarily accurate unless lying down, neurology felt
the possibility of NPH was not to be excluded. The patient
remained horizontal for 6 hours without post-tap headache and
his gait was tested in front of his family and friends. It was
unclear whether or not gait improved, but the family noted
certain improvement in his mental status. The issue of a shunt
placement was discussed with the patient's wife as well as his
other family members and it was agreed that they would like to
pursue more conservative management of the patient's mental
status changes and gait disturbance. Since a shunt placement is
not without risk and it is unclear whether the LP undoutedly
relieved the patient's symtoms, the plan is to have a follow up
appointment with neurosurgery to assess gait, perform LP if
indicated, reassess, and if there is improvement, more
aggressively consider placement of a shunt. The patient himself
was amenable to this and has stated he will keep a mental note
of his gait improvement/regression at rehab.
2) Left sided weakness upper and lower extremities: On admission
to the floor, the patient was noted to have left sided weakness
of his upper and lower extremities. This had not been
documented previously and an xray of his left hip was order to
r/o fracture. Xray was negative. To follow up, Neurology was
consulted and insofar as the MRI findings were not anatomically
consistent with left sided weakness, it was thought the patient
could have exacerbation of an old right lacunar infarct.
Nonetheless, diffusion weighted images were not recommended
because it was questionable how management would change. ESR,
CRP, and SPEP were ordered with the thought that the patient
could have a vasculitis. Unfortunately, the results that
returned are difficult to interpret given the patient's bladder
cancer and vasculitis has not been ruled out. The likely cause
of the patient's possibly recurring CVA's are his known cardiac
vessel disease.
3) Hypotension: After transfer to the floor, the patient was
never hypotensive. IV fluids were made ready in case he had a
hypotensive episode. Metoprolol was started at 25 mg but an ACE
inhibitor was not. Please consider restarting the patient's ACE
inhibiter at rehab or afterward should blood pressures and renal
function remain stable as this would likely improve long term
cardiac function.
4) Bladder cancer: The patient had a significant about of RBC in
his urine (255 on [**5-21**]). This was attributed to his bladder
cancer. The patient has a follow up appointment with Dr.
[**Last Name (STitle) **] and the family has been instructed to follow up on this
issue with urgency. The patient was noted to be iron deficient
and this was felt to be secondary to urinary blood loss
secondary to the patient's bladder cancer.
5) CAD: The patient was kept on aspirin, lipitor, aspirin, and
beta blocker. He did not complain of chest pain, shortness of
breath, palpitations, or lower extremity swelling.
6) Nutrition: The patient passed a swallow test in the ICU. His
diet was slowly advanced on the floor and at discharge, the
patient was able to tolerate a normal house diet. His appetite
remained guarded, but his wife explained this has been a chronic
issue.
7) DVT prophylaxis: The patient was given sc heparin for DVT
prophylaxis and assisted out of bed as often as possible by
nursing and PT. From [**Date range (1) 40197**], the patient's Hct remained in
the upper 20's and this was worrisome for HIT which the patient
reported experienced while at an outside hospital. Heparin was
discontinued and the patient's Hct remained stable around 31-33.
9) Dispo: The patient is being discharged today to [**Hospital1 **].
Please follow up on his gait disturbance and if possible, assess
relatively frequently so that neurosurgery can more accurately
evaluate for shunt placement. Also, the patient has been
instructed to follow up on his bladder cancer with Dr. [**Last Name (STitle) **]
as urgently as possible.
Medications on Admission:
1) nitroglycerin tabs prn
2) niferex 150 mg by mouth once a day
3) ativan 1 mg by mouth every 4 hours as needed
4) ecasa 325 mg by mouth once a day
5) MVI one tab by mouth once a day
6) thiamine 100 mg by mouth once a day
7) folic acid 1 mg by mouth once a day
8) lopressor 100 mg by mouth once a day
9) lisinopril 10 mg by mouth once a day
Discharge Medications:
1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO QD (once a day).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO X1 PRN as
needed for Leg pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
hydrocephalus, bladder cancer, CVA
Discharge Condition:
good
Discharge Instructions:
1) Please
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
ICD9 Codes: 2765, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1406
} | Medical Text: Admission Date: [**2170-10-5**] Discharge Date: [**2170-10-31**]
Date of Birth: Sex:
HISTORY OF PRESENT ILLNESS: Mr. [**Name14 (STitle) 18015**] is a 63 year-old
male with a history of coronary artery disease status post
coronary artery bypass graft in [**2166**], aortic insufficiency
status post aortic valve repair in [**2166**], diastolic congestive
hypertension, diabetes mellitus, end stage liver disease,
cirrhosis secondary to hepatitis B and chronic alcoholism who
presents with increased shortness of breath for two weeks.
There is also a positive thirteen pound weight gain in the
past two weeks. He was told to increase Lasix from 42 mg po
q day one week ago. The patient still with increased weight
and shortness of breath and positive orthopnea. There is
exertion. There is bilateral arm tingling for two weeks.
There is a history of positive bloody stool possibly
secondary to a history of internal hemorrhoids. Positive
chronic cough, but this is unchanged. He has no diarrhea.
No fevers or chills or dysuria. Positive increased lethargy
over the last ten months. The patient does use home oxygen.
He uses it at night, but for the last two weeks he has been
using it around the clock.
In the Emergency Department vital signs were 96.4
temperature. Heart rate 98. Blood pressure 120/70.
Respiratory rate 20. Oxygen saturation was 84% on room air
improved to 99% on 2 liters. The patient was given 80 mg of
Lasix intravenous with 600 cc of urine output and improved
shortness of breath subsequently to this. On
electrocardiogram new onset atrial fibrillation in the 90s.
The patient was in normal sinus rhythm as recently as [**2170-9-20**] while on the Holter monitor.
PAST MEDICAL HISTORY: The patient was considered for
placement on the transplant list secondary to cirrhosis,
secondary to hepatitis B and liver disease secondary to
chronic alcohol use. History of hepatic encephalopathy.
Coronary artery disease status post coronary artery bypass
graft in [**2166**], aortic insufficiency, status post AVR repair
in [**2166**], diastolic congestive heart failure, chronic
obstructive pulmonary disease, hypertension, diabetes
mellitus, home O2 admitted [**2170-7-19**] with pneumonia and
cellulitis, positive reversible defect in the inferior at
apex. Stress test in [**2170-8-12**] Holter monitor, no
electrocardiogram changes and mild apical hypokinesis, medium
to high grade AEA. Episodes of sustained supraventricular
tachycardia initiated by APB. Echocardiogram in [**2170-8-12**]
showed more or less moderate left LA plus [**Last Name (un) **] and mild
symmetrical left ventricular hypertrophy. Normal LVS
function with ejection fraction over 60%.
MEDICATIONS ON ADMISSION: Lasix 80 mg po q.d., potassium
chloride 20 milliequivalents po q.d., Pepcid mg po b.i.d.,
Atenolol 12.5 mg po q.d., Lactulose 30 cc b.i.d., aspirin 81
mg po q day, vitamin E, multiple vitamin, NPH 20 units subQ
q.a.m., 10 Units subQ q.p.m., Os-Cal 500 mg po q.i.d., Maalox
t.i.d., Neomycin 250 mg po q.i.d.
ALLERGIES: Penicillin. Intolerant to sleep medications.
Motrin.
SOCIAL HISTORY: Three cigarettes per day.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 96.5. Pulse
85. Respiratory rate 22. Blood pressure 115/62. O2
saturation 93 to 97% on 4 liters. The patient is mouth
breathing, but in no acute distress. Oriented to person and
place only. Sclera anicteric. Pupils are equal, round and
reactive to light. Extraocular movements intact. Mental
status was at baseline per family. Distended EJ.
Jugulovenous distention at 10 cm. Cardiovascular heart rate
is regularly irregular. 2 out of 6 systolic ejection murmur
at the apex. Lungs, positive rales [**3-17**] of the way up.
Decreased breath sounds on left base. Abdomen distended,
nontender, positive normal bowel sounds. Extremities
positive clubbing, positive fluff hand contracture. 2+
pitting edema to knees bilaterally. Positive chronic
venostasis skin changes with erythema. Neurological
examination is mild to moderate asterixics.
LABORATORIES ON ADMISSION: Chest x-ray positive perivascular
upper hilar haziness consistent with congestive heart
failure. Small bilateral pleural effusion, worsened
congestive heart failure compared to prior study. Patchy
opacity in left lung zone. White blood cell count 4.7,
hematocrit 31, platelets 77 with a baseline platelet of 70
and 90. PT 16.4, PTT 36.5, with an INR of 1.8. Sodium 133,
potassium 4.4., chloride 97, bicarbonate 27, BUN 40,
creatinine 1.1, glucose 287, ALT 36, AST 63, CK 67, alkaline
phosphatase 127, T bili 1.3, troponin I less then .3.
Electrocardiogram showed atrial fibrillation with a rate of
92, normal axis, slightly prolonged QRS to 104, poor R wave
progression. Left ventricular hypertrophy.
HOSPITAL COURSE: In essence this is a 63 year-old male with
a history of coronary artery disease status post coronary
artery bypass graft, aortic insufficiency, status post AVR,
diastolic congestive heart failure, hypertension, chronic
obstructive pulmonary disease, diabetes mellitus, cirrhosis,
now here with new onset of atrial fibrillation and shortness
of breath for two weeks.
HOSPITAL COURSE: 1. Cardiac: The patient was ruled out for
a myocardial infarction. New onset of atrial fibrillation
noted. The patient was continued on aspirin and beta
blocker. The patient had supraventricular tachycardia. The
patient further in his course while in the Intensive Care
Unit developed hypertension to. He had to be maintained on
pressors, which included Levophed and then neo-synephrine.
There were episodes during the hospitalization when the
patient had to be on Amiodarone and Atenolol secondary to his
tachycardiac. Did not anticoagulate the patient due to his
atrial fibrillation secondary to his auto anticoagulation
secondary to his liver disease. Transesophageal
echocardiogram was unremarkable. Periodically the patient
had to be given Lasix secondary to his congestive heart
failure. However, this had to be balance so that the patient
would get hypotensive and hs required pressures by the end of
his hospital admission.
2. Pulmonary: The patient originally presented in
congestive heart failure iwth a fluid overload. The patient
was diuresed. However, the patient did have to be intubated
secondary to inadequate oxygenation. The patient was
intubated and admitted to the medical Intensive Care Unit on
[**2170-10-12**]. The patient was in respiratory acidosis in
the setting of hypotension, which was poor prognostic sign.
The question of congestive heart failure versus development
of new pneumonia. Pneumonia was treated. The patient was
also given Albumin to increase intravascular and glottic
pressure with the hope that this would improve hypotension
and improve perfusion and improve further acidosis. The
patient's presumed pneumonia was treated with Levaquin.
Serial chest x-rays were followed. The patient eventually
grew out Pseudomonas from his sputum. Infectious disease
team was following the patient and was giving
recommendations. After the Pseudomonas was discovered the
patient was placed on Vancomycin and Ceftazidime. Despite
these efforts the patient's ventilation requirements
continued to increase likely secondary to his worsening of
his infection and now possible adult respiratory distress
syndrome (chest x-ray could possibly have interpreted as
consistent with adult respiratory distress syndrome).
3. Neurological: The patient has continued to deteriorate
in terms of his mental status. The patient does have a
history of hepatic encephalopathy and originally his changes
in his mental status were attributed to that. Despite
aggressive treatment with Lactulose the patient was not
improveing. However, the CT scan of the head was performed
and was unremarkable. The patient had extensive neurological
evaluations during his hospital stay. By the end of the
hospital stay the patient was essentially unresponsive to
verbal stimuli or pain. Additionally, by the end of the
hospital stay the patient's pupils became nonreactive to
light. Per neurological examination the patient had an
extremely poor prognosis in terms of his neurological
function. These findings were discussed with family.
However, the family felt compelled to continue the treatment
for some time.
4. Renal: The patient went into acute renal failure. his
creatinine increased to 2. However, the patient did maintain
adequate urine output during this time. The patient kept
going in and out of acute renal failure during his hospital
stay and was monitored carefully in terms of his renal
function. A large component of this was felt to be secondary
to the patient's depleted intravascular volume and therefore
hyperperfusion. The patient was given Albumin in hope to
increase his renal perfusion.
5. Hematologic: The patient's hematocrit fell to 25 during
the hospital stay and the patient received multiple
intermittent transfusion of packed red blood cells. The
patient had guaiac negative stools, platelets were stable at
50.
6. Gastrointestinal: The patient had end stage liver
disease and was continued on Lactulose. The patient at this
time is not considered for a liver transplant secondary to
his very poor medical condition.
7. Social issues: The patient's family wanted to withdraw
the endotracheal tube on [**2170-10-31**]. Subsequently the ET tube
was withdrawn on 12:30 p.m. on that day. A lot of
medications continued per family's wishes. Intern was called
to bedside at 1:35 p.m. to pronounce death. The patient was
examined and there were no heart sounds or breath sounds for
two minutes. No response to sternal rub. Pupils were fixed
and dilated. Death was pronounced at 1:35 p.m. [**2170-10-31**].
Family was present and aware. Post mortem refused by health
care proxy, his son. [**Name (NI) **] was released to morg.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**]
Dictated By:[**Name8 (MD) 7892**]
MEDQUIST36
D: [**2171-6-4**] 08:48
T: [**2171-6-4**] 13:17
JOB#: [**Job Number 18016**]
ICD9 Codes: 4280, 5849, 486, 7907 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1407
} | Medical Text: y
Name: [**Known lastname 95474**], [**Known firstname **] Unit No: [**Numeric Identifier 95475**]
Admission Date: [**2189-3-6**] Discharge Date: [**2189-3-9**]
Date of Birth: Sex: F
Service: [**Company 191**]
HISTORY OF PRESENT ILLNESS: The patient is a 50 year-old
woman who presented to the Emergency Department complaining
of bright red blood per rectum three days after polypectomy.
While at work on the day of admission the patient noted loose
bowel movements, which were brown and without obvious blood.
At 8:00 p.m. on [**3-5**] she had a large bloody bowel movement
times two, felt dizzy, weak and nauseated. She had two more
blood bowel movements and presented to the Emergency
Department feeling lightheaded, dizzy and "presyncopal."
The patient describes vague abdominal cramping. No vomiting,
shortness of breath, chest pain, orthopnea, or paroxysmal
nocturnal dyspnea. She denies hematemesis or melena. She
denies history of ulcers, NSAID use, tobacco or alcohol use.
In the Emergency Department her blood pressure was noted to
be in the 70s. She was given intravenous fluids. She also
had a 10 point hematocrit drop since three days prior to
admission.
PAST MEDICAL HISTORY: [**Doctor Last Name 933**], status post ablation in [**2179**],
colonic polyps per colonoscope on [**2189-3-2**].
MEDICATIONS: Levoxyl 125 micrograms q.d., T3 5 micrograms
q.d.
ALLERGIES: Sulfa, which causes a rash and Ampicillin, which
causes a rash.
SOCIAL HISTORY: The patient is a psychiatrist. She denies
alcohol or tobacco use.
PHYSICAL EXAMINATION: Heart rate 80 lying, 116 sitting up.
Blood pressure initially 70/30 increased to 136/92 after
intravenous fluids and sating 98% on room air. The patient
is an obese woman lying on the stretcher in no acute
distress. HEENT normal. Chest is clear to auscultation
bilaterally. Heart regular rate and rhythm. No murmurs.
Abdomen soft, mild epigastric and left upper quadrant
tenderness. Extremities no edema.
LABORATORIES ON ADMISSION: White blood cell count 13.3,
hematocrit 31.4 (on [**2189-1-21**] her hematocrit was 41), platelets
391. Sodium 141, K 4.1, chloride 105, bicarb 26, BUN 16,
creatinine 0.7, glucose 159, INR 1.1. Electrocardiogram
normal sinus rhythm at 90, normal axis, normal intervals. No
ST or T wave changes. Colonoscopy showed two polyps 8 mm in
diameter 2 mm distal to the transverse colon and rectum.
HOSPITAL COURSE: The patient was admitted to the SICU and
transfused two units of blood and intravenous fluids. She
was also given Golytely and Fleets. She had a few episodes
of maroon stools. She denied abdominal pain. The patient
remained hemodynamically stable and post transfusion
hematocrits were stable around 33. The patient was
transferred from the Intensive Care Unit to the floor on [**3-7**].
Her hematocrit was followed and it remained stable in the low
30s. On [**3-6**] the patient received a Fleets prep with a plan
of doing colonoscopy. However, during the prep her blood
cleared and it felt that she was not longer bleeding. The GI
team wished to pursue a colonoscopy to double check that
there was no active bleeding. The patient refused this and
was felt to be stable and safe for discharge.
Of note, the patient had some right upper quadrant pain on
[**3-6**]. Liver function tests were [**Doctor First Name **], but due to risk
factors a right upper quadrant ultrasound was done to rule
out cholelithiasis. The results of ultrasound are pending at
the time of discharge.
The patient was continued on her thyroid medication without
incident throughout her hospitalization.
DISCHARGE DIAGNOSES:
Lower gastrointestinal bleed, colonic polyps status post
excision, hypothyroidism.
MEDICATIONS ON DISCHARGE: Levoxyl 125 micrograms q.d., T3 5
micrograms q.d.
DISCHARGE STATUS: The patient will be discharged home to
follow up with her primary care physician as needed.
DR.[**First Name (STitle) **],[**First Name3 (LF) 275**] 11-498
Dictated By:[**Last Name (NamePattern1) 6765**]
MEDQUIST36
D: [**2189-3-9**] 14:15
T: [**2189-3-10**] 11:46
JOB#: [**Job Number 95476**]
ICD9 Codes: 5789, 2851 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1408
} | Medical Text: Admission Date: [**2121-2-20**] Discharge Date: [**2121-2-28**]
Date of Birth: [**2057-12-17**] Sex: F
Service: MEDICINE
Allergies:
Ranitidine
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Hypotension, hypothermia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms [**Known lastname 32496**] is a 63 year old woman with history of heart failure,
diabetes, hypertension, and entero-uterine fistula, presenting
with hypotension and hypothermia at her day care unit.
Patient was brought in by her daughter after she was notified by
Day care unit that patient was found less responsive today and
vitals had revealed 76/50 at 20:50. Ms [**Known lastname 32496**] was also recently
evaluated in podiatry clinic for a left foot ulcer and started
on Bactrim. Patient is non verbal at baseline, daughter is not
reachable at this time.
In the ED, vitals: Temp 86 F oral (31.6C rectal), HR 44, BP
110/39, RR 14, O2 Sat 100%. Patient given heated humidifier and
heated blanket. Blood glucose 186.
Patient was given Vancomycin, Zosyn. Given hypotension, left
internal jugular venous line was placed and 3 L NS were given.
Urinalysis with >50 WBC, patient was admitted to [**Hospital Unit Name 153**] for futher
management.
Of note, patient has presented to our hospital two prior
occasions with hypothermia, hypoglycemia and sinus bradycardia.
On both hospitalizations patient has required agressive volume
resusitation (11L on [**10-18**]). On both admissions differential
diagnosis included myxedema coma, adrenal insufficiency and
[**Month/Year (2) 3080**], although no final diagnosis was reached.
Past Medical History:
# Entero-uterine fistula
# Chronic diastolic congestive heart failure (EF >60% 11/4/008)
# Type 2 diabetes mellitus: complicated by nephropathy,
peripheral neuropathy, retinopathy
# Coronary artery disease: History of distant MI per family
report, no PCI or CABG
# Hypertension
# Chronic kidney disease: Baseline creatinine 1.1-1.3
# History of pancreatitis status post pancreatic duct stent
# Anemia: Mixed iron deficient and anemia of chronic disease
# Thrombocytopenia
# History of thickened endometrium
# Osteopenia
# History of stroke
# Dementia
# seizure disorder, on Kepra
# Foot cellulitis s/p surgical debriedment [**7-19**], [**8-20**], s/p Right
BKA
Social History:
Tobacco: Quit 1 year ago, previously 3 ppd x 50 years ETOH:
Rare, illicits: None.
Family History:
Mother with diabetes, breast cancer, myocardial infarction in
her 70s. Brother with diabetes. Sister with heart disease.
Physical Exam:
General Appearance: Thin, Ill appearing
Eyes / Conjunctiva: No(t) PERRL, Conjunctiva pale
Head, Ears, Nose, Throat: Normocephalic, Poor dentition
Lymphatic: Cervical WNL
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Not assessed), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: 1+, Right BKA well healed.
Left foot with well demarcated ulcer, no drainage or purulence
Musculoskeletal: Muscle wasting, Unable to stand
Skin: Cool
Neurologic: Responds to: Verbal stimuli, Movement: Not assessed,
Tone: Not assessed
GU: Stage II ulcer on left buttock. Foley catheter in place,
dark milky urine in tube
Pertinent Results:
====================
ADMISSION LABS
====================
[**2121-2-20**] 05:15PM BLOOD
WBC-12.9*# RBC-2.84* Hgb-8.3* Hct-25.5* MCV-90 MCH-29.1
MCHC-32.5 RDW-17.5* Plt Ct-50*# Gran Ct-[**Numeric Identifier 70565**]
Glucose-186* UreaN-47* Creat-2.3* Na-134 K-4.7 Cl-111* HCO3-12*
AnGap-16
Lactate-1.7
===========
ECHO
===========
([**2120-10-15**])
The left atrium is normal in size. There is severe symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Transmitral Doppler
and tissue velocity imaging are consistent with Grade III/IV
(severe) LV diastolic dysfunction. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The left ventricular inflow pattern
suggests a restrictive filling abnormality, with elevated left
atrial pressure. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2120-7-31**],
left ventricular systolic function has improved.
[**Known lastname **],[**Known firstname **] [**Age over 90 70566**] F 63 [**2057-12-17**]
Radiology Report MR HEAD W/O CONTRAST Study Date of [**2121-2-22**]
4:48 PM
[**Doctor Last Name **],[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] MED [**Hospital Unit Name 153**] [**2121-2-22**] 4:48 PM
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST; MRA NECK W/O
CONTRAST Clip # [**Clip Number (Radiology) 70567**]
Reason: please eval for new IC process
[**Hospital 93**] MEDICAL CONDITION:
63 year old woman with epilepsy, worsened mental status from
baseline
REASON FOR THIS EXAMINATION:
please eval for new IC process
CONTRAINDICATIONS FOR IV CONTRAST:
[**Doctor First Name 48**]
Final Report
MRI SCAN OF THE BRAIN WITH MR ANGIOGRAPHY OF THE NECK AND HEAD
HISTORY: Epilepsy. Worsening mental status from baseline.
Evaluate for new
intracranial process.
TECHNIQUE: Multiplanar T1- and T2-weighted brain imaging was
obtained, as
well as three-dimensional time-of-flight imaging of the circle
of [**Location (un) 431**] and
its tributaries. Finally, two- and three- dimensional
time-of-flight imaging
of the neck arterial vasculature was also acquired.
COMPARISON STUDIES ON PACS ARCHIVE: [**2121-1-9**] MR scan of the
brain.
FINDINGS: Unfortunately, nearly all images of this study are
moderately to
severely degraded by patient motion. Within these limitations,
there is
redemonstration of what has previously been characterized as a
probable
chronic infarct within the right frontal lobe. On the most
extreme cephalad
diffusion-weighted images, there is a question of a
subcentimeter curvilinear
area of restricted diffusion involving the left-sided sensory
cortex (see
series 600, images 23 and 24). It is possible that this area
could represent
a tiny area of evolving infarction. No other areas of diffusion
abnormality
are seen. There is no hydrocephalus or shift of normally midline
structures.
The principal vascular flow patterns are identified. There is
moderate
bilateral ethmoid sinus mucosal thickening, as well as milder
sphenoid and
frontal sinus mucosal thickening, which likely represents a
chronic
inflammatory process.
The intracranial MR angiogram is of extremely poor quality due
to patient
motion. There appears to be less flow within the right middle
cerebral artery,
relative to the left, which could indicate effects of the known
right frontal
lobe infarct.
Similarly, the MR angiography of the neck arterial vasculature
is of very poor
quality. No gross area of hemodynamically significant stenosis
is seen.
CONCLUSION: Question of perhaps a tiny area of evolving
infarction within the
left sensory strip vertex region of the brain. Suboptimal study,
without
other overt interval changes appreciated.
[**Known lastname **],[**Known firstname **] [**Age over 90 70566**] F 63 [**2057-12-17**]
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2121-2-21**]
4:15 PM
[**Doctor Last Name **],[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] MED [**Hospital Unit Name 153**] [**2121-2-21**] 4:15 PM
CT HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 70568**]
Reason: please eval for bleed
[**Hospital 93**] MEDICAL CONDITION:
63 year old woman with baseline dementia, now with worsened
AMS, concern for
seizure activity
REASON FOR THIS EXAMINATION:
please eval for bleed
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
INDICATION: Baseline dementia, now with worsening altered mental
status and
concern for seizure activity. Please evaluate for bleed.
COMPARISON: Multiple prior brain imaging studies, most recently
MRI from
[**2121-1-9**].
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is no intracranial hemorrhage. Right frontal
hypodensity
remains most consistent with encephalomalacia, consistent with
subacute
infarction demonstrated on most recent MRI of [**2121-1-9**]. There
is no evidence
of new infarction. There is no sign of acute vascular
territorial ischemia.
Ventricles and sulci are unchanged in size and configuration,
allowing for
differences in modality. Vascular calcifications are noted in
the carotid
siphons bilaterally. There is a small fluid level in the right
maxillary
sinus, and partial opacification of the ethmoid air cells.
IMPRESSION:
1. No intracranial hemorrhage.
2. Right frontal encephalomalacia, consistent with evolution of
previously
noted subacute infarction.
3. Small fluid level in the right maxillary sinus.
Brief Hospital Course:
Ms [**Known lastname 32496**] is a 63 year old woman with a recent history of 2
prior episodes of recurrent hypotension, hypothermia,
hypoglycemia, who was admitted to the ICU on [**2121-2-20**] for
hypotension and hypothermia.
.
Hospital course by problem:
.
#. Hypotension: The pt has been admitted on 2 prior occasions
for hypotension thought to be secondary to septic shock, and
during these admissions an offending pathogen was never
identified. On this admission pneumonia seemed a possible source
of [**Date Range 3080**] as the pt had a new opacity on chest x-ray, but the
differential also included other infectious processes (known
entero-uterine fistula, yeast in urine culture, lower extremity
ulcers), myxedema coma, adrenal insufficiency, profound
hypovolemia or hemodynamic process. The pt was started on
broad-spectrum antibiotics (Vancomycin, Zosyn) given multiple
potential sources of infection. The pt also had a cortisol
stimulation test that showed an appropriate response. The pt was
transiently on pressors and quickly weaned off, and required a
minimal amount of IVF resuscitation. On transfer to the floor
the pt had been hypertensive in the 160's systolic for 48 hours
and was +7L for length of stay. BP meds held, slowly
re-introduced as pressure tolerated, after auto-regulation given
possible stroke.
.
#. Hypothermia: On prior hospitalizations for hypothermia the
cause has remained unclear, but has been attributed to [**Date Range 3080**].
Also may have been due to hypothyroidism, T4 supplementation
resumed/increased. Resolved
.
# Acute renal failure: The pt's baseline Creatinine was 1.1 to
1.3, and elevated to 2.3 on admission. The pt's acute renal
failure was thought to be secondary to acute tubular necrosis in
the setting of hypotension. Resolved to baseline.
.
#. Thrombocytopenia: Unclear etiology from prior admissions,
suspect bone marrow supression vs consumptive process.
Hematology/oncology followed in hospital, felt due to [**Date Range 3080**].
.
# Leukocytosis - unclear etiology. Rising. Hematology
recommended flow cytometry and outpatient follow up in one month
with Dr. [**Last Name (STitle) 4762**] (see below). No evidence of ongoing
infection on d/c. Neg for c diff times two, no fevers, no
abdominal pain, no dyspnea. Urine with yeast only (chronic).
#. Metabolic Acidosis: Very low bicarbonate on admission,
lactate however was normal. No anion gap. Most likely this
represents GI losses vs decreased bicarbonate production from
acute renal function.
# Labile blood glucose - had low levels when glargine titrated
up to 6 U, so, lowered back to 3 U q am, with conservative SSI
regimen as per prior endocrine recommendations.
# Diarrhea, ? enterovaginal/enterouterine fistula - diarrhea c/w
known pancreatic insufficiency/malabsorption. No abd pain,
fever, to suggest c difficile infection, and cdiff assays
negative times two. Viokase with meals. Fistula discussed with
dtr (health care proxy) - have discussed previously, and decided
against surgery.
# Grade II sacral ulcerations due largely to fecal and urinary
incontinence/diarrhea - wound care as below.
# Stroke, seizure d/o - MR with evidence of possible acute
infarct. Seen by neurology. Statin prescribed. ASA should be
resumed when thrombocytopenia has improved to over 100,000 per
neurology. Keppra continued for seizure d/o.
Medications on Admission:
Kepra 500mg
Novolog SS
Aspirin
Enalapril 20mg
Ergocalciferol
Amlodipine 10mg
Glucagon pen PRN
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Insulin Glargine 100 unit/mL Solution Sig: Three (3) Units
Subcutaneous Q am.
7. Insulin Lispro 100 unit/mL Solution Sig: as per sliding
scale, below units, insulin Subcutaneous QACHS: for BG:
201-250: 2 U
251-300: 4 U
301-350: 6 U
351-400: 8 U
Over 400: [**Name8 (MD) 138**] MD.
8. Amylase-Lipase-Protease 30,000-8,000- 30,000 unit Tablet Sig:
Six (6) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
9. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day:
ONLY WHEN PLATELETS OVER 100,000.
Discharge Disposition:
Extended Care
Facility:
Sachem Skilled Nursing & Rehabilitation - [**Location 21318**]
Discharge Diagnosis:
Pneumonia with [**Location 3080**]
Thrombocytopenia due to above
Leukocytosis, unspecified.
Chronic Kidney Disease, stage III
Acute Stroke
Hypertension
Dementia
Diabetes, type II, uncontrolled, with complication
Diarrhea due to malabsorption from pancreatic insufficiency
Hypothyroidism
Stage II sacral decubitus ulceration
Discharge Condition:
Stable, alert, at baseline of orientation (to self only),
afebrile. BG labile 100s to 300, tolerating po intake. Still
having diarrhea due to known pancreatic
insufficiency/malabsorption.
Discharge Instructions:
Return to the [**Hospital1 18**] Emergency Department for: Fevers, lethargy.
Followup Instructions:
rehabilitation hospital.
With Dr. [**Last Name (STitle) 70569**] of Hematology within one month - This is to
follow up on the results of flow cytometry and cell counts, and
for consideration of further work up of leukocytosis including
possible bone marrow biopsy. See below:
Arranged - Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13999**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2121-4-4**] 1:00
ICD9 Codes: 0389, 5849, 486, 2762, 4280, 2875, 2449, 3572 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1409
} | Medical Text: Admission Date: [**2165-3-18**] Discharge Date: [**2165-3-29**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Tachypnea
Major Surgical or Invasive Procedure:
R IJ placement
History of Present Illness:
Mr. [**Known lastname **] is a 89 year-old man with a history of CAD s/p CABG,
CHF (EF 25%) and PAF who initially p/w respiratory distress,
transferred to the ICU on day of admission for continued
borderline hypoxia and tachypnea, DNR/I, briefly on Dopa gtt for
hypotension, then called out to floor on [**3-20**] at night, now
re-transferred to MICU for recurrent SOB.
.
Of note, two recent admission: First admission ([**2-18**] - [**2-20**]) was
for an enterococcal UTI; he was treated with ampicillin and
discharged to home. Second admission ([**3-1**] to [**3-8**]) was for CHF
in the setting of afib with RVR; he was treated with rate
controlling agents (amiodarone was added to metoprolol);
valsartan was also added to his regimen. At rehab the day before
admission, he developed labored breathing and inability to
urinate.
.
In the ED, initial vitals were HR 124 BP 80s-90s/30s-40s
RR:20-30 O2Sat 97% on 2L NC. BNP [**Numeric Identifier 101296**], down from [**Numeric Identifier 101294**] on last
admission [**2165-3-1**]. A CXR showed bilateral effusions,
atelectasis, and appearance concerning for left lower lobe
pneumonia. He was given 500 mg levofloxacin given and 2 liters
of NS. Also recieved nebs given.
.
On the floor, his labored breathing -> IV lasix, foley placed ->
350cc of cola-colored urine. ABG 7.40/38/64. On arrival to the
MICU, pt with SBPs in 80's then drifting into ?60's-70's. He was
transiently on Dopa gtt, weaned off and started on empiric Vanc
and Zosyn for possible PNA although afebrile and normal WBC but
productive cough. Lactate was initially 3.0, then trended down
to 1.4. Pt had reportedly his flu shot. Legionella Ag was
negative. A repeat Echo did not show worsening EF or tamponade
but worsened MR. Elevated cardiac enzymes were felt to be due to
past event or demand ischemia. Also in acute on chronic renal
failure with Cr of 3.3. INR supratherapeutic, thus coumadin was
held. Once off the dopa, he was called out to the floor in AM on
[**3-20**]. However, developed AF/RVR and was kept in the ICU until
9PM. He received 5mg IV lopressor with rate control. He also
received 40 IV lasix since it was felt that he was now fluid
overloaded. Once stable, he came to the floor on 9PM on [**3-20**].
.
On the floor, he triggered overnight for tachypnea and AF/RVR.
He received 10 IV dilt with rate control. He also received
2x250cc IVF boluses for SBP in 90s. A foley was placed and 1L
dark urine came back. UA without infection. In the morning, he
was restarted on abx (Vanc/CTX this time). He was found to be
tachypneic again. ABG was 7.38/41/77. CXR was ordered. He was
given 40 IV lasix, O2 was uptitrated on NC, then switched to FM.
Nebs were given. It was felt that he was tiring out and would
benefit from retransfer to MICU, also for possible lasix gtt
since BP dropped to low 90s after IV lasix bolus.
.
On arrival to the ICU on [**3-21**], he was less tachypneic, satting
100% on 3L NC but still using accessory muscles. He denied any
CP, palpitations, but has productive cough (whitish sputum x2
weeks). No F/C/N.
.
ROS: negative for abdominal pain, N/V/D, urinary sxs. Last BM
few days ago.
Past Medical History:
1. Systolic Congestive Heart Failure: Infarct-related. EF ~20%
on echocardiogram [**4-/2164**]
2. Coronary Artery Disease: S/P CABG w/ LIMA-LAD, SVG-OM1-OM2,
SVG-RCA-PL. Last P-MIBI [**2-14**] w/ large fixed defect involving the
entire inferior wall and the basal inferoseptum and the basal
inferolateral (PDA region). History of small nonQ wave infarct.
3. Paroxysmal Atrial Fibrillation - on coumadin
4. Type II Diabetes (non-insulin dependent) controlled
5. Peripheral Vascular Disease w/ AAA and common iliac aneurysm
6. CVA in [**2153**]
7. GERD
8. LBBB on EKG
9. NSVT - has declined ICD in the past
10. Hypertension
11. Hyperlipidemia
Social History:
Wife currently has cancer, lives with her in [**Hospital3 **]
apartment. He denies ever smoking, etoh or other illicits.
Family History:
Family history of hypertension and coronary artery disease
Physical Exam:
Vitals: T 96.7, BP 107/34, HR 76 SR, RR 22, 100% on 3L, CVP 10
GEN - Elderly male in mild respiratory distress. Able to
complete full sentences but uses accessory muscles to breathe.
SKIN - bruises over L arm and back, no rash
HEENT - PERRL, EOMI, dry MM, JVP up to jaw (but with known
2+TR), no HJR, R IJ in place
CV - RR, nl S1, S2, no obvious murmur appreciated.
PULM - Dull at bases, crackles half-way up, diffuse wheezes.
ABD - Soft and non-tender. nondistended, sparse BS, no
hepatomegaly appreciately, no hepatic tenderness suggesting
congestion.
EXT - Warm. No peripheral edema. No clubbing or cyanosis.
NEURO - A&O x 3, responds appropriately to all questions. Moves
all extremities.
Pertinent Results:
[**2165-3-18**] 10:35AM WBC-9.9# RBC-3.45* HGB-10.3* HCT-30.2* MCV-88
MCH-29.7 MCHC-34.0 RDW-14.7
[**2165-3-18**] 10:35AM NEUTS-86.3* BANDS-0 LYMPHS-8.7* MONOS-4.7
EOS-0.1 BASOS-0.1
[**2165-3-18**] 10:35AM PLT SMR-NORMAL PLT COUNT-175
[**2165-3-18**] 10:35AM proBNP-[**Numeric Identifier 101296**]*
[**2165-3-18**] 10:35AM GLUCOSE-101 UREA N-93* CREAT-3.2* SODIUM-136
POTASSIUM-4.3 CHLORIDE-94* TOTAL CO2-28 ANION GAP-18
[**2165-3-18**] 10:35AM ALT(SGPT)-17 AST(SGOT)-41* ALK PHOS-66 TOT
BILI-0.5
[**2165-3-18**] 08:07PM LACTATE-3.0*
.
ECG #1: NSR with LBBB.
ECG #2: Afib with RVR (rate 129)
ECG [**2165-3-21**]: LAD, LBBB, no acute ST changes
.
CXR [**3-21**] (read pending): prelim read by MICU with no significant
change to yesterday, retrocardiac opacity visible, b/l
effusions, minimal pulmonary edema.
.
CXR [**3-20**]:
As compared to the previous radiograph, there is no major
change. Extensive cardiomegaly with retrocardiac opacities.
Small bilateral pleural effusions. Unchanged position of the
central venous access right.
.
Echo [**2165-3-19**]:
Severe regional left ventricular systolic dysfunction with
akinesis of the inferior and inferolateral walls, hypokinesis of
the setpum, anterior and lateral walls. The basal to mid septum
contracts best. (LVEF= 20 %). (3+)MR, 2+ TR. moderate pulmonary
artery systolic hypertension. IMPRESSION: Moderately dilated
left ventricular cavity with severe regional dysfunction
consistent with multivessel coronary disease. Moderate to severe
mitral regurgitation. At least moderate pulmonary hypertension.
c/w [**2164-4-25**], the severity of mitral regurgitation has
increased. Estimated pulmonary pressures are higher.
.
CXR ([**2165-3-18**]): Bilateral effusions, atelectasis, and appearance
concerning for left lower lobe pneumonia.
.
PFTs ([**2165-3-8**]): Normal spirometry and lung volumes. The reduced
DLCO suggests a perfusion limitation. There are no prior studies
available for comparison.
.
TTE ([**2164-4-25**]): EF 20%, inferior/inferolateral
akinesis/dyskinesis and hypokinesis elsewhere. Mild to moderate
([**12-12**]+) mitral regurgitation is seen. Biatrial enlargement.
.
Micro data:
[**2165-3-21**] SPUTUM GRAM STAIN-good sample, 2+ GPC IN PAIRS AND
CLUSTERS. Cx-PENDING
[**2165-3-21**] Ucx-PENDING
[**2165-3-20**] Ucx-PENDING
[**2165-3-19**] URINE Legionella Urinary Antigen -negative
[**2165-3-18**] Ucx negative
[**2165-3-18**] Bcx pending x2
Brief Hospital Course:
89M w/ CAD s/p CABG, CHF (EF 25%), PAF p/w tachypnea, cough,
course c/b hypotension in MICU (briefly on dopa gtt), Vanc/Zosyn
for PNA, AF/RVR, A/CRF, on floor again tachypneic,
re-transferred to MICU for possible noninvasive ventilation,
instead pt remained stable on NC, was treated for 7 days with
Vanc/CTX for PNA, remained labile with regards to BP and UOP,
was initially started on NTG gtt and Lasix gtt, then switched to
Milrinone gtt and continue on Lasix gtt with moderate increase
in UOP. His Cr continued to increase and the patient stated that
he would not want hemodialysis if this became necessary.
Decision was made to transition to comfort care, and pt. was
d/c'd of all noncomfort medications. He was transferred to
floor and expired 5PM [**3-29**]. Autopsy declined.
.
Medications on Admission:
MEDICATIONS (rehab):
1. Aspirin 81 mg daily
2. Coumadin 2 mg PO QD
3. Lasix 40 mg PO once a day-recent increase to [**Hospital1 **], but says
was
not taking prior
4. Valsartan 80 mg [**Hospital1 **]
5. Amiodarone 200 mg QD
6. Isosorbide Mononitrate 30 mg
7. Metoprolol 50 mg Sustained Release PO DAILY
8. Simvastatin 20 mg PO DAILY
9. Glipizide 5 mg daily
10. Calcitriol 0.25 mcg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Ampicillin 500 mg PO twice a day for 14 days twice a day
starting [**2-21**].
13. RISS
- miconazole powder 85 gm topical TID
.
MEDICATIONS (on first transfer to MICU on [**3-18**]):
- levofloxacin 250 mg Q48 day 1
- zosyn 2.25g Q8H day 1
- vanco 1 g x1 today
- Isosorbide Mononitrate 30 mg daily
- Metoprolol 50 mg [**Hospital1 **]
- Calcitriol 0.25 mcg PO DAILY
- Aspirin 81 mg Tablet, PO DAILY
- Coumadin 2 mg PO QD
- Lasix 40 mg PO BID
- Amiodarone 400 mg QD
- RISS
- miconazole powder 85 gm topical TID
- Albuterol nebs Q3H; ipratropium neb Q4H
.
MEDICATIONS (on re-transfer to MICU on [**3-21**]):
- Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN
- Insulin SC (per Insulin Flowsheet)
- Ipratropium Bromide Neb 1 NEB IH Q4H
- Lidocaine Jelly 2% (Urojet) 1 Appl TP PRN
- Metoprolol Tartrate 12.5 mg PO BID
- Acetylcysteine 20% 6-10 mL NEB Q6H:PRN congestion
- Miconazole Powder 2% 1 Appl TP TID
- Amiodarone 200 mg PO DAILY
- Senna 1 TAB PO BID:PRN
- Aspirin 325 mg PO DAILY
- Simvastatin 20 mg PO DAILY
- Bisacodyl 10 mg PO DAILY:PRN
- Calcitriol 0.25 mcg PO DAILY
- Cepacol (Menthol) 1 LOZ PO PRN
- CeftriaXONE 1 gm IV Q24H
- Valsartan 80 mg PO DAILY
- Docusate Sodium 100 mg PO BID
- Zolpidem Tartrate 5 mg PO HS:PRN
- Vancomycin 1000 mg IV ONCE
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
chronic CHF
Diabetes
Atrial fibrillation
Hypertension
Discharge Condition:
expired
Followup Instructions:
none
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
ICD9 Codes: 4280, 486, 5849, 5119, 2762, 5185, 4240, 4168, 4439, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1410
} | Medical Text: Admission Date: [**2133-4-5**] Discharge Date: [**2133-4-10**]
Date of Birth: [**2073-2-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2133-4-6**] Coronary Artery Bypass Grafting x4 with Left Internal
Mammary Artery to Left Anterior Descending Artery, reverse
Saphenous Vein Graft to Diagonal Artery, reverse Saphenous Vein
Graft to Obtuse Marginal artery, reverse Saphenous Vein Graft to
Posterior Diagonal Artery), Mitral Valve repair with 28
[**Company 1543**] CG future annuloplasty ring
History of Present Illness:
60 year old White male with recent dyspnea on exertion. Stress
test was abnormal during work up for revision of right total
knee. cardiac catheterization revealed coronary artery disease
and he was referred for surgical evaluation
Past Medical History:
coronary artery disease
hypertension
myocardial infarction (remote by EKG)
nephrolithiasis
[**First Name9 (NamePattern2) 7816**] [**Location (un) **] (42 yrs. ago)
neurogenic bladder (self cath 4-5x/day)
urinary tract infection with sepsis [**2131**]
obesity
bilateral rotator cuff tear
spinal stenosis
gout
diverticulosis
osteoarthritis
Past Surgical History:
bilateral total knee replacements (2x each)
transurethral resection of prostate
cholecystectomy
left inguinal hernia repair x2
tonsillectomy
Social History:
Lives with: alone, divorced
Occupation: NSTAR mechanic
Tobacco: none
ETOH: occasional
Family History:
mom died of MI 68yo, dad living 87 (h/o MI)
sister died 40yo [**Name (NI) **], brother 59 living with DM
Physical Exam:
Pulse: 79 Resp: 17 O2 sat: 99%RA
B/P Right: 130/70 Left:
Height: 5'9" Weight: 225lb
General:
Skin: Dry [x] intact [x] no rash
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [] no varicosities, trace edema b/l [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] healed scars over b/l knees s/p TKR
Neuro: Grossly intact x
Pulses:
Femoral Right: cath Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left: no carotid bruits
Pertinent Results:
Pre-op
[**2133-4-5**] 05:03PM PT-11.5 PTT-24.8 INR(PT)-1.0
[**2133-4-5**] 05:03PM PLT COUNT-196
[**2133-4-5**] 05:03PM WBC-9.3 RBC-4.46* HGB-12.7* HCT-36.6* MCV-82
MCH-28.5 MCHC-34.7 RDW-15.2
[**2133-4-5**] 05:03PM MAGNESIUM-1.9
[**2133-4-5**] 05:03PM GLUCOSE-85 UREA N-28* CREAT-1.2 SODIUM-142
POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-26 ANION GAP-14
[**2133-4-5**] 08:46PM URINE RBC-[**2-27**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-0
[**2133-4-5**] 08:46PM URINE BLOOD-SM NITRITE-NEG PROTEIN-150
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-MOD
[**2133-4-5**] 08:46PM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.012
Discharge
[**2133-4-8**] 06:30AM BLOOD WBC-14.0* RBC-3.91* Hgb-11.0* Hct-34.1*
MCV-87 MCH-28.1 MCHC-32.2 RDW-14.7 Plt Ct-102*
[**2133-4-8**] 06:30AM BLOOD Plt Ct-102*
[**2133-4-6**] 02:44PM BLOOD PT-13.1 PTT-29.4 INR(PT)-1.1
[**2133-4-8**] 06:30AM BLOOD Glucose-120* UreaN-24* Creat-1.2 Na-140
K-4.3 Cl-106 HCO3-26 AnGap-12
[**2133-4-8**] 06:30AM BLOOD Mg-2.1
CHEST (PORTABLE AP) [**2133-4-7**] 8:07 AM
[**Hospital 93**] MEDICAL CONDITION: 60 year old man with CABG/MVrep
REASON FOR THIS EXAMINATION: ? after CT removal
Final Report
CHEST, AP: Examination is limited by underpenetration.
Endotracheal tube,
nasogastric tube, mediastinal drains, and chest tubes have been
removed.
Swan-Ganz catheter remains in standard position. There is no
pneumothorax.
Moderate layering left effusion persists. The cardiomediastinal
silhouette is stably enlarged, post-CABG and mitral valve
replacement. Lung volumes are low, with mild bibasilar
atelectasis.
IMPRESSION: Post-operative changes. Moderate left effusion.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 10307**] HO
DR. [**First Name11 (Name Pattern1) 1569**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 11006**]
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *6.0 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *7.3 cm <= 5.2 cm
Left Ventricle - Inferolateral Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *6.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 30% to 35% >= 55%
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.9 cm <= 3.0 cm
Aorta - Ascending: *3.8 cm <= 3.4 cm
Aorta - Descending Thoracic: *2.7 cm <= 2.5 cm
Aortic Valve - LVOT diam: 1.9 cm
Findings
LEFT ATRIUM: Marked LA enlargement. Elongated LA. No spontaneous
echo contrast or thrombus in the LA/LAA or the RA/RAA. Good (>20
cm/s) LAA ejection velocity. 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. Moderately
dilated LV cavity. Moderate regional LV systolic dysfunction.
Inferobasal LV aneurysm. Moderately depressed LVEF.
RIGHT VENTRICLE: Moderate global RV free wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Mildly dilated ascending aorta.
Simple atheroma in ascending aorta. Simple atheroma in aortic
arch. Mildly dilated descending aorta. Complex (>4mm) atheroma
in the descending thoracic aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. No MS. Moderate (2+) MR.
TRICUSPID VALVE: Tricuspid valve not well visualized.
Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. Suboptimal image
quality. Frequent atrial premature beats. Results were
Conclusions
PRE BYPASS The left atrium is markedly dilated. The left atrium
is elongated. 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 are normal. The left ventricular cavity is
moderately dilated. There is moderate regional left ventricular
systolic dysfunction with severe hypokinesis of the lateral,
anterolateral and inferolateral walls. The rest of the walls are
moderately depressed. There is a likely inferobasal left
ventricular aneurysm. Overall left ventricular systolic function
is moderately to severely depressed (LVEF= 30 %). The right
ventricle displays moderate global free wall hypokinesis. The
ascending aorta is mildly dilated. There are simple atheroma in
the ascending aorta. There are simple atheroma in the aortic
arch. The descending thoracic aorta is mildly dilated. There are
complex (>4mm) atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Moderate (2+)
centrally directed mitral regurgitation is seen. It is likely
due to a combination of bileaflet restriction and annular
dilitation. There is a trivial/physiologic pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results in the
operating room at the time of the study.
POST BYPASS The patient is receiving epinephrine by infusion.
The patient is being atrial paced. Right ventricular free wall
systolic function is improved and is now normal. The left
ventricle dispalys improved function as well. The lateral,
anterolateral, and inferolateral walls are still mild to
moderately hypokinetic. The ejection fraction is about 45%. A
mitral annular ring is in situ. There is trace to mild mitral
regurgitation. The peak gradient across the mitral valve is 11
mmHg with a mean gradient of 7 mmHg at a cardiac output of 9
liters/minute. The thoracic aorta appears intact. No other
significant changes from the pre-bypass study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2133-4-6**] 14:47
Brief Hospital Course:
He was admitted to [**Hospital1 18**] for coronary artery bypass grafting and
mitral valve repair versus replacement. He was found to have a
Klebsiella urinary tract infection and was treated
preoperatively with IV cefepime. On [**4-6**] he was brought to the
operating room please see operative report for details. He
tolerated the operation well and was transferred from the
operating room to the cardiac surgery ICU in stable condition.
He remained hemodynamically stable in the immediate
post-operative period, woke nuerologically intact and was
extubated. On POD1 he was transferred from the cardiac surgery
ICU to the stepdown unit. All tubes, lines and drains were
removed per cardiac surgery protocol. Once on the stepdown unit
he worked with physical therapy and nursing to increase her
activity and endurance. The remainder of his post operative
course was uneventful. On POD four he was discharged home with
services.
Medications on Admission:
amlodipine 10', asa 325', Metoprolol 25 mg [**Hospital1 **], simvastatin 80mg
daily
Discharge Medications:
1. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 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. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **]-[**Location (un) **]
Discharge Diagnosis:
coronary artery disease s/p CABG and MV repair
hypertension
myocardial infarction
nephrolithiasis
[**First Name9 (NamePattern2) 7816**] [**Location (un) **]
neurogenic bladder (self cath 4-5x/day)
urinary tract infection with sepsis [**2131**]
obesity
bilateral rotator cuff tear
spinal stenosis
gout
diverticulosis
osteoarthritis
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Sternal wound 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 the cardiac surgery office [**Telephone/Fax (1) 1504**] for any
questions or concerns. Answering service will page on-call staff
during off hours
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2133-5-14**] 1:00
Please call to schedule appointments
PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5311**] [**Telephone/Fax (1) 5317**] in [**12-27**] weeks
Cardiologist: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**12-27**] weeks
Please call the cardiac surgery office [**Telephone/Fax (1) 1504**] for any
questions or concerns. Answering service will page on-call staff
during off hours
Completed by:[**2133-4-10**]
ICD9 Codes: 5990, 4271, 4019, 412, 2749, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1411
} | Medical Text: Admission Date: [**2171-12-4**] Discharge Date: [**2171-12-14**]
Date of Birth: [**2117-5-3**] Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
shortness of breath, lower extremity edema
Major Surgical or Invasive Procedure:
Pericardiocentesis, tunneled catheter exchange
History of Present Illness:
Mr. [**Known lastname 63305**] is a 54-year-old man with a history of AML 11 months
s/p matched related allo SCT with busulfan/cyclophosphamide
conditioning with complications of CMV viremia, GVHD and
hemorrhagic cystitis, and longstanding disseminated TB s/p
treatment, who presented on [**2171-12-4**] to [**Hospital 478**] clinic with
2-day h/o cough, SOB. No fever, chills, URI symptoms,
hemoptysis, chest pain, palpitations, N/V/D, weight change,
urinary symptoms, or change in BMs. He also noted discomfort in
his left eye which had been bothering him for 1 month. Denied
eye pain.
.
Past Medical History:
ONC HISTORY (per OMR):
1. Diagnosed in early [**8-/2169**] with nightly fevers. BM bx
revealed AML. Flow cytometry showed aberrant expression of CD2,
CD7, HLA-DR, CD 34, dim CD33, CD 117, and CD 71. CT scan
revealednecrotic lymph nodes in the superior mediastinum and
periportalregion, and multiple low attenuation lesions in the
liver and spleen concerning for microabscesses from a
disseminated infection.
2. [**2169-8-17**]: Induction chemotherapy with cytarabine and
idarubicin complicated by persistent fevers and extensive workup
ultimately revealing disseminated tuberculosis infection. His
course was also complicated by rapid atrial fibrillation and
hypotension and the development of a severe cardiomyopathy.
3. S/P one dose of high-dose ARA-C at 1.5 mg per meter squared,
lowered dose due to his disseminated tuberculosis, and then he
received a second course of HiDAC at 3 gram per meter squared
dose and developed acute onset of gait instability. No further
chemotherapy given.
4. Relapsed in 7/[**2170**]. [**Year (4 digits) **] re-induction with ME on [**2170-8-13**].
Noted for pulmonary nodules which were suspicious for
aspergillus and empirically treated with Voriconazole with
improvement noted on CT.
5. Admitted on [**2170-10-25**] for maintenance therapy while awaiting
BMT. However, upon admit he was again found to have blasts. He
proceeded with Idarubicin and Cytarabine(7+2) butdid not achieve
a remission.
6. S/P High dose Ara-c with remission.
7. [**Year (4 digits) **] sibling related allo transplant on [**2171-1-8**]. Allo
course c/b increased LFTs of unclear etiology, possibly from
chemotherapy, renal failure attributed to CSA, and received only
1 dose of MTX due to mucositis.
8. Post transplant course complicated by asymptomatic CMV
viremia and
viral/URI syndromes.
9. In [**2171-5-12**] developed diarrhea with e/o GVH on endoscopy.
He also
had hematuria, but no evidence of BK virus. He started
photopheresis.
Diarrhea abated but LFTs rose. Therapy attempted for GVH of
liver using pulse of prednisone and increase in CellCept with
stabilization but no significant improvement.
10. Received 1mg of Pentostatin on [**2171-6-14**].
11. Liver Biopsy c/w GVHD. Started Rituxan for 4 weeks in
5/[**2171**].
Non-onc PMH
- Disseminated TB - s/p treatment with INH, levofloxacin and
rifabutin
- Hypertension and a heart murmur
- Diabetes mellitus type 2
- Chemo related heart failure and cardiomyopathy, EF 35-40%
[**12-16**]
- h/o atrial fibrillation, recent EKGs in NSR
- CMV viremia ([**2-17**])
Social History:
He is married and lives at home with his wife & children. He is
a machine operator, but is currently not working. He immigrated
from [**Country 5976**] in early [**2144**]. He smoked approximately 3 cigarettes
per day for 20 years and stopped 1 year ago. He does not drink
alcohol.
Family History:
Notable for mother who passed away of myocardial infarction. His
father passed away of liver disease. He has four living brothers
and two living sisters, all in good health.
Physical Exam:
PHYSICAL EXAMINATION ON TRANSFER TO BMT SERVICE:
VS: T 98.7, BP 128/84, HR 86, RR 16, 96%RA
GENERAL: Pleasant middle-aged man lying in bed in NAD
HEENT: PERRL with anicteric sclerae. Left eye non-injected. No
diplopia, extraocular muscle movement intact. OP moist, no
lesion.
LUNGS: Clear to auscultation bilaterally.
HEART: Reg rate, nl S1/S2, no m/r/g. [**Year (4 digits) **] site without
erythema or tenderness.
ABDOMEN: Soft, NT, ND, BS present, no HSM
EXTREMITIES: 2+ pitting LE edema to knees bilaterally
SKIN: Warm and dry with marked hyperpigmentation changes noted
on his torso and lower extremity.
Pertinent Results:
LABS ON ADMISSION:
[**2171-12-4**] 10:40AM WBC-2.2*# RBC-2.75* HGB-9.7* HCT-31.2*
MCV-114* MCH-35.5* MCHC-31.2 RDW-22.4*
[**2171-12-4**] 10:40AM NEUTS-32* BANDS-0 LYMPHS-29 MONOS-35* EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0 PROMYELO-3* NUC RBCS-14*
[**2171-12-4**] 10:40AM PLT SMR-VERY LOW PLT COUNT-27*# LPLT-2+
[**2171-12-4**] 10:40AM GRAN CT-1150*
[**2171-12-4**] 10:40AM GLUCOSE-115* UREA N-41* CREAT-1.2 SODIUM-141
POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-23 ANION GAP-13
[**2171-12-4**] 10:40AM ALT(SGPT)-231* AST(SGOT)-177* LD(LDH)-398*
ALK PHOS-916* TOT BILI-1.3 DIR BILI-0.8* INDIR BIL-0.5
[**2171-12-4**] 10:40AM ALBUMIN-3.3* CALCIUM-8.8 PHOSPHATE-2.1*
MAGNESIUM-2.2 URIC ACID-6.0
.
STUDIES:
* EKG [**12-5**]: Sinus tachycardia. Compared to the previous tracing
tachycardia has appeared. Voltage has increased in the
precordial leads. T wave inversions persist.
* Echo [**12-9**]: LV systolic function appears depressed. There is
a very small pericardial effusion. There are no
echocardiographic signs of tamponade.
* Echo [**12-6**]: There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is a
trivial/physiologic pericardial effusion.
* Echo [**12-5**]: Very limited views. There is only trivial
pericardial effusion.
* Echo [**12-4**]: Overall left ventricular systolic function is
moderately depressed (LVEF= 30-40 %). The right ventricular
cavity is unusually small but is not frankly collapsing in
diastole. The estimated pulmonary artery systolic pressure is
normal. There is a large pericardial effusion. The effusion
appears circumferential. There is sustained right atrial
collapse, consistent with low filling pressures or early
tamponade.
* CXR [**12-4**]: Marked short interval enlargement of the cardiac
silhouette could represent pericardial effusion or myocarditis.
There is a small pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade.
Brief Hospital Course:
Mr. [**Known lastname 63305**] is a 54-yo M h/o AML, 11 months s/p allo SCT, h/o
disseminated TB, who presented with pericardial effusion, which
was drained.
.
# Pericardial effusion: In clinic he was found to have new
cardiomegaly on CXR, and an echocardiogram revealed a large
pericardial effusion. Mr. [**Known lastname 63305**] [**Last Name (Titles) 1834**] a pericardiocentesis
in the cath lab, which removed 1300 ml of serosanguinous fluid,
creating a fall in RA pressure from 25 to 13 mm Hg. The patient
recovered well in the CCU, with no dyspnea. Subsequent
echocardiograms revealed no reaccumulation of the pericardial
fluid. The patient continued to recover well after his transfer
to the BMT service. He experienced no dyspnea, no chest pain by
discharge. The pericardial fluid studies were unrevealing. The
possible etiologies included post-viral pericardial effusion,
GVHD, or TB reactivation. He was sent home with an appointment
for a repeat chest CT on [**2171-12-20**].
.
# AML: On [**2171-11-29**], prior to this admission, the patient
[**Date Range 1834**] a bone marrow for persistent pancytopenia. The marrow
showed no sign of active leukemia. He was continued on
prophylatic regimen of acyclovir, atovaquone, and posaconazole.
He was discharged with instructions to follow up with Dr. [**First Name (STitle) **]
on [**2171-12-20**].
.
# History of TB: Mr. [**Known lastname 63306**] recent disseminated TB infection
prompted TB precautions and isolation. Induced sputum was AFB
negative. He refused bronchoscopy. The patient had no coughs by
discharge. He was to follow up in the [**Hospital **] clinic on [**2171-12-20**].
.
# Urinary tract infection: The patient was found to have
Morganella and enterococcus in his urine. Given his complicated
history of hemorrhagic cystitis, he was started and sent home
with cefpodoxime and daptomycin to finish a 14-day course.
.
# GVHD: chronic extensive GVHD as evidenced by his increased
liver enzymes, skin and mouth changes. He was continued on
prednisone, and mycophenolate 250 mg [**Hospital1 **] was restarted.
.
# pancytopenia: The patient required platelet transfusions. His
WBC was 2.2 on admission. By discharge, however, his WBC was 5.5
with Hct 32 and platelets 63.
.
# Left eye discomfort: not injected, not painful. Ophthalmology
was consulted and recommended aggressive eye hydration and
Lumigan drops. He was sent home with instructions to follow up
in the ophthalmology clinic.
.
# DMII: The patient was continued on an insulin regimen.
.
# HTN: He was continued on metoprolol.
.
#. Access: His double-lumen [**Hospital1 **] catheter was exchanged, by
Interventional Radiology, for a triple-lumen tunneled [**Hospital1 **]
catheter.
Medications on Admission:
ACYCLOVIR 400 mg--1 tablet(s) by mouth twice a day
ATOVAQUONE 750 mg/5 mL--10 ml suspension(s) by mouth once a day
BACITRACIN ZINC 500 unit/gram--Apply topically four times a day
as needed for penile pain
BD Insulin Syringe 25 gauge X [**6-18**]"--as directed
CELLCEPT [**Pager number **] mg--1 capsule(s) by mouth three times a day
DEXAMETHASONE 0.5 mg/5 mL--5 ml by mouth twice a day swish and
spit. do not swallow.
DOCUSATE SODIUM 100 mg--1 capsule(s) by mouth twice a day
Ergocalciferol (Vitamin D2) 50,000 unit--1 capsule(s) by mouth q
friday
FOLIC ACID 1 mg--2 (two) tablet(s) by mouth once a day
HUMALOG 100 unit/mL--per sliding scale
Hydromorphone 2 mg--[**2-12**] tablet(s) by mouth every four (4) hours
as needed for pain
Insulin Glargine 100 unit/mL--16 units sq daily
METOPROLOL SUCCINATE 100 mg--1 tablet(s) by mouth daily
NYSTATIN 100,000 unit/mL--5 ml by mouth four times a day swish
and spit
OMEPRAZOLE 20 mg--1 capsule(s) by mouth once a day
OXYCONTIN 10 mg--3 (three) tablet(s) by mouth twice a day
One Touch Test --as directed qac and qhs
PREDNISOLONE ACETATE 1 %--1 drop ophthalmic twice a day
PREDNISONE 20 mg--1 tablet(s) by mouth once a day
PYRIDIUM 200 mg--0.5 (one half) tablet(s) by mouth once a day
Posaconazole 200 mg/5 mL--1 suspension(s) by mouth three times a
day
Pyridoxine 50 mg--2 tablet(s) by mouth once a day
Saliva Substitution Combo No.2 --30 ml to mucous membrane q2
hours as needed for dryness
TACROLIMUS 0.1 %--Apply to skin affected with gvhd. three times
a day
VITAMIN E 400 unit--1 capsule(s) by mouth daily
Insulin Glargine 100 unit/mL--14 units sq daily
PYRIDIUM 200 mg--1 (one) tablet(s) by mouth once a day
Discharge Medications:
1. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three (3)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*180 Tablet Sustained Release 12 hr(s)* Refills:*2*
2. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
Disp:*120 Capsule(s)* Refills:*2*
3. Dexamethasone 0.5 mg/5 mL Solution Sig: 0.5 ML PO BID (2
times a day).
Disp:*30 ML(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Folic Acid 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
Disp:*1000 ML(s)* Refills:*2*
7. 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*
8. Atovaquone 750 mg/5 mL Suspension Sig: Ten (10) ml PO DAILY
(Daily).
Disp:*300 ml* Refills:*2*
9. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
Disp:*1 bottle* Refills:*2*
10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Pyridoxine 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
12. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
13. Artificial Saliva 0.15-0.15 % Solution Sig: Thirty (30) ML
Mucous membrane Q2H (every 2 hours) as needed.
Disp:*3 L* Refills:*2*
14. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl
Topical QID (4 times a day) as needed.
Disp:*30 grams* Refills:*2*
15. Posaconazole 200 mg/5 mL Suspension Sig: Two Hundred (200)
mg PO TID (3 times a day).
Disp:*[**Numeric Identifier 7206**] mg* Refills:*2*
16. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-12**]
Drops Ophthalmic q4hours and prn.
Disp:*1 bottle* Refills:*2*
17. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic QHS (once a day (at bedtime)).
Disp:*1 bottle* Refills:*2*
18. Lumigan 0.03 % Drops Sig: One (1) drop Ophthalmic at
bedtime: both eyes.
Disp:*1 bottle* Refills:*2*
19. Daptomycin 500 mg Recon Soln Sig: Three Hundred (300) mg
Intravenous Q24H (every 24 hours) for 8 days.
Disp:*3000 mg* Refills:*0*
20. Insulin Regular Human 100 unit/mL Solution Sig: resume your
home insulin regimen Injection four times a day.
21. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
22. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
23. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO
Q6H (every 6 hours) as needed.
Disp:*1000 ML(s)* Refills:*0*
24. Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
25. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO QFRI (every Friday).
Disp:*30 Capsule(s)* Refills:*2*
26. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 8 days.
Disp:*40 Tablet(s)* Refills:*0*
27. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
28. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
29. [**Month/Day (2) **] catheter Sig: One (1) as needed: Please perform
[**Month/Day (2) **] catheter care per protocol. When not in use, [**Month/Day (2) **]
catheter is to be flused with 1000 unit/cc heparin equal to the
volume of the catheter. Caps on the [**Month/Day (2) **] catheter are
changed every 7 days.
Disp:*1 1* Refills:*2*
30. Heparin Flush 100 unit/mL Kit Sig: as needed 1000 units/cc
Intravenous per protocol: 1000 units/cc heparin flush.
Disp:*qs * Refills:*2*
31. Saline Flush 0.9 % Syringe Sig: as needed Injection as
needed.
Disp:*qs * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Critical Care Systems
Discharge Diagnosis:
Primary diagnoses: Pericardial tamponade, urinary tract
infections
Secondary diagnoses: acute myelogenous leukemia, tuberculosis
infection, diabetes mellitus type 2, hypertension
Discharge Condition:
Stable. No respiratory difficulty. No chest pain. No pulsus.
Lower extremity edema 2+ bilaterally.
Discharge Instructions:
You presented to [**Hospital1 18**] with shortness of breath on [**2171-12-4**]. You
were found to have fluid in the sac surrounding your heart, a
condition called pericardial effusion. The fluid was removed. It
was unclear what caused the fluid accumulation. You were given
medications to help remove extra fluid in body to help you
breath better and reduce your leg swelling. You were also found
to have a urinary tract infection. Please take your antibiotics
as [**Date Range 8757**].
Please follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 8757**] below. Please
take all medications as [**Last Name (Titles) 8757**].
If you develop shortness of breath, chest pain, any difficulty
breathing, worsening leg swelling, fevers, chills, or any other
symptom that concerns you, please call your doctor or go to the
nearest Emergency Room.
Followup Instructions:
* Radiology for chest CT: 9 am [**2171-12-20**], [**Hospital Ward Name 23**] Building,
[**Location (un) **], [**Hospital1 69**]
* Oncologist: Dr. [**First Name (STitle) **], [**2171-12-20**], at 2:30 p.m.
* Infectious Disease: Dr. [**Last Name (STitle) 63307**], [**2171-12-20**], at 11:30 a.m.
* Ophthomologist: please call [**Telephone/Fax (1) 253**] to make an
appointment within 2 weeks for follow-up care of your eyes
* Primary care: please call Dr.[**Name (NI) 63308**] office at [**Telephone/Fax (1) 63309**]
to make an appointment within 2 weeks
ICD9 Codes: 4280, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1412
} | Medical Text: Admission Date: [**2153-4-23**] Discharge Date: [**2153-4-28**]
Date of Birth: [**2102-7-22**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Codeine
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
Viral Syndrome NOS
Major Surgical or Invasive Procedure:
Lumbar Puncture
History of Present Illness:
50-year-old gentleman with HIV since [**2145**] (last cd4 463, vl <50
[**2153-4-16**]), who recently stopped his ARVs about 1 week ago.
Presented [**4-23**] to [**Hospital **] clinic with complaints of 3 days of fevers
to 103-104, chills, sore throat, myalgias, and HA, intermittent
RLQ pain, photophobia, and neck stiffness.
.
He says he began to feel ill which started with fevers and
chills
3 days prior to presentation (early saturday morning). He also
reports HA that was diffuse and that responded to tylenol,
although he says the fevers did not. He also reports mylagias,
sore throat, nausea, no emesis or diarrhea. HAs not been eating
much over the weekend, but has tried to drink fluids. No sick
contacts. [**Name (NI) **] travel. Per [**Hospital **] clinic notes, says that this feels
"just like I did when I converted."
.
He does report unprotected receptive and insertive anal sex over
the past few weeks with a partner of unknown status. One episode
3 days ago of dysuria.
.
Initial VS in the ED: 102.2, HR 72, BP 106/67, RR16, 02 sat 97.
Given Decadron, CTX, Vanco, Acyclovir and Motrin.
Past Medical History:
1. HIV (per clinic notes)
Diagnosed with HIV in [**2146-2-2**], risk factor being MSM. On
diagnosis, his initial CD4 count was 300 and his viral load was
>100,000. By record, his known CD4 nadir was 60 from his initial
years in care in [**Location (un) 9012**]. He started HAART in [**2145**] with Epivir,
Sustiva, and d4T. He was on that regimen for about 60 days and
had ?lactic acidosis so his Epivir was switched Videx at that
time. He discontinued all medications in [**2147**] and moved to
[**Location (un) 86**]. He had been off medications until [**2148**] when he started
the regimen of Truvada and Kaletra which he has been on since
that time. (Of note, his viral load was 3,160,000 on [**12-6**], when
he started haart.) Good response to that regimen with viral load
becoming undetectable by [**6-5**].
2. Rheumatic fever as a child.
3. h/o non-cardiac chest pain (negative cath in [**2147**])
4. major depressive disorder (hospitalized at [**Hospital 8**] Hospital
in [**2147**])
5. chronic renal insufficiency (baseline 1.4-1.6)
6. chronic elevation in CPK.
7. h/o genital herpes
Social History:
Works as a social worker, [**Name (NI) **] tobacco, EtOH, or IV drug use. Rare
marijuana.
Family History:
NC
Physical Exam:
PE 101.6 108/68 60 93RA
Gen: laying in bed, non-toxic, but uncomfortable appearing
HEENT: MMM
Neck: supple but pain with neck movement JVD flat, no carotid
bruits
Chest: CTAB, no wheezes, rales or rhonci
CVS: rrr, no m/r/g
Abd: soft, NABS, ND, no rebound. Mild vol gaurding and mild RLQ
tenderness to palpation
Extrem: no c/c/e
Neuro: CN II-XII intact, no kernigs or brudzinskis
MSK: no joint effusions, normal ROM
Pertinent Results:
Ehrlichia/Babesia Ab: P
[**2153-4-23**] 09:25AM [**Month/Day/Year 3143**] HCV Ab-NEGATIVE
[**2153-4-23**] 09:25AM [**Month/Day/Year 3143**] HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE
[**2153-4-23**] 09:25AM [**Month/Day/Year 3143**] ALT-81* AST-57* AlkPhos-118* TotBili-0.3
[**2153-4-26**] 06:15AM [**Month/Day/Year 3143**] ALT-74* AST-76* AlkPhos-76 TotBili-0.3
[**2153-4-26**] 06:15AM [**Month/Day/Year 3143**] Glucose-95 UreaN-10 Creat-1.6* Na-136
K-4.1 Cl-103 HCO3-27 AnGap-10
[**2153-4-23**] 09:25AM [**Month/Day/Year 3143**] WBC-6.8 Lymph-25 Abs [**Last Name (un) **]-1700 CD3%-60
Abs CD3-1027 CD4%-19 Abs CD4-330* CD8%-38 Abs CD8-642
CD4/CD8-0.5*
[**2153-4-24**] 07:25AM [**Month/Day/Year 3143**] Parst S-NEGATIVE
[**2153-4-23**] 09:25AM [**Month/Day/Year 3143**] WBC-6.8 RBC-4.62 Hgb-15.0 Hct-44.5 MCV-96
MCH-32.5* MCHC-33.7 RDW-12.5 Plt Ct-309
[**2153-4-26**] 06:15AM [**Month/Day/Year 3143**] WBC-2.6* RBC-3.96* Hgb-13.2* Hct-37.6*
MCV-95 MCH-33.3* MCHC-35.0 RDW-11.8 Plt Ct-183
[**2153-4-23**] 11:30AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-0 Polys-0
Lymphs-75 Monos-25
[**2153-4-23**] 11:30AM CEREBROSPINAL FLUID (CSF) TotProt-25 Glucose-66
.
Micro
Crypto Ag negative ([**Month/Day/Year **]/CSF)
RPR: positive
HIV VL: Greater than 100,000 copies/ml
Urine GC/CT: negative
HBV VL pending
.
CT abd/pelvis: Unremarkable CT of the abdomen and pelvis.
.
CT head w and w/o: No acute intracranial hemorrhage or enhancing
mass. Please note most often CT is normal in meningitis.
.
pCXR: No acute cardiopulmonary process.
.
Brief Hospital Course:
#+RPR: Felt to be primary Syphillis given lack of rash and
recent gential lesions; LP bland making tertiary syphillis
unlikely. Intially started on Doxycycline given PCN allergy;
however, ID eventually recommended PCN desensitization.
Transferred to the ICU, where he underwent desensitization.
After the desensitization he was treated an infection of 2.4 mU
IM PCN. This will be followed immediately by PCN VK 250 mg po
qid X2 weeks with weakly PCN shots for 3 shots total.
#Febrile Syndrome NOS: No evidence of meningitis or other
intraabdominal process. CSF, Urine and [**Month/Day/Year **] cutlures pending.
Likely rebound syndrome from withdrawl of HAART (Retroviral
Rebound Sydrome) vs spirochetemia vs infection with new HIV
strain as HIV VL was >100,000. However, given pulse/temp
disconnect, Ehrlichia and Babesia were sent and was (penidng at
time of d/c).
.
#Unprotected sexual encounter: RPR and HIV results as above; Hep
C Ab negative. Hepatits B panel with evidence of prior
infection; Hep B VL pending.
.
#Elevated LFTs: Hep B/C as above; ?secondary to HIV viremia of
syphillis. LFTs stable during Hospital course.
.
#HIV: per ID, holding HAART initally held until Cr improves
.
#ARF: Cr above baseline, likely secondary to dehydration. Was
given aggressive IVF and recheck in am
.
#Post LP headache: Pt developed worsening positional HA after
LP. Given Caffeine, hydration, and Morphine tried with limited
success. Seen by Chronic pain service who recommended PCA for
pain control. Felt that a [**Month/Day/Year **] patch was too risky of leading
to epidural abscess. Headache subsequently improved.
.
#Leukopenia: during the hospitalization developed mild
leukopenia (6.8-->2.6), felt to be likely secondary to HIV
Viremia.
Medications on Admission:
Kaletra, Truvada (recently discontinued)
Wellbutrin SR 150 [**Hospital1 **]
Androgel
Ativan
Trazodone 50 qhs prn
Discharge Medications:
1. Penicillin V Potassium 250 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) for 2 weeks.
Disp:*56 Tablet(s)* Refills:*0*
2. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
4. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours): Take until 3 days after rash resolves. .
Disp:*30 Capsule(s)* Refills:*2*
5. Truvada 200-300 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Kaletra 200-50 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*2*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain for 3 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
syphilis
HIV
post-LP headache
Discharge Condition:
stable
Discharge Instructions:
During this hospiltalization you were diagnosed with syphillis
as well as possible rebound syndrome from stopping your HIV
meds. You were desensitized to penicillin and treated with
acyclovir for possible herpes infection. Please restart your
Truvada and Kaletra.
It is extremely important that you take your penicillin every
six hours - if you miss a dose you could be at risk for having
an allergic reaction again. It is also imperative that you
attend your Nurse appointments and your appointment with Dr.
[**Last Name (STitle) **].
Please resume your HIV medications.
Followup Instructions:
1. Provider: [**Name10 (NameIs) 12082**],PECK PSYCHIATRY HMFP Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2153-5-3**] 2:00pm
2. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 250**] Call to schedule
appointment.
3. Please follow up with ID nurse [**5-3**] at 9am and on [**5-10**] at 9am for your penacillin shot in the basement of the [**Hospital Unit Name 3269**].
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43851**], RN Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2153-5-3**] 9:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43851**], RN Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2153-5-10**] 9:00
4. Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**First Name (STitle) 3143**] Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2153-5-14**] 10:00am
ICD9 Codes: 5849, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1413
} | Medical Text: Admission Date: [**2181-2-26**] Discharge Date: [**2181-2-28**]
Date of Birth: [**2160-5-10**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Hyperglycemia/DKA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
20 yoF with h/o DMI, hypothyroidism who presents to ED with
tachypnea following 2 days of elevated blood sugars at home.
She reports that she noted blood sugar consistently greater than
her monitor was able to read (>600) at home over the past 2
days. She did not present to the ED because she felt as though
she would be able to control her glucose at home, but reports
persistently high readings. She denies any recent illness, no
sick contacts, no N/V/diarrhea, no dysuria/hematuria. She
reports she did develop dry cough, but this is after she
developed tachypnea in the setting of her elevated BS. She also
reports emesis x1 today, but reports her hyperglycemia preceded
this episodes x2 days. She says that she has not been eating or
drinking well over the past 36 hours because she overall felt
unwell, but is unable to elaborate further on specific
localizing symptoms. She reports having taken her lantus dose
as usual as well as using her humalog sliding scale. She came
to the ED when she developed tachypnea as this is a symptom that
she frequently experiences in the setting of DKA.
.
She was diagnosed approximately 10 years ago with diabetes and
reports 5 episodes of DKA since then. She is followed at [**Last Name (un) **]
diabetes center. She reports her episodes of DKA are always in
the setting of illness, usually a GI syndrome.
.
In the ED initial VS revealed T 97.2, HR 113, BP 144/90, RR 28
with 100% O2 sat on RA. Her BS was found to be 371, with sodium
135, bicarb of 5 and anion gap of 29. VBG revealed pH of 7.16.
UA revealed glucose, ketones, and trace protein. She received
7U regular insulin as well as a total of 4L NS and 1 amp bicarb,
and following set of labs demonstrated BS 197 from 371, bicarb
of 13 from 5 and anion gap of 17 from 29. Her RR improved as
well and she reports decreasing dyspnea.
Past Medical History:
1. Diabetes mellitus
2. Hypothyroidism
Social History:
Student at [**Hospital1 **]. She is a nonsmoker and reports social EtOH
occassionally on the weekends. She has 2 roommates.
Family History:
Diabetes
Physical Exam:
98.4 110/76 96 12 100% RA
Gen: NAD, cooperative, states she is hungry/thirsty
HEENT: PERRL, MMM
Neck: supple, no LAD
CV: RRR, no murmurs
Resp: mild crackles b/l lung bases
Abd: +BS, soft, NT, ND
Ext: No c/c/e, 2+ DP and PT pulses
Neuro: AAOx3, strength, sensation, CN 2-12 grossly intact
Pertinent Results:
[**2181-2-26**] 07:30PM BLOOD WBC-6.5 RBC-4.66 Hgb-15.5 Hct-45.8 MCV-98
MCH-33.2* MCHC-33.8 RDW-13.5 Plt Ct-439
[**2181-2-27**] 05:07AM BLOOD WBC-6.2 RBC-3.74* Hgb-12.0# Hct-34.4*#
MCV-92 MCH-32.1* MCHC-34.9 RDW-13.5 Plt Ct-362
[**2181-2-28**] 03:51AM BLOOD WBC-6.2 RBC-3.96* Hgb-12.8 Hct-36.4
MCV-92 MCH-32.4* MCHC-35.2* RDW-13.6 Plt Ct-321
[**2181-2-26**] 07:30PM BLOOD Neuts-72.3* Lymphs-20.7 Monos-5.2 Eos-0.5
Baso-1.3
[**2181-2-26**] 07:30PM BLOOD Glucose-371* UreaN-12 Creat-0.9 Na-135
K-3.8 Cl-101 HCO3-5* AnGap-33*
[**2181-2-26**] 09:25PM BLOOD Glucose-197* UreaN-9 Creat-0.7 Na-139
K-3.7 Cl-109* HCO3-13* AnGap-21*
[**2181-2-27**] 01:02AM BLOOD Glucose-223* UreaN-8 Creat-0.6 Na-141
K-3.5 Cl-111* HCO3-9* AnGap-25*
[**2181-2-27**] 05:07AM BLOOD Glucose-236* UreaN-6 Creat-0.6 Na-140
K-3.4 Cl-113* HCO3-14* AnGap-16
[**2181-2-27**] 03:21PM BLOOD Glucose-216* UreaN-6 Creat-0.6 Na-140
K-3.9 Cl-113* HCO3-19* AnGap-12
[**2181-2-27**] 09:19PM BLOOD Glucose-186* UreaN-8 Creat-0.7 Na-143
K-3.5 Cl-108 HCO3-23 AnGap-16
[**2181-2-28**] 03:51AM BLOOD Glucose-173* UreaN-9 Creat-0.5 Na-144
K-3.8 Cl-113* HCO3-19* AnGap-16
[**2181-2-28**] 11:15AM BLOOD Glucose-171* UreaN-7 Creat-0.5 Na-140
K-4.0 Cl-110* HCO3-20* AnGap-14
[**2181-2-26**] 07:30PM BLOOD ALT-23 AST-19 AlkPhos-166* Amylase-145*
TotBili-0.2
[**2181-2-26**] 07:30PM BLOOD Lipase-27
[**2181-2-27**] 01:02AM BLOOD Calcium-7.2* Phos-2.0* Mg-1.6
[**2181-2-27**] 05:07AM BLOOD Albumin-2.9* Calcium-7.7* Phos-1.8*
Mg-1.5* Iron-83
[**2181-2-27**] 03:21PM BLOOD Calcium-8.6 Phos-2.6* Mg-1.7
[**2181-2-27**] 09:19PM BLOOD Calcium-8.6 Phos-1.5* Mg-1.7
[**2181-2-28**] 03:51AM BLOOD Calcium-8.6 Phos-2.9 Mg-1.7
[**2181-2-28**] 11:15AM BLOOD Calcium-8.2* Phos-2.3* Mg-1.6
[**2181-2-27**] 05:07AM BLOOD calTIBC-246* Ferritn-121 TRF-189*
[**2181-2-27**] 05:07AM BLOOD TSH-0.18*
[**2181-2-27**] 05:07AM BLOOD Free T4-1.4
[**2181-2-27**] 03:49PM BLOOD Type-[**Last Name (un) **] Temp-36.6 pO2-56* pCO2-32*
pH-7.38 calTCO2-20* Base XS--4 Intubat-NOT INTUBA
[**2181-2-26**] 07:42PM BLOOD Glucose-353* Lactate-2.1* Na-138 K-3.7
Cl-110
[**2181-2-26**] 09:34PM BLOOD Glucose-189* Lactate-1.7 Na-140 K-3.6
Brief Hospital Course:
20 yo F with h/o DMI, hypothyroidism, and ? of adherence to
diabetes med regimen who presents with DKA.
.
# DKA: Unclear precipitator as she denies any recent illness.
She is afebrile and without an elevated WBC count. UA was
negative with the exception of ketones and glucose and CXR did
not reveal infiltrate. Urine and blood were sent for culture.
Only note in our system is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] social work note that
addresses issues of compliance, but pt. does not elaborate on
this. Thus, ? whether poor adherence to her insulin regimen
contributed to this. Poor PO and dehydration is certainly a
contributor as well as she reportedly has not been eating or
drinking well over the past 36 hours. She responded well to 7U
insulin alone (BS 371-->197 and anion gap 29 to 17, w/ bicarb
increasing from 5 to 13), but concern for rebound hyperglycemia
if just maintained on SS exists. She was therefore, managed
with insulin drip. Her electrolytes were monitored Q4H and she
was transitioned to D51/2NS once her potassium dropped <4. She
was able to transition to sliding scale insulin following
closure of her anion gap and her gap remained close on
subcutaneous insulin alone. However, she continued to have
extremely high BGs despite receiving 60 units of hs lantus.
[**Last Name (un) **] was consulted and recommended continuing this dose of
lantus as well as aggressive sliding scale. However, they did
note that given compliance issues with sliding scale, she may be
better served with [**Hospital1 **] NPH. Patient was ready to be called out
of MICU but then requested to leave AMA. The risks of her
leaving prior to stabilization of her BGs and creation of a good
insulin regimen were reviewed with her as documented in her
discharge paperwork. In addition, [**Last Name (un) **] was contact[**Name (NI) **] and also
met with the patient. However, she could not be convinced to
stay. She was therefore discharged against medical advice on
her usual insulin regimen. It was requested that she follow up
[**First Name9 (NamePattern2) 16647**] [**Last Name (un) **] and her PCP in the next week.
.
# Hypothyroidism: TSH was low but free T4 was normal. She was
continued on her regular dose of Synthroid.
.
# FEN: Regular, diabetic diet
.
# Proph: Pneumoboots while in bed
.
# Code: FULL
Medications on Admission:
1. Lantus 60U qhs
2. Humalog SS
3. Levothyroxine ("very low dose" per pt. although note from
[**2180-6-5**] states dose of 125mcg)
Discharge Medications:
1. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lantus 100 unit/mL Solution Sig: Sixty (60) units
Subcutaneous at bedtime.
3. Humalog 100 unit/mL Solution Sig: One (1) injection
Subcutaneous as directed: per your preset sliding scale from
[**Last Name (un) **] .
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Ketoacidosis
Discharge Condition:
poorly controlled blood sugars. Closed anion gap. Ambulatory.
Tolerating diet.
Discharge Instructions:
Please note that you have elected to leave the hospital against
medical advice. You were advised to stay because your diabetes
is uncontrolled and because of this you are at risk for long
term health complications including loss of vision, neuropathy,
amputation, heart attack, stroke, but also short term
complications including infection, dehydration, acidosis,
hypotension, and in extreme cases, death.
Followup Instructions:
Please call your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 4643**] to schedule a follow up
appointment in the next week. Phone: [**Telephone/Fax (1) 67966**]
Please call your Diabetes doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] the set up a follow
up appointment in the next week.
ICD9 Codes: 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1414
} | Medical Text: Admission Date: [**2107-1-4**] Discharge Date: [**2107-1-11**]
Date of Birth: [**2042-5-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
angina with STEMI [**11-24**]
Major Surgical or Invasive Procedure:
CABG x3/LAD endarterectomy [**2107-1-6**] (LIMA to prox. LAD, SVG to
distal LAD, SVG to PDA)
History of Present Illness:
64 yo male who developed chest pain in [**11-24**] and r/i for STEMI
at OSH. Transferred to [**Hospital1 18**] at that time and underwent cardiac
cath. This showed severe LAD and RCA disease. Angioplasty of LAD
was unsuccessful and the vessel dissected. He was referred for
surgery at tht time, but chose to delay this option. He
represents now for pre-admission testing prior to surgery
planned for [**1-25**].
Past Medical History:
CAD/STEMI s/p PCI([**11-24**]), HTN, hiatal hernia, tonsillectomy,
BPH, Vasectomy
Social History:
Prior 15 year h/o tobacco use, but he is currently a non-smoker.
He drinks ETOH occasionally. Lives with wife.
Family History:
No family history of premature coronary artery disease or sudden
death, but his father and mother both had MIs at age>70 yrs.His
mother had diabetes.
Physical Exam:
5'6" 86 kg
HR 63 RR 14 right 138/118 left 118/94 repeat BP while
diaphoretic 79/54 100% RA sat.
pale, diaphoretic,dizzy in mild distress
HEENT unremarkable
neck supple, full ROM
CTAB
distant heart sounds
soft, non-distended,RUQ slightly tender to palpation
extrems cool, trace edema
no obvious varicosities
neuro grossly intact
2+ bil. fem/DP/PT/radials
no carotid bruits appreciated
Pertinent Results:
[**2107-1-10**] 04:39AM BLOOD WBC-9.8 RBC-2.65* Hgb-8.5* Hct-23.8*
MCV-90 MCH-32.2* MCHC-36.0* RDW-18.1* Plt Ct-158
[**2107-1-10**] 03:41PM BLOOD Hct-30.9*#
[**2107-1-10**] 04:39AM BLOOD K-4.5
[**2107-1-9**] 06:00AM BLOOD Glucose-109* UreaN-22* Creat-0.9 Na-134
K-3.9 Cl-101 HCO3-30 AnGap-7*
[**2107-1-4**] 11:10AM BLOOD %HbA1c-6.0*
RADIOLOGY Final Report
CHEST (PA & LAT) [**2107-1-9**] 8:55 AM
CHEST (PA & LAT)
Reason: eval for pleural effusions
[**Hospital 93**] MEDICAL CONDITION:
64 year old man s/p CABG x3
REASON FOR THIS EXAMINATION:
eval for pleural effusions
CHEST, TWO VIEWS ON [**1-9**]
HISTORY: Status post CABG, question pleural effusions.
REFERENCE EXAM: [**1-8**].
FINDINGS: There are bilateral pleural effusions, left greater
than right, with dense retrocardiac opacity, which may represent
effusion/volume loss/infiltrate. The right IJ line is unchanged.
DR. [**First Name (STitle) **] [**Doctor Last Name **]
Approved: SUN [**2107-1-9**] 9:51 AM
Conclusions
PRE-BYPASS:
1. The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler.
2. Left ventricular wall thicknesses and cavity size are normal.
There is mild regional left ventricular systolic dysfunction
with apical septal hypokinesis. Overall left ventricular
systolic function is low normal (LVEF 50-55%).
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. There is no aortic
valve stenosis. No aortic regurgitation is seen.
6. Physiologic mitral regurgitation is seen (within normal
limits).
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including phenylephrine and is
being AV paced.
1. Biventricular function is preserved. Apical septum is less
hypokinetic.
2. Aorta is intact post decannulation
3. Other findings are unchanged
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2107-1-6**] 11:59
?????? [**2102**]
Brief Hospital Course:
Admitted to ER directly from [**Hospital 30523**] clinic on [**1-4**] for
cardiology evaluation, given his hypotension and distress. Dr.
[**Last Name (STitle) **] consulted immediately for plan for admission and surgery
this admission rather than in [**Month (only) 75706**]BP meds were held and then
titrated as part of cardiac surgery work-up. He underwent echo
in the ER which showed a trivial (unchanged from [**11-24**])
pericardial effusion and plavix was stopped.He underwent cabg x3
and LAD endarterectomy on [**1-6**] and was tranferred to the CVICU
in stable condition on phenylephrine and propofol drips.
Extubated later that day and chest tubes were also removed on
POD #1. Plavix was restarted and he was gently disuresed toward
his preop weight.Transfered to the floor on POD #1. Transfused
2u PRBCs for Hct of 18;post-transfusion was 24. Pacing wires
removed on POD #3.Beta blockade titrated. Aditional unit
transfused on POD #4 and Hct rose to 30. Plan is for plavix for
one month for endarterectomy per Dr. [**Last Name (STitle) **].Cleared for
discharge to home with services on POD #5. Pt. is to make all
followup appts. per discharge instructions.
Medications on Admission:
ASA 325 mg daily
plavix 75 mg daily
lipitor 40 mg daily
metoprolol 50 mg [**Hospital1 **]
HCTZ 12.5 mg daily
lisinopril 10 mg daily
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours).
Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*50 Tablet(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*50 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:*50 Tablet(s)* Refills:*0*
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*50 Tablet(s)* Refills:*2*
8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*40 Tablet(s)* Refills:*2*
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
vna of [**Hospital3 635**]
Discharge Diagnosis:
Coronary artery disease s/p PCI [**11-24**], s/p cabg x3 [**2107-1-6**]
HTN
STEMI [**11-24**]
hiatal hernia
BPH
Discharge Condition:
Satisfactory
Discharge Instructions:
Sternal precautions
Cardiac healthy diet
call for fever greater than 100.5, redness or drainage
Shower daily and pat incisions dry.
No lotions, creams or powders on any incision.
No driving for one month.
No lifting greater than 10 pounds for 10 weeks
Followup Instructions:
F/U with Dr. [**Last Name (STitle) 41415**] in [**1-19**] weeks
F/U with cardiologist in 2 weeks
F/U with Dr. [**Last Name (STitle) **] in [**3-21**] weeks
Completed by:[**2107-4-19**]
ICD9 Codes: 4589, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1415
} | Medical Text: Admission Date: [**2128-12-6**] Discharge Date: [**2128-12-9**]
Date of Birth: [**2060-5-28**] Sex: M
Service: SURGERY
Allergies:
Ivp Dye, Iodine Containing
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
AAA
Major Surgical or Invasive Procedure:
PROCEDURE:
1. Endovascular repair of aorta iliac aneurysms.
2. Zenith modular bifurcated stent graft.
3. Embolization of right hypogastric artery with a 16 mm
Amplatzer.
4. Extension of stent graft into right external iliac
artery.
5. Left iliac extender.
6. Bilateral catheter in aorta.
7. Complicated repair of right common femoral artery.
History of Present Illness:
[**Known firstname **] [**Known lastname **] presents for followup of his aortic/iliac aneurysm.
I saw him extensively in the hospital. He has a very recent and
extensive cardiac history and has aneurysms of the aortoiliac
artery and both popliteal arteries
Past Medical History:
Relevant PAST MEDICAL HISTORY:
-COPD uses 2L 0xygen @ night
-Prostate cancer with radiation and hormone treatment 3 yrs ago,
-Obstructive sleep apnea wih occasional CPAP; however does not
use CPAP
-Cor pulmonale
-Obesity
-? elevated cholesterol (never checked)
Social History:
Social history is significant for the tobacco use: quit [**3-14**]
weeks ago, but had previously smoked 2 PPD for >30 years. There
is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death. His father died of CHF at age 85 (also had
prostate cancer). No other members had heart disease of any
kind.
Physical Exam:
a/o x 3
nad
grossly intact
supple
farom
neg lymphandopathy
cta
rr
abd benign
groin inc / surgical / C/D/I
Pulses: Fem [**Doctor Last Name **] DP PT
Rt 2+ 2+ 2+ 2+
Lt 2+ 2+ 2+ mono
Pertinent Results:
[**2128-12-8**] 06:15AM BLOOD
WBC-10.2# RBC-3.11* Hgb-9.4* Hct-28.8* MCV-93 MCH-30.2 MCHC-32.6
RDW-14.6 Plt Ct-173
[**2128-12-8**] 06:15AM BLOOD
Plt Ct-173
[**2128-12-8**] 06:15AM BLOOD
Glucose-116* UreaN-15 Creat-1.0 Na-139 K-4.3 Cl-103 HCO3-32
AnGap-8
[**2128-12-8**] 06:15AM BLOOD
Calcium-9.0 Phos-2.9 Mg-2.1
[**2128-12-7**] 8:07 AM
CHEST (PORTABLE AP)
Reason: r/o inf, eff
Comparison is made with prior study performed 12 hours earlier.
Cardiac size is top normal. The lungs are clear aside from left
basilar atelectasis. There is no pneumothorax or pleural
effusion.
[**2128-12-6**] 8:03:00 PM
EKG
Sinus rhythm. Baseline artifact makes interpretation difficult.
Non-specific T wave changes in leads I and aVL. Low QRS voltage
in the limb leads.
Compared to tracing of [**2128-12-1**] bradycardia is absent.
Rate PR QRS QT/QTc P QRS T
67 144 92 420/432 75 33 85
Brief Hospital Course:
Mr. [**Known lastname **],[**Known firstname **] W [**Numeric Identifier 100576**] was admitted on [**2128-12-6**] with iliac
Anuerysm. He agreed to have an elective surgery.
Pre-operatively, he was consented. A CXR, EKG, UA, CBC,
Electrolytes, T/S - were obtained, all other preperations were
made.
PROCEDURE:
1. Endovascular repair of aorta iliac aneurysms.
2. Zenith modular bifurcated stent graft.
3. Embolization of right hypogastric artery with a 16 mm
Amplatzer.
4. Extension of stent graft into right external iliac
artery.
5. Left iliac extender.
6. Bilateral catheter in aorta.
7. Complicated repair of right common femoral artery.
.
He was prepped, and brought down to the operating room for
surgery. Intra-operatively, he was closely monitored and
remained hemodynamically stable. He tolerated the procedure well
without any difficulty.
Because of the complication of the case. Pt was transfered to
the [**Date Range 42137**] for further care. In the [**Date Range 42137**] opt extubated. Pt also
r/o for MI. Upon being stabalized from the [**Name (NI) 42137**], pt transferd
to the VICU for further care.
While in the VICU he recieved monitered care. When stable he was
delined. His diet was advanced. A PT consult was obtained. When
he was stabalized from the acute setting of post operative care,
he was transfered to floor status
On the floor, he remained hemodynamically stable with his pain
controlled. He progressed with physical therapy to improve her
strength and mobility. He continues to make steady progress
without any incidents. He was discharged home in stable
condition
To note pt die recieve 1 unit of PRBC for post operative anemia
secondary to acute blood loss during the OR procedure.
Medications on Admission:
[**Last Name (un) 1724**]: ASA 325', Colchicine 0.6', Flovent MDI, Lisinopril 2.5',
Metformin 500'', Neurontin 100 prn, Spiriva inhaler, Plavix 75',
Simvastatin 80', Toprol XL 25'
Discharge Medications:
1. Other
ASA 325', Colchicine 0.6', Flovent MDI, Lisinopril 2.5',
Metformin 500'', Neurontin 100 prn, Spiriva inhaler, Plavix 75',
Simvastatin 80', Toprol XL 25'
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Neurontin 100 mg Capsule Sig: One (1) Capsule PO once a day.
8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Aortoiliac aneurysms
Anemia secondary to blood loss / requiring blood transfusion
DM, HTN, CAD, Chol, CHF (EF 45%), COPD (home O2 2L)obesity
Discharge Condition:
Good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Division of Vascular and Endovascular Surgery
Endovascular Abdominal Aortic Aneurysm (AAA) Discharge
Instructions
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? Do not stop Aspirin unless your Vascular Surgeon instructs you
to do so.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**2-14**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and 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
?????? Call and schedule an appointment to be seen in [**4-16**] weeks for
post procedure check and CTA
What to report to office:
??????1 Numbness, coldness or pain in lower extremities
??????2 Temperature greater than 101.5F for 24 hours
??????3 New or increased drainage from incision or white, yellow or
green drainage from incisions
??????4 Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
??????1 Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office. If bleeding does not stop, call 911 for
transfer to closest Emergency Room.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2128-12-28**] 10:30
Completed by:[**2128-12-9**]
ICD9 Codes: 2851, 4280, 3572, 2720, 4019, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1416
} | Medical Text: Admission Date: [**2132-1-7**] Discharge Date: [**2132-1-16**]
Date of Birth: [**2055-4-25**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2132-1-7**] - Aortic Valve Replacement (21mm [**Last Name (un) 3843**] [**Doctor Last Name **]
Perimount Pericardial)
History of Present Illness:
Mrs. [**Known lastname 6330**] is a 76-year-old lady with worsening symptoms related
to critical aortic stenosis. She underwent evaluation that
showed a valve area of about 0.7
square centimeters. A cardiac catheterization showed critical
aortic stenosis with mild right coronary artery disease. She is
presenting for aortic valve replacement.
Past Medical History:
Hypertension
h/o Cerebrovascular Accident
s/p Vein Stripping
s/p Bladder suspension
s/p Cholecystectomy
Social History:
Retired. Lives with son and daughter.
Family History:
Father died with MI in his 80's. Brother died with MI in 70's.
Physical Exam:
GEN: WDWN in NAD
SKIN: Unremarkable
HEENT: Unremarkable, NC/AT, EOMI, PERRL
LUNGS: Clear -w/r/r
HEART: RRR, III/VI systolic ejection murmur
ABD: Benign, Soft, NT/ND +BS
EXT: warm, 2+ edema
NEURO: A+Ox3, nonfocal
Pertinent Results:
CXR [**1-12**]: Worsening bibasilar atelectasis. Left-sided pleural
effusion, unchanged.
CXR [**1-16**]: There is continued atelectasis/consolidation at the
left base which is unchanged. On the lateral view, this is
apparent as a left basilar peripheral wedge shaped opacity,
which is more conspicuous on today's exam. Consolidation vs.
infarct are the major considerations.
RUE U/S [**1-10**]: No evidence of DVT in the right upper extremity.
[**2132-1-7**] 11:01AM BLOOD WBC-10.0 RBC-3.13*# Hgb-9.1* Hct-25.7*#
MCV-82 MCH-29.1 MCHC-35.4* RDW-14.5 Plt Ct-100*#
[**2132-1-9**] 06:08AM BLOOD WBC-12.5* RBC-2.96* Hgb-9.1* Hct-24.9*
MCV-84 MCH-30.6# MCHC-36.5* RDW-14.6 Plt Ct-41*#
[**2132-1-16**] 05:35AM BLOOD WBC-7.0 RBC-3.44* Hgb-9.4* Hct-27.5*
MCV-80* MCH-27.4 MCHC-34.3 RDW-15.3 Plt Ct-126*
[**2132-1-7**] 12:15PM BLOOD PT-15.8* PTT-42.1* INR(PT)-1.7
[**2132-1-11**] 05:40AM BLOOD PT-22.2* INR(PT)-2.2*
[**2132-1-16**] 05:35AM BLOOD PT-15.2* PTT-24.4 INR(PT)-1.4*
[**2132-1-8**] 03:03AM BLOOD Glucose-87 UreaN-14 Creat-0.8 Na-142
K-4.1 Cl-113* HCO3-22 AnGap-11
[**2132-1-16**] 05:35AM BLOOD Glucose-88 UreaN-17 Creat-0.9 Na-140
K-3.7 Cl-100 HCO3-31 AnGap-13
[**2132-1-16**] 05:35AM BLOOD Calcium-8.3* Phos-3.2
[**2132-1-11**] 09:23PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
Brief Hospital Course:
Ms. [**Known lastname 6330**] was admitted to the [**Hospital1 18**] on [**2132-1-7**] for surgical
management of her aortic valve disease. She was taken directly
to the operating room where she underwent an aortic valve
replacement utilizing a 21mm [**Last Name (un) 3843**] [**Doctor Last Name **] pericardial
valve. Postoperatively she was taken to the cardiac surgical
intensive care unit for monitoring. On postoperative day one,
Ms. [**Known lastname 6330**] [**Last Name (Titles) 5058**] neurologically intact and was extubated. Beta
blockade and aspirin were started. She was then transferred to
the cardiac surgical step down unit for further recovery. She
was gently diuresed towards her preoperative weight. The
physical therapy service was consulted for assistance with her
postoperative strength and mobility. She developed atrial
fibrillation for which amiodarone was started. Coumadin was
started for anticoagulation, but was eventually stopped. She
converted back to sinus rhythm and remained in NSR at time of
discharge. On post op day three she developed 2+ right arm
pitting edema. RUE U/S was performed and was negative for DVT.
She had low platelet count and required platelet transfusion.
Because of this her epicardial pacing wires remained in until
post op day seven when her platelet count increased. She
developed some superficial left arm phlebitis on post op day
six. Antibiotics were started and a vascular consult was made on
post op day seven. Over the next two days she required
aggressive diuresis/pulmonary toilet and eventually had
improvements with her oxygen saturation. She eventually cleared
level 5 with physical therapy and was discharged home on post op
day nine with VNA services and the appropriate follow-up
appointments.
Medications on Admission:
Diltiazem
Aspirin
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. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 7 days: After 1 week, take 200mg thereafter until stopped by
Cardiologist.
Disp:*40 Tablet(s)* Refills:*0*
6. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO TID (3 times a day) for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO every
eight (8) hours for 10 days.
Disp:*30 Packet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
10. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO three times a day
for 10 days.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
Post-op Atrial Fibrillation
Hypertension
h/o Stroke
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) Report any weight gain of greater then 2 pounds in 24 hours
or 5 pounds in 1 week.
4) No lifting greater then 10 pounds for 10 weeks.
5) No driving for 1 month.
6) [**Month (only) 116**] take shower. Do not bath. Do not apply lotions, creams,
ointments, or powders to incisions.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 1 month.
Follow-up with Dr. [**Last Name (STitle) 5017**] (cardiologist) in [**12-17**] weeks.
Follow-up with Dr. [**Last Name (STitle) 64659**] in 2 weeks.
Completed by:[**2132-1-30**]
ICD9 Codes: 4241, 9971, 2875, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1417
} | Medical Text: Admission Date: [**2101-4-30**] Discharge Date: [**2101-5-2**]
Date of Birth: [**2026-1-3**] Sex: M
Service: MEDICINE
Allergies:
Amantadine Hcl / Zocor
Attending:[**First Name3 (LF) 19836**]
Chief Complaint:
OSH transfer for sepsis
Major Surgical or Invasive Procedure:
brochoscopy
History of Present Illness:
75 y/o M with hx type 2 DM c/b ESRD and failed renal tx started
on HD 3 months ago, CAD s/p CABG, PVD, afib on coumadin who is
transferred from OSH for sepsis.
.
He had been in USOH until [**4-27**] when after HD he began to
experience fatigue, malaise, weakness and shaking chills. At OSH
ED, he received CTX 1 gm IV X1, azithromycin 500 mg IV X1, Vanc
1 gm X1, lantus 12 U X 1. No other medications were given
including home meds. Blood Cx drawn X 2 (one from HD line). CXR
c/w mild volume overload or possible pneumonia. He underwent HD
and was noted to be more lethargic. He was subsequently
transferred to ICU at OSH for declining mental status and T 104.
His HD line was removed at OSH. Per family request, he was
transferred to [**Hospital1 18**].
Currently, he reports feeling much better. He denies any
pain,N/V/diarrhea/URI/hematuria/dysuria. He does endorse mild
non productive cough. He denies any CP, palpitations, SOB, DOE.
At baseline at home he walks 1 mile/day.
Past Medical History:
# Diabetes: insulin dependent c/b ESRD, neuropathy
-- rarely has low glucose readings at home, but recently had low
readings in hospital
# Hypothyroidism
# ESRD s/p failed cadaveric renal transplant in [**2089**] now on HD
(M/W/F)
# left AV graft placement in the past
# toe ulcers s/p toe amputation
# CHF: EF 35%, presumed ischemic
# biventricular ICD pacemaker
# s/p myocardial infarction with CABG [**2090**]
# chronic atrial fibrillation on Coumadin
# hypertension
# dyslipidemia
# PVD with revascularization procedures including stents in his
SMA for intestinal ischemia last year.
# s/p appy for acute appendicitis [**2099**]
Social History:
Lives with his wife and spends [**11-20**] time in [**State 108**]
Smoking: remote 20 pack year hx, but quit 40 years ago
EtOH: social
Illicits: none
Family History:
The patient notes a brother with coronary artery disease as well
as a coronary artery bypass graft. The patient also notes a
mother with coronary artery disease. Father died at age 70 of
colon cancer.
Physical Exam:
Vitals: T: 101 BP: 130/51 P:61 R: 18 O2:99% 2LNC
General: Alert, oriented X3, lethargic
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: coarse crackles at bases R>L
CV: paced, 1/6 SEM, no rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no edema
Pertinent Results:
[**2101-4-30**] 5:06 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL FLUID.
GRAM STAIN (Final [**2101-4-30**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2101-5-2**]): NO GROWTH, <1000
CFU/ml.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final [**2101-5-2**]):
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2101-5-1**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
ACID FAST SMEAR (Final [**2101-5-2**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
Blood culture [**4-30**], [**5-1**] NGTD at discharge
Urine [**5-1**] negative
RSV culture [**4-30**] pending, CMV VL pending
[**2101-4-30**] 03:31AM BLOOD WBC-8.8# RBC-4.07* Hgb-12.6* Hct-37.6*
MCV-92 MCH-31.0 MCHC-33.6 RDW-16.7* Plt Ct-108*
[**2101-5-2**] 05:20AM BLOOD WBC-5.0 RBC-3.97* Hgb-11.8* Hct-36.7*
MCV-92 MCH-29.6 MCHC-32.1 RDW-16.4* Plt Ct-124*
[**2101-4-30**] 03:31AM BLOOD Neuts-79.8* Lymphs-13.7* Monos-5.5
Eos-0.6 Baso-0.3
[**2101-4-30**] 03:31AM BLOOD PT-18.7* PTT-31.6 INR(PT)-1.7*
[**2101-5-2**] 05:20AM BLOOD PT-16.3* PTT-30.2 INR(PT)-1.4*
[**2101-4-30**] 03:31AM BLOOD Glucose-71 UreaN-46* Creat-2.8* Na-137
K-3.6 Cl-100 HCO3-28 AnGap-13
[**2101-5-2**] 05:20AM BLOOD Glucose-130* UreaN-96* Creat-4.1* Na-134
K-3.9 Cl-96 HCO3-22 AnGap-20
[**2101-4-30**] 03:31AM BLOOD Calcium-8.0* Phos-3.3 Mg-1.7
[**2101-5-2**] 05:20AM BLOOD Calcium-8.4 Phos-4.4 Mg-2.1
[**2101-5-2**] 11:15AM BLOOD Vanco-10.1
[**2101-4-30**] 07:50PM BLOOD B-GLUCAN-PND
[**2101-4-30**] 07:50PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-PND
[**2101-5-1**] 06:45AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.020
[**2101-5-1**] 06:45AM URINE Blood-TR Nitrite-NEG Protein-500
Glucose-TR Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2101-5-1**] 06:45AM URINE RBC-0-2 WBC-0-2 Bacteri-MANY Yeast-NONE
Epi-0
[**2101-4-30**] 05:06PM OTHER BODY FLUID Polys-60* Lymphs-6* Monos-4*
Macro-30*
CXR [**5-1**]
The lungs are hyperinflated and diaphragms are flattened,
consistent with
COPD. There is borderline cardiomegaly with left ventricular
configuration.
The patient is status post sternotomy, with mediastinal clips.
The two lower sternotomy wires may be fractured, but are
unchanged compared with [**2096-10-18**]. The aorta is calcified and
slightly unfolded. ICD device with 3 leads is unchanged.
Lucencies are seen crossing several of the wires associated with
the leads, but this is also unchanged compared with [**2096-10-18**].
There is patchy opacity in the right suprahilar and perihilar
region and to a lesser extent in the right cardiophrenic region
and possible minimal
atelectasis at the left base. There is minimal blunting of right
and ? left
costophrenic angles, consistent with a small amount of pleural
fluid and/or
thickening.
IMPRESSION:
Compared with one day earlier and allowing for technical
differences, patchy perihilar opacity is probably unchanged.
OSH cultures ([**Hospital **] hospital)
HD line tip [**4-29**] coag neg staph (grew [**5-2**]), [**Last Name (un) 36**] to gent, vanc,
tetra, rifampin only
blood cultures 6/11 NGTD
Brief Hospital Course:
75 y/o M with CAD s/p CABG, CHF (EF 20%) with ICD, severe PVD,
DM c/b ESRD s/p failed transplant now on HD presents with
pneumonia.
.
# Fever: Etiology is most likely line infection vs pneumonia.
CXR consistent with pneumonia. Urine legonella and strep pneumo
negative at the OSH. Covered empirically with Vancomycin,
Ceftriaxone, and azithromycin but was broadened to vanco,
cefepime, and cipro for HCAP coverage given that he is at
dialysis centers. Beta glucan and galactomannan were sent.
Brochoscopy was performed for BAL on HD#2, and samples were
negative at time of discharge. Patient remained afebrile in the
ICU and was transferred to the floor on HD #2. His HD line tip
from the OSH grew Coag neg staph (see sensitivities on previous
page). His fevers were therefore thought most likely to be due
to a line infection (without bacteremia as blood cultures were
still negative) and pneumonia. He was switched to Vancomycin
and Levofloxacin only at time of discharge to complete a 10-day
course. Patient remained afebrile on the floor.
.
# ESRD s/p failed tx: Renal was following along. Patient was
continued on cellcept and steroids, as well as bactrim
prophylaxis. After blood cultures were negative for 48 hours, a
tunneled line was placed by IR on the right side on [**5-2**] given
plans for eventually AV fistula on the left.
.
# HTN: BP medications held while in the ICU. These were
restarted on the floor.
.
# DM: lantus 12 units QAM and humulog SS AC only
.
# afib on coumadin: Coumadin held while awaiting new HD line. It
was restarted at discharge.
.
# PVD: On fenofibrate, hx statin intolerance
.
# CAD/?ischemic cardiomyopathy: EF 35%; currently appears
euvolemic. Torsemide restarted prior to discharge.
.
# Hypothyroid - Continued LT4 75 mcg daily
.
# Bone health: on chronic immunosuppression and known
osteopenia. He has fallen a few times his past year, but no
fractures. Continued Calcium.
.
# Code: full, discussed with family and patient in ICU
Medications on Admission:
Medications on Transfer:
CTX 1 gm X 1
Azithro 500 X 1
Vanc 250 X 1
Per report: Zosyn and bactrim (not in papers from OSH)
Lantus 12 QAM
.
Home Medications:
Synthroid 75 mcg daily
Torsemide 40 mg daily
Lantus 12 units QAM + humalog SS
Calcium carbonate 600 mg [**Hospital1 **]
Coumadin 2.5 mg daily
Carvedilol 25 mg [**Hospital1 **]
Amlodipine 10 mg daily
ASA 325
fenofibrate 48 mg daily
Bactrim DS M/W/F
Cellcept [**Pager number **] mg [**Hospital1 **]
Prednisone 5 mg daily
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Insulin
Lantus 20units in the morning
Resume home humalog sliding scale
4. Calcium Carbonate 600 mg (1,500 mg) Tablet Sig: One (1)
Tablet PO twice a day.
5. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: take as directed by your coumadin clinic.
6. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO
daily ().
10. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO Q M/W/F ().
11. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
12. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) gram
Intravenous HD PROTOCOL (HD Protochol): continue through [**5-10**].
14. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO ONCE for 1
doses: take on [**5-3**].
Disp:*1 Tablet(s)* Refills:*0*
15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q48H for 3
doses: start on [**5-5**].
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-pneumonia
-line infection
Secondary
-ESRD on HD
-T2DM
-CAD
-atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to [**Hospital1 69**]
because of fever and concern of infection while you were at
dialysis. You were found to have a pneumonia and an infection
of your dialysis catheter.
Your dialysis catheter was removed at [**Hospital6 33**] and
you were started on antibiotics. You had a new dialysis
catheter placed at [**Hospital1 69**] on [**5-2**].
While you were here, some of your medications were changed.
You should continue antibiotics through [**5-10**]:
Vancomycin (to be given at dialysis)
Levaquin orally
Continue all other medications as prescribed by your doctors.
Be sure to follow-up with your doctors at the [**Name5 (PTitle) 648**] below.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2101-5-6**] at 9:40 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PAT-PREADMISSION TESTING
When: TUESDAY [**2101-5-10**] at 8:30 AM
With: PAT-PREADMISSION TESTING [**Telephone/Fax (1) 2289**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: TRANSPLANT CENTER
When: TUESDAY [**2101-8-16**] at 9:20 AM
With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD, [**MD Number(3) 19838**]
ICD9 Codes: 0389, 5856, 486, 4280, 3572, 2720, 2449, 4439, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1418
} | Medical Text: Admission Date: [**2137-4-26**] Discharge Date: [**2137-6-5**]
Date of Birth: [**2072-11-26**] Sex: M
Service: MEDICINE
Allergies:
Morphine
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
abd distension/leg swelling
Major Surgical or Invasive Procedure:
Transesophageal Echocardiogram on [**2137-4-26**]
Paracentesis on [**2137-4-29**] and [**2137-5-2**]
EGD on [**2137-5-1**], [**2137-5-7**], [**2137-5-17**]
Colonoscopy [**2137-5-17**]
Transjugular liver biopsy on [**2137-5-3**]
History of Present Illness:
64 year old patient of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**] who lives part time in the
[**Country 13622**] and part time in the US, just returned from the
[**Country 13622**]. Hx of CABG/Mechanical MVR in [**2131**] at [**Hospital1 18**], HIV+
(dx'ed approx 7 yrs). Admitted to [**Hospital1 34**] on [**4-23**] with decompensated
heart failure, endocarditis of aortic valve (seen on TTE), LVEF
40-45%. Blood cultures grew Enterococcus but no follow-up blood
cultures drawn. He states prior to admission he was getting
more short of breath, dry cough, his abdomen became more
distended, weight loss 15-20lb weight gain in past couple of
months, some abdominal pain, poor appetite, leg swelling. He
notes one day of fever. He denies any chest pain.
At [**Hospital6 33**], he was started on ceftriaxone and
azithro which was switched to Vancomycin, Gent, Ampicillin,
Azithro after ID was consulted. His CD4 count was checked and
was 50 (Viral load checked but currently do not have these
results). Patient does not know what medications he takes at
home, and has pill bottles of truvada and zerit. He identifies
Dr. [**Last Name (STitle) 6173**] as his ID physician although does not appear he has
seen him since [**2135**]. CT Abd/Pelvis done with old splenic
infarcts, ascites but no acute bowel pathology. Patient/wife
state that approximately one month prior he had a GI Bleed
requiring transfusion. They are unable to provide additional
info and tell me that they think he was admitted here (although
no record of this in our system). Troponin 0.08, CK negative.
They wanted to do TEE at [**Hospital3 **] but he has been too SOB to
tolerate it. As of this morning, nurse states that his
respiratory status looks stable; patient is able to lie flat so
transferred to [**Hospital1 18**] for TEE and further evaluation.
ROS: no CP, (+) DOE, (+) orthopnea, (+) LE edema, (+) fever (but
not currently), abd distension - but much improved, no blood in
stools recently
Past Medical History:
1. HIV (VL 175 on [**2135-6-21**])- on HAART
2. HTN
3. CAD s/p MI x 2 and 5V CABG [**2131**]
4. MVR [**2131**] w/ cabg
5. left thoracotomy [**8-5**] for pleural effusion
6. cord compression/spinal stenosis w/ c4-c6 laminectomy and
decompression [**10-7**]
7. H pylori positive [**9-5**] - unclear whether he got treated
8. EF 40% [**2132**]
9. anemia - fe deficiency (baseline hct 30), had been worked up
for pancytopenia in the past and this was when his HIV dx was
discovered. per pt, his only risk factor was transfusions during
CABG. Family all aware.
10. Type II DM
Social History:
+smoker, 1pack/day for 42 years, occasional EtOH, lives in
[**Hospital1 1474**] with wife and 2 sons. [**Name (NI) **] used to work in business
importing merchandise. Born in [**Country 13622**] Republic.
Family History:
Non-contributory
Physical Exam:
VS - 96.6F HR 67 145/70 16 100%/2L
205lbs
Gen: awake, alert, NAD
HEENT: PERRL, anicteric, OP clear, no evidence of thrush, small
area of erythema under tongue
Neck: supple, no LAD, JVP 9cm
CV: regular, S1, mech S2, soft systolic murmur
Pulm: Crackles bilaterally [**2-6**] way up with exp wheeze
Abd: (+) BS, distended, firm, mild, diffuse TTP, no rebound or
guarding
Ext: WWP, 2+ LE edema b/l, 1+ DP pulse b/l
skin: no rash
Pertinent Results:
TEE ECHOCARDIOGRAM [**2137-4-26**]:
The left atrium is dilated. The right atrium is dilated. No
atrial septal defect is seen by 2D or color Doppler. The left
ventricular cavity is dilated. LV systolic function appears
depressed. 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. No masses or vegetations are
seen on the aortic valve. Trace aortic regurgitation is seen. A
bileaflet mitral valve prosthesis is present. The gradients are
higher than expected for this type of prosthesis. There is a 2.5
x 1 cm mass on the atrial side of the mitral valve prosthesis.
This may represent a vegetation or thombus. Mild to moderate
([**2-5**]+) mitral regurgitation is seen. This regurgitation is
central and there is no evidence of a paravalvular leak,
dehiscence, or abscess. There is no pericardial effusion.
CT TORSO [**2137-4-27**]:
TECHNIQUE: Contiguous axial CT images of the chest, abdomen, and
pelvis are obtained with the administration of intravenous
contrast [**Doctor Last Name 360**], 130 cc of Optiray. Multiplanar reformation
images are reconstructed.
CHEST: The patient is status post CABG with median sternotomy.
Coronary
arteries are calcified. There is moderate cardiomegaly. The
patient is post mitral valve replacement. There is edema in the
mediastinum. Right
hemidiaphragm is eventrated. There is bilateral small pleural
effusion. In
the lung window, note is made of bibasilar plate-like
atelectasis. Evaluation of the lung is somewhat limited due to
motion artifact. There is diffuse anasarca.
ABDOMEN: There is massive ascites, as mentioned in the history.
There is no evidence of free air or fluid collection or abscess
in the abdomen.
Gallbladder is unremarkable without evidence of calcification.
There is a
large cystic lesion in the spleen, measuring 5.6 cm. There is no
evidence of bowel obstruction. There is no calcification in the
gallbladder. Pancreas is unremarkable. Adrenal glands and
kidneys are within normal limits. The hepatic vasculatures are
not completely assessed on this single-phase study, however,
there is no definite clot in the portal vein visualized. There
are several areas of hypodensities in the spleen.
PELVIS: There is massive ascites. Appendix is normal filled with
oral
contrast. There is no evidence of bowel dilatation.
There is no suspicious lytic or blastic lesion in skeletal
structures.
IMPRESSION:
1. Massive ascites and anasarca. No evidence of abscess or fluid
collection in the abdomen.
2. 5.6 cm fluid collection in the spleen with several foci of
hypodensity in the spleen, probably representing infarction with
necrosis. There is no
secondary sign of infection.
3. Atelectasis in the lungs with edema in the mediastinum and
cardiomegaly, post-CABG.
LIVER ultrasound with dopplers [**2137-4-27**]: 1. Heterogeneous nodular
liver consistent with history of cirrhosis with associated free
fluid. No focal liver lesions identified. 2. Normal hepatic
Doppler waveforms.
EGD [**2137-5-1**]: No esophageal varices. Dieulafoy lesion in the
proximal stomach body (ligation). There was no portal
hypertensive gastropathy, andd no gastric varices. Blood in the
stomach body. Otherwise normal EGD to second part of the
duodenum
EGD [**2137-5-7**]: Grade I esophageal varices in the distal esophagus.
Erythema and congestion in the stomach. Normal mucosa in the
duodenum. Recommendations: [**Hospital1 **] proton pump inhibitor. No source
of bleeding seen on this exam. No contraindication to
coumadinization.
CXR [**2137-5-1**]: PICC with tip overlying proximal portion of the
superior vena
cava.
EGD [**2137-5-17**]: Impression: Normal mucosa in the esophagus. Normal
mucosa in the stomach. Normal mucosa in the duodenum.
COLONOSCOPY [**2137-5-17**]: Impression: Grade 1 internal hemorrhoids
Otherwise normal colonoscopy to cecum.
Liver Biopsy Pathology [**2137-5-3**]:
Liver, transjugular biopsy:
1. Minimal portal and lobular mononuclear inflammation.
2. No fatty change, features of venous outflow obstruction are
seen..
3. Trichrome stain shows focal increased sinusoidal fibrosis.
4. Reticulin stain shows no definitive features of nodular
regenerative hyperplasia.
5. Iron stain shows no stainable iron.
Brief Hospital Course:
64 year old male with CAD s/p CABG and mech mitral valve [**2131**],
HIV+ CD4 50, DM2, transferred from outside hospital with CHF,
Enterococcal endocarditis, and ascites. Course here complicated
by chronic GI bleeding and fevers. See below for hospital
course by problem.:
1) Endocarditis: TEE done on [**4-26**] revealed a vegetation on his
prosthetic mitral valve. Sensitivities from the outside
hospital indicated sensitive to PCN and vancomycin, with high
resistance to Gentamicin and streptomycin. ID was consulted for
further management and recommended changing to ampicillin and
ceftriaxone, based on sensitivities done at [**Hospital1 18**]. The first
day of these medications is [**4-29**], and he is to continue these
medications for 8-12 weeks as directed by infectious disease,
with whom he will follow up. Daily EKGs were followed, and were
without evidence of abscess or conduction disease. Of note, OSH
TTE showed possible aortic (and not mitral) vegetation which was
not seen on TEE here. Blood cultures were persistently
negative.
2) GI Bleed: On [**5-1**] his Hct was noted to drop from 27 the day
prior to 22. He was guaiac positive. He underwent EGD and
blood was seen in the stomach as well as a Dieulafoy's ulcer,
which was was ligated. He was transfused 2 units pRBCs and Hct
stabilized. He was started on PPI iv bid. He had an episode of
melena on [**5-4**] and was transfused 2 additional units with
appropriate increase in Hct. He underwent repeat EGD on [**2137-5-7**]
and no active bleeding was seen. His hematocrit continued to
gradually trend down, with trace guaiac positive stools,
therefore he had a third EGD, this time with colonoscopy, on
[**5-17**]. Again, these were unrevealing. His anemia was felt to be
multifactorial, possibly with a chronic slow GI bleed, but also
secondary to chronic disease (HIV) and chronic renal failure
(see below). On [**5-31**] the patient had another hematocrit drop to
19, with melena. This time a tagged RBC scan was performed,
which demonstrated a proximal source of bleeding, likely
stomach. He was transferred to the CCU where he had another
EGD, this time with visualization of bleeding from clips at site
of Dieulafoy. This lesion was reclipped, and it was decided to
hold his heparin and coumadin to achieve a period of 24 hours
completely off anticoagulation to see if this lesion would clot.
Heparin was restarted on the evening of [**6-3**] and his hematocrit
was stable >31 after a day. He should be started on Warfarin
starting tonight at 5mg but of note, he required high doses to
be therapeutic in the past (9mg). He will start back on
Warfarin on the evening of [**6-4**] at 5mg and recheck PT/INR daily
and trend up to therapeutic before discontinuing Heparin.
Monitor HCT daily given recent bleed. He should continue on
protonix 40 mg [**Hospital1 **] until instructed otherwise.
3) Chronic renal failure: Creatinine baseline appears to be
around 1.0, however he has been between 1.3 and 2.0 on many
occasions over the last few years, likely related to his fluid
balance, making his clearance < 60. Given his persistent
anemia, he was started on erythropoetin 8,000 units per week as
well as iron. He should have a repeat hemoglobin in 2 weeks and
every 2-4 weeks thereafter. Goal hemoglobin is [**12-16**], so if >
12, stop erythropoetin.
4) CHF: Echo at the outside hospital revealed EF 45-50%, which
is likely underestimated in the setting of mitral regurgitation.
He was diuresed aggressively initially, and ultimately
restarted on PO lasix 80 mg daily, which maintained an even
fluid balance. He should continue lasix, however dose should be
increased if he is consistently gaining weight. He was also
continued on lisinopril 5 mg daily for afterload reduction,
spironolactone 50 mg daily, and metoprolol XL 75 mg daily.
5) Ascites: Etiology remained elusive despite extensive
investigation. In the end, it is felt most likely secondary to
liver cirrhosis with sampling error on the liver biopsy making
fibrosis look less extensive than it is. Reported history of
HBV and HCV, however here he is HCV negative, and has prior HBV
exposure but negative surface antibody and antigen. He does
have a history of heavy EtOH. His transaminases were never
elevated, though alk phos was mildly elevated at 200 (with
elevated GGT). HIV cholestasis is possible. Anti-mitochondrial
antibody was negative (making primary biliary cirrhosis less
likely). [**Doctor First Name **] was mildly positive, with elevated IgG, however
without transaminase elevation auto-immune hepatitis was less
likely. He ultimately underwent liver biopsy which showed only
mild portal inflammation. Hepatology felt that his ascites was
unlikely to be secondary to a primary liver process, however
again, this seems statistically most likely. Additionally, he
had 2 diagnostic/therapeutic paracentesis, both of which
demonstrated SAAG < 1.1, with many WBC and > 250 polys. He was
already on ceftriaxone for his endocarditis, and cultures were
without growth, making an infectious etiology unlikely.
Potential etiologies include liver disease with pseudoexudate
from diuresis, versus TB peritonitis, versus carcinomatosis. CT
abdomen with contrast was negative for peritoneal
carcinomatosis, and cytology was negative from the ascites.
Acid fast smears were negative, though culture is still pending.
Surgery was consulted for consideration of peritoneal biopsy,
however they felt that given the possibility that this is
pseudoexudate from diuresis, he would best be followed up as an
outpatient. They also felt that peritoneal biopsy would be
unlikely to yield the diagnosis. He will see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
in outpatient surgery clinic. His last paracentesis was on
[**5-29**], about 10 days after his last one. He will therefore
probably need paracenteses at rehab every 2 weeks or so. This
should be done when his abdomen is tense. He tolerated these
without any difficulty, without any creatinine elevations. He
will continue on lasix 80 mg daily, spironolactone 50 mg daily.
5) Pseudogout: He complained of acute onset left knee pain
shortly before discharge. He had an effusion that was tapped,
revealing calcium pyrophosphate crystals consistent with
pseudogout (no evidence of septic arthritis). His pain actually
remitted on its own without treatment. If this pain recurrs
could use colchicine 0.6 mg daily (decreased dose for renal
failure).
6) Atrial fibrillation: He was in sinus rhythm during this
hospitalization. He was continued on coumadin for
anticoagulation, with heparin drip while subtherapeutic (he
always needs to be anticoagulated with heparin bridge while INR
< 2.5 given structural AF in the setting of mitral regurgitation
and high risk of embolus). His INR was stable at 3.0 on 8 mg of
coumadin.
7) Mechanical mitral valve: His INR subtherapeutic for the
majority of the hospitalization and his coumadin was held at
various times for procedures. Prior to procedures, his INR
seemed to be stable at 3.0 on 8 mg of coumadin. Needs frequent
INR checks until therapeutic consistently on a stable dose of
coumadin.
8) HIV: It was unclear whether or not he had actually been
taking antivirals before admission, and ID recommended holding
HAART for now. CD4 count 50 at outside hospital. Bactrim DS
was started for PCP [**Name Initial (PRE) 1102**]. Azithromycin for MAC
prophylaxis will be considered as an outpatient (once acid fast
cultures from peritoneal fluid are known to be negative).
9) DM: Continued insulin sliding scale and monitored finger
sticks. It is unclear if the patient is on a medical regimen as
an outpatient for this. Meformin is contraindicated given his
creatinine, and thiazolidenediones are difficult in the setting
of CHF (fluid retention). A sulfonylurea is a possibility, but
this can be started at rehab or in the outpatient setting -
given his renal insufficiency would use glipizide rather than
glyburide. For now, continue insulin sliding scale.
10) Nutrition: Ordered for a diabetic/cardiac diet.
11) Access: He had a PICC placed on [**5-1**], confirmed in good
position by CXR and in working order.
Medications on Admission:
Largely unknown. Patient states he was taking coumadin, he also
had bottles of truvada and zerit on admission to OSH.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 2222**] - [**Location (un) 538**]
Discharge Diagnosis:
Enterococcus Endocarditis
Coronary artery disease
Congestive heart failure
Mechanical mitral valve
HIV
Diabetes Mellitus
Ascites
Dieulafoy lesion with upper GI bleeding
Anemia
Chronic kidney disease
Discharge Condition:
Ambulating, afebrile, no joint pain.
Discharge Instructions:
As you know, you had an infection on your heart valve. You will
be at rehab in order to received your IV antibiotics for another
4-6 weeks or so - the duration of the course will be determined
by your infectious disease doctors.
You will need to get the fluid in your abdomen drained out
periodically. This can be done at rehab.
Please call your primary care physician [**Last Name (NamePattern4) **] 911 if you experience
fevers, chills, chest pain, shortness of breath, increased leg
swelling, weight gain, nausea, vomiting, abdominal pain or other
concerning symptoms.
Followup Instructions:
Please schedule follow-up with your primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 8499**] ([**Telephone/Fax (1) 7976**]) within 1-2 weeks after discharge from
Rehab.
Please schedule follow-up with Dr. [**Last Name (STitle) 73**]
(Cardiology),([**Telephone/Fax (1) 1920**], within 1 month from discharge from
the hospital.
You have a follow-up appointment scheduled with Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], [**Telephone/Fax (1) 673**], in transplant surgery clinic for
consideration of peritoneal biopsy: Date/Time:[**2137-6-14**] 2:20p.m.
You have a follow-up appointment scheduled in the Infectious
Disease Clinic with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13632**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2137-6-24**] 10:30
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
ICD9 Codes: 4280, 5856, 5715, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1419
} | Medical Text: Admission Date: [**2179-10-30**] Discharge Date: [**2179-11-5**]
Date of Birth: [**2104-2-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
emergent CABGx3 (LIMA->LAD, SVG->, SVG->) [**10-30**]
History of Present Illness:
75 y.o. female that presented to OSH with chest pain and
shortness of breath. She was found to have 2mm ST segment
depressions in I, aVL, II, aVF, V4 and V6 with reportedly old
LBBB. She was started on heparin, eptifibatide, clopidogrel
600mg and underwent left-heart cath and found to have 95% LCx,
90% LMCA, 90% LAD, and occluded RCA with collaterals from LAD.
LCx was stented with Voyager 2.5x15mm. Patient was felt to have
worsened MR secondary to papillary muscle dysfunction that
seemed to improve with stenting of LCx. IABP was placed, and she
was started on dopamine and transferred to [**Hospital1 **] for further
management and possible CABG.
Past Medical History:
HTN, DM, Osteoarthritis, Dyslipidemia
Social History:
denies tobacco, etoh
Family History:
unknown
Physical Exam:
On admission:
BP 126/56 HR 82 RR 20
Elderly F intubated and sedated
CV RR, IABP
Lungs clear anteriorly
Abdomen obese, soft, NTND
Extrem cool, no edema
Pertinent Results:
[**2179-11-5**] 06:25AM BLOOD WBC-17.1* RBC-3.62* Hgb-11.7* Hct-34.6*
MCV-96 MCH-32.2* MCHC-33.7 RDW-15.0 Plt Ct-575*
[**2179-11-5**] 06:25AM BLOOD Plt Ct-575*
[**2179-11-2**] 02:14AM BLOOD PT-13.2* PTT-30.0 INR(PT)-1.2*
[**2179-11-5**] 06:25AM BLOOD Glucose-133* UreaN-24* Creat-0.9 Na-139
K-4.5 Cl-96 HCO3-33* AnGap-15
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 76038**], [**Known firstname 4617**] [**Hospital1 18**] [**Numeric Identifier 76039**]TTE (Complete)
Done [**2179-11-4**] at 3:09:03 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2104-2-18**]
Age (years): 75 F Hgt (in): 65
BP (mm Hg): 123/493 Wgt (lb): 156
HR (bpm): 105 BSA (m2): 1.78 m2
Indication: s/p CABG.
ICD-9 Codes: 414.8, 424.2
Test Information
Date/Time: [**2179-11-4**] at 15:09 Interpret MD: [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **],
MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **], RDCS
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Suboptimal
Tape #: 2007W046-1:12 Machine: Vivid [**7-4**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.6 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.4 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.4 m/s
Left Atrium - Peak Pulm Vein D: 0.3 m/s
Right Atrium - Four Chamber Length: 4.7 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 3.4 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 40% >= 55%
Left Ventricle - Lateral Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.05 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 13 < 15
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A ratio: 1.14
Mitral Valve - E Wave deceleration time: 140 ms 140-250 ms
TR Gradient (+ RA = PASP): *26 to 29 mm Hg <= 25 mm Hg
Findings
LEFT ATRIUM: Elongated LA.
LEFT VENTRICLE: Normal LV wall thickness. Small LV cavity.
Mildly depressed LVEF. No resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Normal RV wall thickness. Mildly dilated RV
cavity. Borderline normal RV systolic function.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets.
Characteristic rheumatic deformity of the mitral valve leaflets
with fused commissures and tethering of leaflet motion. No MVP.
Mild mitral annular calcification. Moderate thickening of mitral
valve chordae. Calcified tips of papillary muscles. No MS.
Trivial MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Thickened/fibrotic tricuspid valve supporting structures. No TS.
Mild [1+] TR. Borderline PA systolic hypertension.
PERICARDIUM: Small pericardial effusion. Effusion
circumferential. No echocardiographic signs of tamponade.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Suboptimal image quality - poor parasternal views. Suboptimal
image quality - poor apical views. Left pleural effusion.
Conclusions
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is unusually small.
Overall left ventricular systolic function is mildly depressed
(LVEF= 40 %) secondary to hypokinesis of the anterior septum and
posterior wall. There is no ventricular septal defect. The right
ventricular cavity is mildly dilated. Right ventricular systolic
function is borderline 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
mildly thickened. The mitral valve shows characteristic
rheumatic deformity. There is no mitral valve prolapse. There is
moderate thickening of the mitral valve chordae. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. The supporting structures of the tricuspid valve are
thickened/fibrotic. There is borderline pulmonary artery
systolic hypertension. There is a small pericardial effusion.
The effusion appears circumferential. There are no
echocardiographic signs of tamponade.
Brief Hospital Course:
She was admitted to the CCU. She was taken to the operating room
emergently for cardiogenic shock where she underwent a CABG. She
was started on vancomycin periop for prophylaxis was she was in
house preoperatively. She was transferred to the ICU in critical
but stable condition on epinephrine, neosynephrine and propofol.
She was transfused 3 units post op for anemia/hypotension and
shock. She remained intubated with IABP overnight. Her IABP was
dc'd in the morning of post op day 2. Her epi was weaned to off
and she was extubated on the morning of post op day 3. She was
transferred to the floor on POD #4. She was seen by physical
therapy who [**Hospital 24260**] rehab placement, and she was ready for
discharge on POD #6. Her white count on discharge was 17, her
incisions appear to be healing well, and her white count should
be rechecked on [**11-8**].
Medications on Admission:
Simvastatin 40', Ezetimibe 10', Lisinopril 40', Atenolol 50',
Metformin 500'
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 BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
Disp:*225 Tablet(s)* Refills:*0*
9. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Four (4) Capsule, Sustained Release PO Q12H (every 12 hours) for
7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 2971**] Rehabilitation and Nursing Center - [**Hospital1 1474**]
Discharge Diagnosis:
CAD now s/p CABG
HTN, DM, Osteoarthritis, Dyslipidemia
Discharge Condition:
Good.
Discharge Instructions:
Call with fever, redness or drainage from incisions or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions, creams or powders to incisions.
No lifting more than 10 pounds or driving until follow up with
surgeon.
Followup Instructions:
Dr. [**Last Name (STitle) 3314**] (PCP) 2 weeks
Dr. [**Last Name (STitle) **] (cardiologist) 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
Completed by:[**2179-11-5**]
ICD9 Codes: 5849, 2859, 4240, 4280, 2724, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1420
} | Medical Text: Admission Date: [**2159-4-14**] Discharge Date: [**2159-4-17**]
Date of Birth: [**2085-1-23**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 73-year-old female who
presented with three days of progressive sore throat and
odynophagia.
The symptoms began three days prior to admission with upper
respiratory infection like syndrome including a mild cough
without sputum, a stuffy nose, and sore throat. There were
no fevers or chills. Over the last two days prior to
admission, there was worsening left throat pain and
odynophagia with decreased oral intake; although normal vocal
quality with no air hunger or dyspnea.
She came to the Emergency Department on the morning of
admission and a fiberoptic scope was done that showed no
obvious swelling. There was normal vocal cord function and
excessive secretions noted. A computed tomography scan of
the neck with contrast showed soft tissue thickening at the
left hypopharynx.
Ear/Nose/Throat Service saw the patient in the Emergency
Department and repeated the fiberoptic laryngoscopy which
showed an injected epiglottis without swelling, markedly
swollen left retinoid at the AE fold, and normal vocal cords.
The air flow was felt to be "adequate but borderline." The
diagnosis of supraglottitis was made, and it was recommended
to initiate Decadron 10 mg intravenously q.8h. times three
doses. The first dose was given in the Emergency Department.
Clindamycin 600 mg intravenously q.8h. was also given. She
was given morphine for pain control as well as Dilaudid which
relieved her pain but made her extremely groggy. In light of
the severity of her infection as well as her decreased mental
status, she was admitted to the Intensive Care Unit for
observation.
PAST MEDICAL HISTORY: (Past Medical History includes)
1. Hypertension.
2. Back pain with lumbar radiculopathy.
3. Motor vehicle accident in [**2157-6-24**] resulting in a
right tibial fracture for which an open reduction/internal
fixation and skin graft were performed.
4. Atypical chest pain; although a normal Persantine MIBI in
[**2157**].
5. Multinodular goiter.
6. Subclinical hypothyroidism.
7. Peptic ulcer disease.
9. Diet-controlled type 2 diabetes mellitus.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Medications included Avapro,
hydrochlorothiazide, and atenolol.
SOCIAL HISTORY: She is originally from Russian and came to
the United States 10 years ago. She is a retired engineer.
No tobacco, ethanol, or intravenous drug use. She lives
alone and performs her activities of daily living, and she
walks with a cane. She speaks some English. Her daughter
was present to translate.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs in the
Emergency Department revealed temperature was 99.1, blood
pressure was 166/65, heart rate was 68, respiratory rate was
16, and oxygen saturation was 97% on room air. While she was
sedated with morphine, her oxygen saturation was 85% on room
air which increased to 97% on 2 liters nasal cannula. On
arrival to the Intensive Care Unit temperature was 97.2,
blood pressure was 139/64, heart rate was 55, respiratory
rate was 16, and oxygen saturation was 99% on 4 liters nasal
cannula. In general, she was somnolent but awakened to her
name. She answered questions appropriately. Head, eyes,
ears, nose, and throat revealed normocephalic and atraumatic.
Pupils were equal, round, and reactive to light. Extraocular
movements were intact. The throat was clear with no lesions
visible. Neck examination revealed jugular venous pulsation
was seen at 6 cm at the general notch left mandibular fold
especially compared to the right. There was no
lymphadenopathy or stridor, and there were no bruits heard.
Pulmonary examination revealed she was perfectly clear to
auscultation bilaterally. Cardiovascular examination
revealed a regular rate and rhythm. Normal first heart
sounds and second heart sounds. There was a 2/6 systolic
murmur at the left sternal border. The abdomen was obese,
soft, nontender, and nondistended with positive bowel sounds.
Extremity examination revealed 2+ dorsalis pedis pulses
bilaterally. No clubbing, cyanosis, or edema.
Neurologically, cranial nerves II through XII were intact.
Deep tendon reflexes were 2+ in the upper extremity.
Strength was full. The sensation was intact to light touch.
She was alert and oriented times three; although somnolent.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on
admission revealed white blood cell count was 12.1 (with a
differential of 77% neutrophils, 1% bands, 19% lymphocytes,
and 3% monocytes), hematocrit was 41.6, and platelets were
245. Mean cell volume was 89. Sodium was 137, potassium was
3.5, chloride was 99, bicarbonate was 26, blood urea nitrogen
was 15, creatinine was 0.7, and blood glucose was 260, with
an anion gap of 12.
PERTINENT RADIOLOGY/IMAGING: A computed tomography of the
neck preliminary read revealed no retropharyngeal abscess.
There was soft tissue thickening at the left hypopharynx to
the level of the epiglottis.
IMPRESSION: This is a 73-year-old female with
supraglottitis.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. SUPRAGLOTTITIS ISSUES: The Ear/Nose/Throat Service
continued to follow the patient, and the patient was
discharged from the Intensive Care Unit on hospital day two
in the care of the Ear/Nose/Throat Service. She was
continued on clindamycin, and ceftriaxone was added.
Decadron was continued. No racemic epinephrine was needed,
as the patient never became stridorous. The patient's diet
was slowly advanced as tolerated. Roxicet elixir orally was
given for pain control. Decadron was stopped on [**4-16**],
and on [**4-17**] a repeat fiberoptic examination evaluated
normal retinoids with a bit of erythema on the left retinoid.
There was no more supraglottic swelling or inflammation.
The patient was switched to Augmentin and discharged on a
7-day course.
2. DIABETES ISSUES: Given the patient's diabetes and that
she was on steroids, she was covered with a regular insulin
sliding-scale.
3. SEDATION ISSUES: This was felt to be due to the large
doses of narcotics given in the Emergency Room, and her
mental status returned to [**Location 213**] after narcotics were held
for several hours.
DISCHARGE DISPOSITION: The patient was discharged on seven
days of Augmentin along with her regular antihypertensive
regimen and was instructed to follow up in one week with Dr.
[**Last Name (STitle) **] in the Ear/Nose/[**Hospital 6212**] Clinic.
CONDITION AT DISCHARGE: Condition on discharge was good.
DISCHARGE STATUS: Discharge status was to home.
DISCHARGE DIAGNOSES: Supraglottitis.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 968**]
Dictated By:[**Name8 (MD) 2734**]
MEDQUIST36
D: [**2159-5-18**] 15:11
T: [**2159-5-22**] 07:23
JOB#: [**Job Number 8319**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1421
} | Medical Text: Admission Date: [**2166-9-5**] Discharge Date: [**2166-9-15**]
Date of Birth: [**2096-7-26**] Sex: M
Service: THORACIC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old
male who was first noted to have bilateral lung masses on a
chest x-ray in preparation for possible sinus surgery. A
follow-up CAT scan of the chest in [**2166-3-26**] originally had
shown a 6.5 cm left upper lobe mass and a 3.5 cm lobulated
right upper lobe mass. He consequently underwent
fluoroscopic biopsy of the right-sided mass which showed
adenocarcinoma. Bronchial biopsy of the left upper lobe
showed poorly differentiated large cell carcinoma with
squamous differentiation. Metastatic work-up of the head,
bone, and abdomen was negative. His laboratory studies
remained relatively normal.
He was seen by the Oncology Service and started on
chemotherapy. The follow-up imaging showed marked regression
of his tumor. He was consequently referred to Thoracic
Surgery for a possible surgical intervention. The patient
has not lost significant weight and has not had any fevers,
headaches, or chest pain. He has had good appetite
PAST MEDICAL HISTORY: 1. Hypertension. 2.
Hypercholesterolemia. 3. Nasal polyps. 4. Bilateral lung
carcinoma. 5. Chronic maxillary and ethmoid sinusitis. 6.
Peptic ulcer disease.
PAST SURGICAL HISTORY: None.
MEDICATIONS: Hydrochlorothiazide 25 mg q.d., Lipitor 10 mg
q.d., Atrovent, Vanceril, antihistamines for allergies.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: Likely asbestos exposure. History of
smoking (60 pack years).
PHYSICAL EXAMINATION: General: Well-developed, in no
apparent distress. HEENT: Anicteric. No lymphadenopathy
palpated. Lungs: Clear to auscultation bilaterally. Heart:
Regular, rate and rhythm without murmurs. Abdomen: Soft,
nontender, nondistended. Extremities: Pulses present
bilaterally. Warm and well perfused.
LABORATORY DATA: White blood cell count 7.0, hematocrit 38,
platelet count 351; BUN 17, creatinine 0.8, sodium 141,
potassium 3.9, chloride 100, carbon dioxide 28; liver
function tests within normal limits; FEV1 was 44% of the
predicted value.
HOSPITAL COURSE: Given the diagnosis of bilateral lung
cancer, Thoracic Surgery was consulted. On [**2166-9-5**],
the patient underwent median sternotomy, left upper
lobectomy, bronchoscopy, pedicled pericardial flap, right
upper wedge resection, and decortication of the left lung.
The patient tolerated the procedure well, and there were no
immediate complications. Please see the full operative
report for details.
The patient was transferred to the Intensive Care Unit in
fair condition. He had to be reintubated and maintained on
pressure support. He was transfused with 2 U of packed red
blood cells for a hematocrit of 23.6. Chest x-ray obtained
at that time, showed left lower lobe collapse/consolidation
but appeared relatively unchanged. The patient underwent a
series of therapeutic bronchoscopies during his stay in the
Intensive Care Unit. It showed mucous plugging and thick
secretions. He had an increased need of Neo requirement.
The patient was weaned of sedation. His chest x-ray showed
some interval improvement.
He continued to have low-grade fevers. He was placed on
Ceftriaxone and Kefzol. His hematocrit remained stable.
There was some difficulty weaning him off of pressure
support. In addition, his tube feeding was initiated. He
continued to have thick oral secretions. He remained in
sinus rhythm but had an eight-beat run of ventricular
tachycardia was noted. The patient was started on Amiodarone
drip. He was transfused again with one unit of red blood
cells. The patient was successfully extubated on
postoperative day #4.
He was transferred to the red floor on postoperative day #5
in stable condition. He continued to produce good urine. He
remained in sinus rhythm. He continued to be afebrile with
stable blood pressure and heart rate. Physical Therapy was
consulted which recommended rehabilitation facility upon
discharge.
The chest tubes were removed. The patient was discharged to
the rehabilitation facility on [**2166-9-16**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: Rehabilitation facility.
DISCHARGE DIAGNOSIS:
1. Bilateral lung carcinoma status post medial sternotomy,
left upper lobectomy, bronchoscopy, pedicled pericardial
flap, right upper wedge resection, and decortication of the
left lung.
2. Hypertension.
3. Hypercholesterolemia.
DISCHARGE MEDICATIONS: Amiodarone 400 mg q.d. x 1 month,
Ambien 5 mg p.o. h.s., Atenolol 12.5 mg p.o. b.i.d.,
Fluticasone Propionate 110 mcg 2 puffs b.i.d., Keflex 500 mg
q.6 hours p.o. x 7 days, Heparin subcue 5000 U b.i.d. until
sufficiently mobile, Albuterol Ipratropium 1-2 puffs inhalers
q.6 hours p.r.n., Hydrochlorothiazide 25/25 one tab q.d.,
Lipitor 10 mg p.o. q.d., Vanceril.
DISCHARGE INSTRUCTIONS: 1. The patient is to follow-up with
his surgeon Dr. [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) 952**] in approximately 1-2 weeks. 2.
The patient is to follow-up with his primary care physician
[**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 35888**] in approximately 1-2 weeks. 3. The patient
is to follow-up with his oncologist as scheduled (Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) 3274**]).
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern1) 1741**]
MEDQUIST36
D: [**2166-9-15**] 18:13
T: [**2166-9-15**] 19:35
JOB#: [**Job Number 43211**]
ICD9 Codes: 5185, 2762, 5180, 4271, 2720, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1422
} | Medical Text: Admission Date: [**2145-11-14**] Discharge Date: [**2145-11-18**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Found Down
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo male with chronic kidney disease who presents to the ED
after being found down at apt. Pt found by landlord after not
being seen in 2 days and found in own feces.
.
ED: While in the ED, found to have K of 7, creat of 10, trop of
3 with nl CK. Received 10 U Insulin/ 1 amp D 50, Haldol/ativan,
Kayexalate PR, Calcium gluconate 1 g x 2. Patient pulled foley
catheter and NGT was unable to be placed.
.
When arrived on MICU floor, patient agitated and not responsive
to questions. Withdraws to pain.
Past Medical History:
1. Hypertension.
2. Chronic renal insufficiency (with a baseline creatinine
of 4 documented as far back at [**2140**]). The patient has
refused a workup for this in the past.
Social History:
Patient living alone, wife in rehab/[**Hospital1 1501**]. Per OMR: He is a former
[**Company 2318**] worker. He use to drink heavily in his youth. No alcohol at
all in the last 10
years. No tobacco.
Family History:
NC
Physical Exam:
t 97 BP 122/71 RR 19, 02 91-100%, HR 111
GEN: Arousable, agitated
HEENT: MM dry, PERRL, EOMI
Neck: JVP 6 cm
CV: RRR, [**2-15**] murmur at LLSB
Pulm: occ exp wheezes, otherwise clear bilaterally
Abd: + bs-hypoactive, soft, non-distended, no masses
Ext: [**1-11**] + pulses, no edema
Skin: excoriations of LE and UE
Neuro: moves all extremities
Pertinent Results:
[**2145-11-14**] 05:15PM WBC-7.8 RBC-2.90* HGB-10.0* HCT-31.1*
MCV-107* MCH-34.3* MCHC-32.0 RDW-14.6
[**2145-11-14**] 05:15PM NEUTS-81.1* LYMPHS-11.0* MONOS-3.8 EOS-3.8
BASOS-0.3
[**2145-11-14**] 05:15PM PLT COUNT-292
[**2145-11-14**] 05:15PM PT-13.2* PTT-25.3 INR(PT)-1.2*
[**2145-11-14**] 05:15PM TSH-0.26*
[**2145-11-14**] 05:15PM ALBUMIN-3.4 CALCIUM-9.4 PHOSPHATE-9.3*#
MAGNESIUM-3.0*
[**2145-11-14**] 05:15PM cTropnT-3.02*
[**2145-11-14**] 05:15PM GLUCOSE-128* UREA N-204* CREAT-10.0*#
SODIUM-157* POTASSIUM-7.1* CHLORIDE-127* TOTAL CO2-8* ANION
GAP-29*
[**2145-11-14**] 05:15PM AST(SGOT)-25 CK(CPK)-98 ALK PHOS-234*
AMYLASE-197* TOT BILI-0.2
[**2145-11-14**] 05:43PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
Brief Hospital Course:
[**Age over 90 **] yo male with acute on chronic renal failure with severe
electrolyte disturbances and azotemia.
.
ARF- Patient with longstanding renal failure with current
azotemia and electrolyte disturbance consistent with acute
worsening. The cause of the acute worsening was unclear but may
have been partially due to hypovolemia causing a prerenal
worsening of the function.
Per renal recommendations, the patient was not immediately a
candidate for dialysis treated with IV fluids and electrolytes
were monitored.
.
Elevated troponin- no clear signs of cardiac ischemia, but does
have significantly elevated troponin. No CK increase. Either
purely due to ARF or recent ischemic event.
.
Social Issues - the patient had no health [**Doctor First Name 4540**] proxy upon
admission, and we managed to contact a next of [**Doctor First Name **] ([**Name (NI) **]
[**Name (NI) 4541**], nephew) after three days. Until that point, patient was
deemed full code and was evaluated by both renal and orthopedics
for hemodialysis and fractured femur respectively. We also
contact[**Name (NI) **] the patient's PCP, [**Name10 (NameIs) 1023**] provided us with ample
documentation of the patient's history of refusing treatments,
including blood draws, colonoscopy, and chronic dialysis. Upon
contacting the next of [**Doctor First Name **], the patient was made DNR/DNI, but
preparations were made to proceed with dialysis. On the morning
of [**11-18**], the patient became apneic and subsequently went into
cardiopulmonary arrest with no obvious etiology. He was
pronounced at 12:29pm, and the next of [**Doctor First Name **] was alerted.
Medications on Admission:
Nicardipine and toprol
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
ICD9 Codes: 5849, 2767, 2760, 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1423
} | Medical Text: Admission Date: [**2187-3-5**] Discharge Date: [**2187-3-10**]
Date of Birth: [**2109-8-16**] Sex: M
Service: Vascular Surgery
CHIEF COMPLAINT: Symptomatic carotid stenosis.
HISTORY OF PRESENT ILLNESS: This is a 77-year-old white male
with coronary artery disease (status post coronary artery
bypass graft), history of congestive heart failure, diabetes,
and hypertension who presented to the Emergency Department on
[**2187-3-5**] with a 3-hour to 4-hour history of left
hand weakness.
The patient's family also noticed that he was having
difficulty with expressing his thoughts. The patient's
family brought him to the Emergency Room for further
evaluation.
By the time he came to the Emergency Department, most of the
patient's speech symptoms had returned to [**Location 213**] and he had
very little weakness remaining in his left hand.
A head computed tomography scan was negative for an acute
bleed. A magnetic resonance imaging showed a small lacunar
infarction of the right internal capsule. A carotid
ultrasound showed 70% to 79% right internal carotid artery
stenosis.
PAST MEDICAL HISTORY:
1. Coronary artery disease; status post coronary artery
bypass graft times four in [**2174**].
2. Congestive heart failure.
3. Hypercholesterolemia.
4. Peripheral vascular disease.
5. Shrapnel in the right.
PAST SURGICAL HISTORY:
1. Coronary artery bypass graft times four in [**2174-2-17**].
2. Cholecystectomy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Lopressor 100 mg p.o. b.i.d.
2. Captopril 50 mg p.o. t.i.d.
3. Lasix 40 mg p.o. q.d.
4. Lipitor 10 mg p.o. q.d.
5. Aspirin 325 mg p.o. q.d.
6. Ditropan 5 mg p.o. b.i.d.
7. NPH insulin 70 units subcutaneously q.a.m.
8. Regular insulin 6 units subcutaneously q.a.m.
9. NPH insulin 30 units subcutaneously q.p.m.
10. Regular insulin 8 units subcutaneously q.p.m.
11. Timoptic 0.25% one drop b.i.d.
12. Alphagan 0.15% two drops q.h.s.
13. Pilopine gel q.d.
SOCIAL HISTORY: The patient is married and lives with his
wife. [**Name (NI) **] worked as a road builder. He does not smoke
cigarettes or use alcohol. He has two sons.
FAMILY HISTORY: Mother died at the age of 83 with diabetes.
Father died at the age of 83 of unknown cause. The patient
has four brothers and one sister and is unaware of any
illnesses of his siblings.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed
heart rate was 88, respiratory rate was 22, blood pressure
was 160/90. In general, an alert and cooperative while male
in no acute distress. Head, eyes, ears, nose, and throat
examination revealed normocephalic. Sclerae were anicteric.
The neck was supple. No bruits. The lungs were clear
bilaterally. Heart was regular in rate and rhythm and
without murmurs. The abdomen was obese and soft. Bowel
sounds were present. No hepatosplenomegaly or masses.
Extremity examination revealed mild edema at the ankles.
Feet were equally warm. No ulcerations of the feet. Pulse
examination revealed carotid and radial pulses were palpable
bilaterally. The femoral and distal pulses were all
dopplerable bilaterally. On neurologic examination, speech
was clear. There was a slight left lower facial droop. The
tongue was midline with good movement. Sensation was intact
to touch and pinprick. Slight left pronator drift. Motor
function was intact except for a mild decrease in left hand
grip.
PERTINENT LABORATORY VALUES ON PRESENTATION: Admission
laboratories revealed white blood cell count was 9.2,
hematocrit was 44.8, and platelets were 220,000. Prothrombin
time was 14.6 and partial thromboplastin time was 28.3.
Sodium was 140, potassium was 4, chloride was 103,
bicarbonate was 23, blood urea nitrogen was 16, creatinine
was 1, and blood glucose was 133. Creatine kinases were 271
and 246. CK/MB were 4 and 5. Troponin was less than 0.3.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray showed no acute
pulmonary disease.
Electrocardiogram showed sinus bradycardia with a rate of 52.
Possible old anterior myocardial infarction. No acute
ischemic changes.
HOSPITAL COURSE: The patient was admitted to the Neurology
Service on [**2187-3-5**]. The patient's symptoms
remained stable.
Vascular Surgery was consulted. After evaluating all the
studies on admission, Dr. [**Last Name (STitle) 1476**] recommended doing a right
carotid endarterectomy during this hospitalization.
The Cardiology Service was consulted for preoperative
clearance. Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] (the patient's cardiologist)
cleared the patient for surgery.
On [**2187-3-9**] the patient underwent an uneventful
right carotid endarterectomy. Possibility, overnight, the
patient did well. He was discharged on [**2187-3-10**].
He was instructed to follow up with Dr. [**Last Name (STitle) 1476**] in the
office in one week for staple removal from his right neck
incision.
Aggrenox was started by the Neurology Service, and the
patient was to continue this medication per their
instruction.
MEDICATIONS ON DISCHARGE:
1. Lopressor 100 mg p.o. b.i.d.
2. Captopril 50 mg p.o. t.i.d.
3. Lasix 40 mg p.o. q.d.
4. Lipitor 10 mg p.o. q.d.
5. Aspirin 325 mg p.o. q.d.
6. Ditropan 5 mg p.o. b.i.d.
7. NPH insulin 70 units subcutaneously q.a.m.
8. Regular insulin 6 units subcutaneously q.a.m.
9. NPH insulin 30 units subcutaneously q.p.m.
10. Regular insulin 8 units subcutaneously q.p.m.
11. Timoptic 0.25% one drop b.i.d.
12. Alphagan 0.15% two drops q.h.s.
13. Pilopine gel q.d.
14. Aggrenox one capsule p.o. b.i.d.
CONDITION AT DISCHARGE: Condition on discharge was
satisfactory.
DISCHARGE STATUS: Discharge status was to home.
PRIMARY DISCHARGE DIAGNOSES: Symptomatic right internal
carotid artery stenosis.
SECONDARY DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Diabetes.
3. Hypertension.
4. Hypercholesterolemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**], M.D. [**MD Number(1) 1478**]
Dictated By:[**Last Name (NamePattern1) 3954**]
MEDQUIST36
D: [**2187-4-11**] 13:56
T: [**2187-4-11**] 14:02
JOB#: [**Job Number **]
ICD9 Codes: 4280, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1424
} | Medical Text: Admission Date: [**2180-10-19**] Discharge Date: [**2180-11-1**]
Date of Birth: [**2106-4-19**] Sex: M
Service: MEDICINE
Allergies:
Lopressor / Keflex
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 39530**] is a 74 yo M with history of CAD s/p MI, 3V CABG
[**2167**], CHF (EF 25% in [**2179**]), VF arrest s/p ICD [**2179**], who
presented to [**Hospital 1281**] Hospital on [**10-19**] with dyspnea. Of note, he
had been discharged approximately 12 hours before from [**Hospital 487**]
Hospital, where he had a 30 day admission for CHF exacerbation.
Per the daughter, he was still "full of fluid" upon discharge
from [**Hospital1 487**]. He returned home to his assissted living facility
Wednesday evening [**10-18**], and his daughter stayed over with him.
She reports that he was experiencing sever SOB and DOE, and that
he was barely able to walk the length of the hallway without
becoming SOB. She notes that he sounded wheezy and "couldn't
pee." When the VNA nurse came on Thursday morning, he
recommended that he go straight to the hospital "or he will
die." Was brought to [**Hospital 1281**] Hospital for temporary stabilization
before transfer to [**Hospital1 18**] for continuity of care with patient's
cardiologist Dr. [**Last Name (STitle) 5686**].
.
At [**Hospital 1281**] Hospital found to have O2 sat 84% on RA improved to
100% on 40% O2 NRB. Exam showed bibasilar crackles, LE edema to
knees and edema in arms. Given ASA, Lasix 80mg IV, nitropaste,
SL nitro x 3. Put out 300cc urine. OSH labs significant for HCT
28, K 5.0, Cr 2.0, alb 3.0.
.
In the [**Hospital1 18**] ED t 97.5, HR 71, BP 89/49 rr 24 02 98% venti mask.
Nitropaste removed. BP 75-80s and dopamine started with good
effect. CPAP placed. Had an episode of "VT" and ICD fired in ED.
Admitted to CCU for CHF exacerbation.
.
Per daughter, patient has not had chest pain. He has dyspnea on
exertion as well as orthopnea and ankle edema. No syncope or
presyncope Has no history of stroke, TIA, deep venous
thrombosis, or pulmonary embolism. No recent fevers, chills,
rigors, or sick contacts. [**Name (NI) **] of the other review of systems
were negative.
Past Medical History:
hypertension
hyperlipidemia
CAD s/p CABG in [**2167**]
ICD placement [**2179**] [**2-18**] VF arrest
CHF (EF 20-30% on this admission)
h/o of chronic A-fib on Coumadin
h/o Colon ca with remote surgery and uptodate colon-ca screening
Depression/anxiety/ mild dementia
h/o of RBBB
Social History:
Lives in Sunrise Senior [**Hospital3 400**] in [**Location (un) 16848**]. Has meds
dispensed and administered to him there. Social history is
significant for the absence of current tobacco use. Former
smoker with 20-40 year pack history, quit 20 years ago.
Family History:
There is a + family history of premature coronary artery
disease: brother died of MI at 38, dad died when pt was 17 (? of
CAD), son died of stroke @47
Physical Exam:
VS: T 97.1, BP102/87 , HR 76, RR14 , O2 100 % on CPAP 50% FIO2
Gen: WDWN elderly male in NAD, resp or otherwise. CPAP in place,
awakens, but does not want to participate in exam.
HEENT: NCAT. Sclera anicteric. Eyes closed, mask overlying edges
of eyelids. Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa.
Neck: Supple Neck veins engorged with apex of JVP unseen while
patient laying in bed at approx 60 degrees.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. Intermittent s3 with 3/6 holosystolic murmur
at LLSB, soft diastolic murmur at LLSB, Distant heart sounds. No
rv heave
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Coarse breath sounds
bilaterally, crackles at bases
Abd: Obese, soft, NTND, + hepatomegaly with pulsatile liver. No
abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: Has ecchymoses on UE, stasis dermatitis on LE,
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
ADMISSION LABS
CBC:
WBC-6.1 RBC-3.33* Hgb-9.8* Hct-30.1* MCV-90 MCH-29.3 MCHC-32.4
RDW-16.8* Plt Ct-128*
.
CHEM:
Glucose-80 UreaN-54* Creat-2.0*# Na-134 K-5.0 Cl-101 HCO3-26
AnGap-12
.
COAGS:
PT-17.5* PTT-36.5* INR(PT)-1.6*
.
LFTs:
ALT-16 AST-24 LD(LDH)-324* CK(CPK)-42 AlkPhos-123* TotBili-1.4
.
LIPIDS:
Triglyc-54 HDL-57 CHOL/HD-2.2 LDLcalc-60 Total Chol 128
.
CEs:
cTropnT-0.10*
cTropnT-0.09*
.
Digoxin-0.9
.
TFTs:
TSH-1.1
Free T4-1.4
.
Random cortisol
Cortsol-19.5
.
[**2180-10-19**] CXR:
IMPRESSION:
1. CHF with bilateral pleural effusions, worse than on [**2179-4-3**].
2. Retrocardiac opacity may represent atelectasis, pulmonary
consolidation or combination of both.
.
[**2180-10-19**] EKG
7PM: Ventricular paced rhythm with wide QRS complexes. Compared
to the prior tracing of [**2179-5-19**] there is a marked diminution in
QRS voltage. Clinical correlation is suggested.
10PM: Atrial fibrillation and increase in rate. As compared with
prior tracing of [**2180-10-19**] right bundle-branch block is now
evident. The limb lead voltage is markedly diminished. There was
low limb lead voltage recorded on [**2179-4-2**] and it is further
reduced. Followup and clinical correlation are suggested.
.
[**2180-10-20**] ECHO
The left atrium is markedly dilated. The right atrium is
markedly dilated. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is severely depressed (LVEF=
20-30 %) secondary to severe hypokinesis/akinesis of the
interventricular septum, anterior free wall, and apex. The right
ventricular free wall is hypertrophied. The right ventricular
cavity is dilated. Right ventricular systolic function appears
depressed. There is abnormal septal motion/position consistent
with right ventricular pressure/volume overload. The aortic root
is mildly dilated at the sinus level. The ascending aorta is
moderately dilated. The aortic valve leaflets are moderately
thickened. There is mild aortic valve stenosis. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. The tricuspid
valve leaflets are mildly thickened. The supporting structures
of the tricuspid valve are thickened/fibrotic. Severe [4+]
tricuspid regurgitation is seen. The main pulmonary artery is
dilated. The branch pulmonary arteries are dilated.
.
[**2180-10-25**] CT Abd/Pelv
IMPRESSION:
1. Bilateral rectus sheath hematomas.
2. Small focal dissection of the infrarenal aorta.
3. Large bilateral pleural effusions, trace ascites.
4. Diffuse calcified granulomata involving the visualized
aspects of the lungs.
5. Diffuse edema and venous distention consistent with the
provided history of CHF. A surgical staple line is seen in the
region of the sigmoid colon, suggesting prior surgery in this
region, although a radiopaque anastomotic suture line is not
identified.
.
Brief Hospital Course:
#. CHF - Presented in decompensated heart failure with
hypotension and respiratory distress. Was placed on dopamine and
CPAP in the ED. In the CCU we began a lasix drip with eventual
diuresis of almost >10 liters. His home CHF reg of carvedilol
and lisinopril were held given his hypotension and ARF on
presentation. Eventually weaned from dopamine gtt with marginal
BPs (MAP in 50-60s). An echo confirmed systolic CHF with an EF
of 20-30% as well as severe (4+) TR. Patient was eventually
taken off lasix drip and begun on an oral diuresis regimen of
budesonide and metolazone. For CHF, he was started on
spironolactone and eventually a BB (Toprol XL) was restarted as
well. He was also restarted on digoxin qMWF. His repsiratory
status improved throughout his stay and he was in compensated
heart failure at the time of discharge. On discharge, his
diuretic regimen included spirnolactone and bumex. His ACE was
held at discharge pending creatinine stabilization and blood
pressure tolerance. This should be reassesses after discharge.
.
# Rhythm - Has a ventricularly paced rhythm with paroxysmal
a-fib. Had pacer placed in [**2179**] after a VF arrest. The ICD fired
in the OSH and he was restarted on amiodarone loading. In the ED
here, the ICD reportedly fired again, but EP interrogation of
the pacer revealed no VT/VF or discharges. We continued
antiarryhthmic regimen with amiodarone loading (now down to
maintenence of 400mg daily). There were no episodes of VT during
this hospitalization. Of note, he was found to have bilateral
rectus sheath hematomas on evalutation for palpable suprapubic
mass, and for this reason anticoagulation was held during his
stay. Coumadin should be restarted as an outpatient.
.
#. Persistent Hypotension - Patient presented to ED hypotensive
and was started on doapmine drip. Was refractory to weaning for
almost one week, but eventually able to wean off and maintain
BPs in 90s SBP. The most likely etiology for his hypotension was
cardiogenic shock.
.
#. CAD - gave medical secondary prevention with ASA, statin, but
initially held BB and ACE in setting of hypotension and renal
failure. Small troponin leak most consistent with CHF
exacerbation. EKGs with no obvious ischemia. Eventually added on
Toprol XL.
.
# Renal insufficiency - unclear baseline, diuresed to small
creatinine bump (Cr 1.7).
.
# Dementia - continued aricept 5mg daily. Patient exhibited
frequent disorientation and forgetfulness while int he hospital.
He was also agitated at night, and so olanzapine 2.5mg qHS was
added with good effect.
.
# Depression/Anxiety: appeared depressed and irritable
throughout stay. Increased mirtazapine to 30mg po qHS
.
# Rectus Sheath Hematoma: stable during hospitalization.
Coumadin and hep SC held pending resolution. Coumadin should be
restarted on resolution of rectus sheath hematoma.
.
# FEN - FLUID RESTRICTION of 1200cc daily!! Low NA+ cardiac
diet!
.
# Code: confirmed DNR/DNI
.
Medications on Admission:
Aricept 5mg daily
carvedilol 6.25mg [**Hospital1 **]
Lisinopril 5mg daily
ASA 81mg daily
Simvastatin 40mg daily
digoxin 0.125mg qMWF
potassium 20mEq [**Hospital1 **]
Remeron 22.5mg qHS
amiodarone 400mg [**Hospital1 **]
Advair Diskus 1 puff inh [**Hospital1 **]
Tylenol 650mg q4h prn
Kenolog 1% apply [**Hospital1 **]
Coumadin 1 mg daily
Ativan 0.5mg q6h prn
Milk of Magnesia 30mL prn
Colace 100mg [**Hospital1 **]
Discharge Medications:
1. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
7. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
9. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Bumetanide 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
13. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
14. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO MWF
(Monday-Wednesday-Friday).
15. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-18**]
Drops Ophthalmic PRN (as needed).
16. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
[**Hospital1 **] (2 times a day) as needed for itchiness.
17. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
18. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
19. Triamcinolone Acetonide 0.1 % Cream Sig: One (1) Appl
Topical TID (3 times a day) as needed for pruritis.
20. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 14468**] Nursing & Rehabilitation Center - [**Location (un) 1456**]
Discharge Diagnosis:
Primary: Congestive Heart Failure
.
Secondary:
Coronary Artery Disease
atrial fibrillation
chronic renal insufficiency
dementia
Discharge Condition:
improved, normotensive, no respiratory distess
Discharge Instructions:
You were admitted ot the hospital with an exacerbation of your
congestive heart failure. We gave you diuretics ("water pills")
to remove the excess fluid that was causing your shortness of
breath. We also had to temporarily support your blood pressure
with a medicine called dopamine until your body could regulate
the blood pressure better on its own.
.
While you were here we also did a CT scan of your abdomen since
we felt a mass there. It turns out that the mass was a hematoma
(bleed) in the wall of an abdominal muscle. Your body will
absorb the blood on its own.
.
You have a heart rhythm called atrial fibrillation, which puts
you at an increased risk for having a stroke. To prevent
strokes, most patients with atrial fibrilliation take a blood
thinning medicine called coumadin. You will need to begin taking
coumadin as an outpatient. We are not giving it to you right now
due to the bleeding you had in your abdominal wall. Your primary
care doctor should begin this medicine at a future date.
.
Please take all of your medicines as prescribed. Please keep all
of your follow up appointments. If you experience any shortness
of breath or chest pain please call your doctor or go to the ER.
Followup Instructions:
You have an appointment to see your Primary Care Physician
[**Name9 (PRE) 24576**],[**Name9 (PRE) 198**] [**Name Initial (PRE) **] [**Telephone/Fax (1) 24579**] on Wednesday, [**11-8**],
at 3:15PM.
.
Please follow-up with your cardiologist Dr. [**Last Name (STitle) 5686**], [**First Name3 (LF) **] ,
MD [**Telephone/Fax (1) 11554**], in [**1-18**] weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
Completed by:[**2180-11-1**]
ICD9 Codes: 5849, 311, 5859, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1425
} | Medical Text: Admission Date: [**2147-9-16**] Discharge Date: [**2147-9-19**]
Date of Birth: [**2103-7-8**] Sex: M
Service: MED
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Known firstname 943**]
Chief Complaint:
emesis/melena
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
Pt is a 44 yo male with h/o Hep C/etOH cirrhosis and hepatoma
s/p ablation and known esophageal varices who p/w emesis and
melena since yesterday. He was given 7 day course of amoxicillin
and naprosyn for toothache and was scheduled to have his
extraction today. However, he started to have black stool(X6)
and threw up black material(X2). No BRBPR. Called his liver
doctor and referred to ED for evaluation of GIB. Despite known
varices, he has no known history of GIB requiring transfusion in
the past. Pt denied any CP/SOB/F/C/NS. In ED, afebrile and
hemodynamically stable. He was transfused 1U plt in ED for plt
count of 47.
Past Medical History:
1. Cirrhosis (Hep C/etOH)
2. hepatoma -s/p ablation now on transplant list/evaluation
3. Esophageal varices
4. s/p femur/tibia/fib fx
5. h/o polysubstance abuse
Social History:
44 yo man, currently unemployed who lives with girlfriend.
h/o alcohol use remission for 5 years
tobacco-1ppd X22 yrs
h/o cocaine, heroine, amphetamine abuse - none since [**2138**]
Family History:
mother died of MI at 65 yo
Physical Exam:
On admission:
T: 98 HR: 72 BP: 102/55 RR: 20 O2 sat: 99% RA
General: mildly juandiced middle aged male, A&OX3, NAD
HEENT: PERRL, EOMI, OP-clear, neck supple, no LAD, JVP flat
lungs: CTA bilat with good air movt, nml work of breathing
cardiac: distant heart sounds, rrr, no m/g/r
abd:mod distention, non tender +ascites, stool black and guaiac
positive
no flank/CVA tenderness
ext: no c/c/e, warm with good capillary refill
Pertinent Results:
[**2147-9-16**] 09:05PM HCT-26.8*
[**2147-9-16**] 03:47PM GLUCOSE-88 UREA N-22* CREAT-0.6 SODIUM-137
POTASSIUM-4.1 CHLORIDE-108 TOTAL CO2-24 ANION GAP-9
[**2147-9-16**] 03:47PM ALT(SGPT)-51* AST(SGOT)-64* LD(LDH)-210 ALK
PHOS-84 TOT BILI-1.6*
[**2147-9-16**] 03:47PM ALBUMIN-3.3* CALCIUM-8.8 PHOSPHATE-3.1
MAGNESIUM-1.7 IRON-319*
[**2147-9-16**] 03:47PM calTIBC-332 FERRITIN-237 TRF-255
[**2147-9-16**] 03:47PM ETHANOL-NEG
[**2147-9-16**] 03:47PM WBC-5.5# RBC-3.00*# HGB-11.0*# HCT-30.1*#
MCV-101* MCH-36.6* MCHC-36.4* RDW-15.3
[**2147-9-16**] 03:47PM NEUTS-60.8 LYMPHS-31.7 MONOS-5.2 EOS-1.9
BASOS-0.4
[**2147-9-16**] 03:47PM MACROCYT-2+
[**2147-9-16**] 03:47PM PLT COUNT-47*
[**2147-9-16**] 03:47PM PT-14.5* PTT-29.7 INR(PT)-1.3
[**2147-9-16**] 03:47PM RET AUT-4.2*
Brief Hospital Course:
A/P: pt is 44 yo male with hep c cirrhosis, HCC and UGI bleed in
setting of known varices s/p 7 days of nsaid use.
1. GI bleed: Pt was admitted to the MICU for evaluation and
urgent EGD. He was hemodynamically stable throughout admission.
GI bleed thought more likely due to NSAID use than esophageal
varices as varices noted to be mild in past. On admission, he
was started on octreotide transiently. He was transfused 2 units
of PRBC's to keep hct >25 prior to transfer to floor. Endoscopy
revealed: 3 cords of grade 1 varices in lower [**1-14**] of esoph but
no active bleeding. Stomach: melena seen in body but no sign of
active bleeding;antrum with erythema but no bleeding; multiple
acute superficial ulcers 2-5mm in antrum with pigmented material
suggestive of recent bleeding. He was started on carafate,
protonix, and H pylori serology sentand were negative for
H.Pylori. Emesis resolved s/p EGD and advanced to PO diet which
he tolerated well. Transferred to floor on [**9-17**]. That evening hct
dropped from 31 to 25.1(24.6 on repeat) and he was transfused 1
unit of blood(3rd during admission). He responded appropriately
with hct inc to 27.9. His hct remained stable throughout rest of
admission and had increased to 30.5 by time of discharge. On
discharge, reinforced importance of avoiding NSAIDS to prevent
further GI bleeds.
2. HEME: Thrombocytopenic on admission with platelets of 47. He
has received 1 Units of platelets on admission. On the floor, pt
was transfused another 3 units of platelets to keep plt>75, per
hepatology recommendations. Plt on discharge were 89.
3. [**Name (NI) 52965**] Pt is currently undergoing transplant evaluation.
He was continued on oupt dose of nadalol during admission. He
received one week of ciprofloxacin for SBP prophylaxis in
setting of UGIB. Pt will be in touch with Dr. [**Last Name (STitle) 497**] for
recommendations of oral surgeons to perform his tooth
extraction. He will need this procedure to be done in hospital
setting where hct and platelets can be monitored. He is also to
f/u in liver center on [**9-21**] as previously scheduled.
4. Smoking cessation - discussed with patient impact of smoking
on health and benefits of cessation. He expressed interest in
quiting and was successful on nicotine patch during admission.
He was discharged on the patch
Medications on Admission:
nadolol 60 mg po daily
lactulose
mvi
Discharge Medications:
1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
2. Pantoprazole Sodium 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*
3. Multivitamin Capsule Sig: One (1) Cap PO QD (once a day).
4. Nadolol 20 mg Tablet Sig: Three (3) Tablet PO QD (once a
day).
5. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal QHS (once a day (at bedtime)).
6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
7. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain uncontrolled by Tylenol.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. GI bleed
2. PUD - EGD on [**2147-9-16**]
3. cirhhosis
4. HCC
5. esophageal varices
Discharge Condition:
stable
Discharge Instructions:
Please call the liver clinic or return to the ER if you
experience nausea, vomiting, dizziness, or continued black
stools.
Please take all medications as prescribed. Complete the
remaining 3 days of Ciprofloxacin.
Please call Dr.[**Name (NI) 948**] office tomorrow regarding appointment
with the oral surgeon who will be performing your tooth
extraction. This should be done in a supervised setting where
your blood levels and platelets can be monitored.
Followup Instructions:
Provider: [**Name10 (NameIs) **] TRANSPLANT,ORIENTATION TRANSPLANT
CENTER-MEDICINE Where: TRANSPLANT CENTER-MEDICINE
Date/Time:[**2147-9-21**] 3:00
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Where: LM [**Hospital Unit Name 7129**]
CENTER Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2147-10-12**] 9:15
Where: PSYCH TRANSPLANT Date/Time:[**2148-2-27**] 1:30
ICD9 Codes: 2851, 5715 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1426
} | Medical Text: Admission Date: [**2186-9-3**] Discharge Date: [**2186-9-8**]
Date of Birth: [**2142-12-16**] Sex: M
Service: MEDICINE
Allergies:
Demerol
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
cardiac arrest
Major Surgical or Invasive Procedure:
Pacemaker/ICD generator change [**2186-9-5**]
History of Present Illness:
42 yo M CAD s/p MI '[**78**] (tx with TPA with rescue PCI of p LAD),
no significant dz on cath in '[**84**], ESRD on HD, former smoker, h/o
recent tunnelled HD line sepsis (pulled 2 weeks ago, on vanco at
HD since) p/w n/v and respiratory distress. Found by EMS to be
bradycardic HR 50 with agonal respirations at a rate of 4/min,
then became pulseless with wide complex irregular rhythym,
shocked 3 times, unclear number of shocks delivered by patients
own device, pulse regained, but with wide complex rhythym.
Intubated in the field. Self extubated en route to [**Location (un) **].
.
At [**Location (un) **] vitals V paced at 70, BP 140/113 R 17 sat 100% NRB,
had ABG 7.19/32/116 K 5.2 HCO3 12 trop I 0.11, treated with:
lidocaine gtt (which had been stopped prior to arrival to [**Hospital1 **]),
D50, insulin, Ca; He was then medflighted to [**Hospital1 **] for further
management.
.
On arrival to [**Hospital1 **], vital signs remained stable. ABG 7.27/36/228 K
5.6 lactate 2.6, given D50, insulin, bicarb, Ca, and kayexylate.
K peaked at 6.3, but most recently is 5.0. EKG here shows V
paced rhythym at 82 bpm.
EP interrogated the device.
Past Medical History:
ESRD on HD via L forearm AV graft at [**Location (un) 1157**] North County
Kidney Center
CAD s/p MI '[**78**], tPA and rescue PCI of LAD
EF 20%
LV thrombus
h/o VT
s/p pacer and ICD
recent line sepsis, line pulled, treating with vanco at HD
Social History:
former smoker
Family History:
non-contributory
Brief Hospital Course:
Overnight: Renal came to see patient and felt K was not the
precipitant for these rhythyms. EP interogated his paced and
found several episodes of VT and VF, many of the VT episodes
were below his lower rate threshold to shock (> 188 bpm). His
device was reprogrammed to treat VT at rate > 170 and record
rates >150. There was no inappropriate function of ICD detected.
We increased his toprol from 25 to 50, left his amio at 200
daily, plan for possible EPS in next few days.
.
A/P
42 yo M CAD s/p MI '[**78**], no significant dz on cath in '[**84**], EF
20%, ESRD on HD, presents with V-fib/v-tach arrest with delayed
ICD response.
1. V-tach/v-fib:
Interrogation of the device revealed that the pt had episodes of
V-tach which degenerated into v-fib. The device was found to be
functioning appropriately to the parameters with which it was
programmed. The device was not programmed to detect V-tach so it
only shocked him when it degenerated into v-fib. The EP
consultant changed v tach sensing parameters to detect rates
below 188 and added in anti-tachycardia pacing function. The
device will try ATP twice, then shock. The pt underwent a
prcedure for the generator change of the device. The pt
underwent this procedure without complications. The pt remained
stable without further episodes of arrhythmia during the
hospitalization.
.
2. CHF:
pt currently well compensated. EF 20% by report. Echo was done
at [**Hospital1 18**] to eval cardiac fxn. The coumadin which the pt takes
for mural thrombus and CHF was held for the EP procedure, then
restarted afterwards. The pt was continued on his home
medications.
.
3. Renal failure
Pt was found to be in metabolic acidosis with bicarb 17. K 6.3.
Pt recieved calcium, insulin, bicarb, kayhexelate in ED. He was
dialyzed while in the hospital. The AV graft was not functioning
optimally for dialsis, with elevated pressures and suboptimal
flow, although he was able dialyze. A AV fistulogram was
obtained which revealed venous obstruction. Renal and transplant
surgery teams followed the pt. The pt was informed of the need
to see his regular renal physician for planning to revise the
AVF.
.
4. CAD:
no active ischemia during hospitalization. ASA/statin/BB were
continued
.
5. ID:
being treated for tunneled r IJ line infection. R IJ was pulled
2 weeks ago. Vanco with HD was recommended for an additional
week, because a device was implanted.
.
6. Ppx: heparin when INR <2
.
7. FEN: follow K, renagel 2400, NPO p MN
Medications on Admission:
ASA 81 po qd
dig 0.125 po qfriday
Toprol XL 25 po qd
Warfarin 2.5 daily
Lipitor 40 PO qd
Amio 200 po qd
Discharge Medications:
1. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Sevelamer 800 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
6. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (once) for
1 doses.
7. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous QHD (each hemodialysis) for 7 days.
8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a week.
Discharge Disposition:
Home
Discharge Diagnosis:
Ventricular tachycardia
Unstable arrhythmia
Discharge Condition:
good
Discharge Instructions:
Please take all of your medicines as directed.
.
Please continue the vancomycin for one week with the dialysis
sessions to prevent the new pacemaker device from becoming
infected.
.
If you have chest pain that lasts longer than 20 minutes, or if
you have episodes of passing out or dizziness, please call your
doctor or go to the emergency room.
Followup Instructions:
Provider DEVICE CLINIC Where: [**Hospital6 29**] CARDIAC SERVICES
Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2186-9-14**] 1:30.
.
Please make an appointment to see your nephrologist regarding
sugery to improve the function of the AV fistula.
ICD9 Codes: 4271, 4280, 2762, 412, 2859, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1427
} | Medical Text: Admission Date: [**2193-5-9**] Discharge Date: [**2193-5-22**]
Date of Birth: [**2161-1-29**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 983**]
Chief Complaint:
Overdose
Major Surgical or Invasive Procedure:
- Flexible bronchoscopy with bronchoalveolar lavage
and upper endoscopy [**5-9**]
- Temporary HD line placed on [**2193-5-13**]
- Permanent Right HD line placement on [**2193-5-17**]
History of Present Illness:
The patient is a 32 y/o M with unknown PMHx who was brought to
OSH ED after being found altered at his apartment. Was found
with suicide note as well as numerous empty Coridicin HBP
packages (>100tabs). Febrile to 105 at OSH, agitated, delirious.
Intubated at OSH and found to have elevated AST/ALT. Per MA/RI
PCC, pt was started on NAC. Was also given vanc/ceftriaxone due
to fever and Leukocytosis to 35 with bandemia.
On arrival to [**Hospital1 18**] ED, toxicology was consulted. Recommended to
continue NAC. Labs were significant for Na 150, Cl 114, HCO3 18,
Cr 3.9. CK [**Numeric Identifier 111890**]. Ca 6.8. ALT 185, AST 1070. Lipase 95. Serum
Osm 321 (Osmolar gap 1). WBC 17.9. Urine tox was positive
opiates and cocaine. Serum tox was negative (including
acetaminophen). Most recent ABG 7.23/50/114/22. CXR was
unremarkable. CT head showed no acute intracranial process but
did show soft tissue air in the right masticator, parapharyngeal
and prevertebral space. CT neck and chest showed
pneumomediastinum, bilateral pneumothoraces, as well as
subcutaneous air. ETT noted to have cuff leak and was changed.
On arrival to the MICU, the patient was intubated and sedated.
ROS was unable to be obtained.
(At the time of admission, patient's identity was [**Last Name (un) 6722**])
Past Medical History:
- Bipolar Disorder II
- Depression: H/o multiple suicide attempts and prior h/o
dextromethorphan abuse and overdose in past. Recently
hospitazied twice at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for depression. Since [**93**] yo
had issues w/ etoh and marijuana; at 16 yo milatary academy; ICU
2x during college for dextramethorphan abuse; 10 years ago otc
decongestant w/ ste/htn crisis
3 years manic depressive girlfriend broke up with
- has been at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] 3x (last time [**Month (only) **] for depression;
suicide attempt; od on adderal)
-does not have outpatient psychiatrist
Social History:
Patient works as a professor [**First Name (Titles) **] [**Last Name (Titles) 21569**] History at an online
college program based in Cypress, [**State 2690**]. Has had job for 4 yrs.
He also recently taught at Northshore Community College but lost
his teaching contract in this Spring. Pt currently lives alone.
- tobacco:+ 2 packs of cigarettes a day
- etoh: 12 packs of beer/wk.
- illicits: prior h/o dextromethorphan abuse, Patient uses
Adderall one week per month. Stated occasional use of cocaine
but "not often" because of cost. Last used it over the weekend.
EtOH use: Smokes
- housing: lives alone
- employement: teaches history, graduate degree
- family: father in [**Location (un) 3844**] ENT physician, [**Name10 (NameIs) **] in
[**State 15946**], one of 8 (oldest son) children
Family History:
No significant family history of kidney disease
Physical Exam:
ADMISSION
Vitals: T: 97.2 BP: 133/95 P: 75 R: 22 O2: 100%
General: sedated and intubated, no apparent distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, pupils
dilated but reactive
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: Foley present, dark brown urine
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: sedated
DISCHARGE
Vitals: T 98.7 BP 170/98 HR 87 RR 18 pOx 95 on RA
General: NAD
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
CV: rrr, normal S1 + S2, no murmurs, rubs, gallops
CHEST: tunneled dialysis line (RIGHT IJ) in place
non-erythematous
Lungs: clear through out
Abdomen: soft, non-tender no rebound or gaurding
Ext: No clubbing/cyanosis/edema.
NEURO: CN III-XII intact, motor 5/5 strength through out,
tremulous w/ FNF no asterixis.
PSYCH: Denies SI/HI, depressed mood with constricted affect
Pertinent Results:
ADMISSION LABS
[**2193-5-9**] 12:00AM BLOOD WBC-17.9* RBC-3.64* Hgb-13.0* Hct-38.3*
MCV-105* MCH-35.6* MCHC-33.8 RDW-14.0 Plt Ct-155
[**2193-5-9**] 12:00AM BLOOD Neuts-92* Bands-2 Lymphs-3* Monos-2 Eos-0
Baso-0 Atyps-0 Metas-1* Myelos-0
[**2193-5-9**] 12:00AM BLOOD Glucose-128* UreaN-35* Creat-3.9* Na-150*
K-3.5 Cl-114* HCO3-18* AnGap-22*
[**2193-5-9**] 12:00AM BLOOD ALT-185* AST-1070* CK(CPK)-[**Numeric Identifier 111890**]*
AlkPhos-44 TotBili-0.3
[**2193-5-9**] 12:00AM BLOOD Albumin-3.9 Calcium-6.8* Phos-5.5* Mg-2.6
PERTINENT LABS:
[**2193-5-9**] 12:00AM BLOOD Glucose-128* UreaN-35* Creat-3.9* Na-150*
K-3.5 Cl-114* HCO3-18* AnGap-22*
[**2193-5-9**] 12:00AM BLOOD ALT-185* AST-1070* CK(CPK)-[**Numeric Identifier 111890**]*
AlkPhos-44 TotBili-0.3
[**2193-5-9**] 12:00AM BLOOD Lipase-95*
[**2193-5-9**] 12:00AM BLOOD cTropnT-<0.01
[**2193-5-9**] 12:00AM BLOOD Lithium-LESS THAN
[**2193-5-9**] 12:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2193-5-9**] 12:04AM BLOOD pO2-227* pCO2-44 pH-7.26* calTCO2-21 Base
XS--6
[**2193-5-9**] 12:36AM BLOOD Lactate-0.4*
[**2193-5-9**] 03:00AM BLOOD O2 Sat-94
[**2193-5-9**] 06:06AM BLOOD freeCa-0.97*
[**2193-5-9**] 12:00AM BLOOD Lithium-LESS THAN
SEROLOGIES:
[**2193-5-13**] 04:01PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2193-5-13**] 04:01PM BLOOD HCV Ab-NEGATIVE
CXR - FINDINGS: Comparison is made to previous study from
[**2190-12-13**]. There is an endotracheal tube whose tip is
2.5 cm above the carina. This could be pulled back
approximately 1 cm for more optimal placement. There is a
nasogastric tube whose tip and side port are below the
gastroesophageal junction. Lungs are grossly clear. There is
scoliosis. There is normal heart size. No pneumothoraces are
identified.
NCHCT [**2193-5-9**]:
1. Normal brain CT.
2. Soft tissue air in the right masticator, parapharyngeal and
prevertebral space of unknown etiology. CT of the neck and
chest might be considered.
CT CHEST [**2193-5-9**]:
1. Moderate pneumomediastinum and small bilateral
pneumothoraces.
2. Small bilateral pleural effusions and bibasilar opacities,
likely
aspiration or atelectasis.
3. Bilateral supraclavicular soft tissue air.
4. Appropriately placed ET and OGT. No evidence of esophageal or
tracheal
injury on CT.
5. No fractures.
CT NECK [**2193-5-9**]:
1. Moderate to large amount of soft tissue gas, most pronounced
in the R>L supraclavicular regions, along the
sternocleidomastoid muscles of the neck, the upper neck
prevertebral soft tissues and the partially seen mediastinum.
2. Small, only partially seen left pneumothorax.
3. No large neck hematoma, and no fracture.
RENAL US [**2193-5-9**]:
1. Echogenic renal parenchyma bilaterally, compatible with
diffuse
parenchymal disease. No hydronephrosis.
2. Trace right perinephric fluid.
CT NECK [**2193-5-11**]:
1. Interval decrease in soft tissue gas involving mediastinum,
bilateral
supraclavicular regions, right sternocleidomastoid, and right
masticator
spaces.
2. New bilateral moderate-sized pleural effusions, right
slightly greater than left, incompletely imaged.
3. Interval extubation.
4. Previously seen left apical pneumothorax is no longer
visualized.
CT CHEST [**2193-5-11**]:
1. Interval decrease in pneumomediastinum and supraclavicular
subcutaneous soft tissue air.
2. Slight interval decrease in size of bilateral small pleural
effusions. Associated atelectasis is also present.
3. Interval resolution of small bilateral pneumothoraces.
BARIUM SWALLOW [**2193-5-11**]:
Swallows of thin barium in the frontal, lateral, and oblique
positions show normal swallow function without evidence of leak.
The column of barium is seen extending through the esophagus to
the stomach without evidence of leak in the esophagus. There is
no definite motility dysfunction. The stomach fills normally.
There is no evidence of obstruction at the gastroesophageal
junction or elsewhere in the upper GI tract.
IMPRESSION: No evidence of pharyngeal or esophageal leak with
persistent
pneumomediastinum and soft tissue gas.
KUB [**2193-5-12**]:
There is contrast material seen throughout the colon including
the
appendix. There are few air-filled loops of small bowel,
however, there is no free intra-abdominal gas. Contrast in the
stomach fundus is also seen. Bony structures are grossly
intact.
RUQ US [**2193-5-14**]:
The liver is normal in size and appearance. No focal liver
lesion
is identified. No biliary dilatation is seen and the common
duct measures 0.4 cm. The portal vein is patent with
hepatopetal flow. The gallbladder is normal. The pancreas is
unremarkable, but is only partially visualized due to overlying
bowel gas. The spleen is at the upper limits of normal
measuring 12.2 cm. No hydronephrosis is seen on limited views
of the kidneys. The aorta is of normal caliber but is only
minimally visualized. The intrahepatic portion of the IVC is
unremarkable. No ascites is seen in the abdomen. A small right
and left pleural effusion is noted.
IMPRESSION:
1. No gallstones and no biliary dilatation.
2. Small bilateral pleural effusions.
CXR [**2193-5-15**]:
PA and lateral radiographs of the chest demonstrate interval
resolution of pulmonary edema from the mid and upper lung field
when compared to the study from three days ago. There are
persistent bilateral lower lung
opacities representing residual edema and/or atelectasis. Small
pleural
effusions are also present. The hilar and cardiomediastinal
contours are
normal. There is no pneumothorax. There is no evidence of
residual
pneumomediastinum. A right subclavian hemodialysis catheter has
been placed and terminates at the expected location of the
cavoatrial junction.
IMPRESSION:
1. Interval improvement in pulmonary edema with some persistence
in the
bilateral lung bases.
2. Small bilateral pleural effusions and atelectasis.
3. No evidence of pneumomediastinum.
NCHCT:
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass
effect, or infarction. Specifically, regions of the posterior
occipital lobes are unremarkable. The ventricles and sulci are
normal in size and configuration for the patient's age. The
basal cisterns are patent. There is preservation of [**Doctor Last Name 352**]-white
matter differentiation. No fracture is identified. There is a
small mucous retention cyst within the right maxillary sinus.
The remainder of the visualized paranasal sinuses, mastoid air
cells, and middle ear cavities is clear. The previously seen
subcutaneous emphysema has resolved.
IMPRESSION: No acute intracranial process. Specifically, no
changes in the posterior occipital lobes suggestive of PRES
syndrome.
CXR [**2193-5-20**]:
Lung volumes remain quite low and there is substantial bibasilar
atelectasis which has not cleared over several days. Mild
vascular congestion is new, small bilateral pleural effusions
are stable. Small nodular opacities in the lungs are probably
vessels on end and hazy opacification in the lower lungs is
probably mild pulmonary edema. Dialysis catheters end in the
right atrium. Small bilateral pleural effusions are slightly
larger today than on [**5-15**]. No pneumothorax. Heart size top
normal, unchanged.
DISCHARGE LABS:
[**2193-5-22**] 08:00AM BLOOD WBC-11.7* RBC-2.42* Hgb-8.3* Hct-24.8*
MCV-103* MCH-34.4* MCHC-33.6 RDW-13.4 Plt Ct-238
[**2193-5-22**] 08:00AM BLOOD Glucose-80 UreaN-20 Creat-8.2*# Na-137
K-3.9 Cl-98 HCO3-29 AnGap-14
[**2193-5-21**] 08:20AM BLOOD ALT-59* AST-91* AlkPhos-41 TotBili-0.3
[**2193-5-20**] 11:15AM BLOOD Lipase-298*
[**2193-5-22**] 08:00AM BLOOD Calcium-8.2* Phos-4.1 Mg-1.9
MICROBIOLOGY:
Urine culture [**2193-5-9**] negative
Blood culture [**2193-5-13**] negative
Blood cultures 06/15/-[**5-22**] pending (no growth to date)
Brief Hospital Course:
32M with a history of bipolar disorder and depression who
presented from an outside hospital with anuric renal failure due
to rhabdomyolysis secondary to a toxic ingestion of cough syrup,
acute hypoxemic respiratory failure s/p traumatic intubation
resulting in pneumomediastinum. He is currently medically stable
on chronic hemodialysis.
#OVERDOSE: Patient was brought to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] hospital ED where
he was found to be febrile to 105, agitated, and delirious with
elevated LFTs. He was intubated in setting of airway protection
and hypoxemic respiratory failure, and empirically started on
n-acetylcysteine (NAC)as well as vancomycin/ceftriaxone due to
fever and leukocytosis to 35 with bandemia. Following transfer
to [**Hospital1 18**] ED, toxicology was consulted. The patient was
continued on NAC. Notable labs included Na 150, Cl 114, HCO3 18,
Cr 3.9, and CK [**Numeric Identifier 111890**], Ca 6.8, ALT 185, and AST 1070, WBC 17.9.
Per the initial toxicology recs, patient most likely experienced
serotonin syndrome as a result of his ingestion (Coricidin
contains dextromethorphan, chlorpheniramine, +/- acetaminophen).
The patient's urine tox screen was also positive for cocaine and
opiates, but his serum tox screen was negative for
acetaminophen. Patient's LFTs continued to worsen in the
setting of patient's significant rhabdomyolysis despite
aggressive fluid hydration. His rhabdomyolysis resolved with CK
and LFTs trending downward.
#RHABDOMYOLYSIS: The patient's rhabdomyolysis was likely due to
hyperthermia and his toxic ingestion. He received aggressive LR
fluid hydration in the setting of hyperchloremia and
hypernatremia. He was repleted with bicarb and 1 liter NS. Over
the course of his hospitalization, the patient's CKs began to
trend downwards and had normalized with the initiation of
dialysis.
#TRANSAMINITIS: The patient had a transaminitis on admission
initially concerning for ischemia or tylenol use and was started
on NAC treatment, though these were rapidly elminated from the
differential. His transaminitis were felt to be secondary to
rhabdomyolysis and began to improve over the course of his stay
and with the initiation of dialysis. There was no evidence of
hepatologic pathology, hepatitis serologies were sent and were
negative.
#ANURIC RENAL FAILURE: The [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) **] was most likely [**1-3**]
rhabdomyolysis. The patient was aggressive hydrated initially
with LR in the setting of hyperchloremia/hypernatremia. Per
renal consult's recs, LR was discontinued briefly because of
transient hyperkalemia and the patient was switched to 1/2 NS
and repleted with more bicarb. The patient was once more
switched back to LR because of recurrent hyperchloremia and
hypernatremia. The patient's Cr continued to trend up during
his stay in the MICU, and urine output was minimal. Renal
recommended a trial of Lasix 150 mg to help diuresis him, given
his volume overload and anuria but he was not responsive.
Patient continued to develop a worsening acidosis with
compensatory tachypnea. A temporary dialysis catheter was
placed by IR on [**5-13**] and the patient was started on dialysis
with rapid correction in his acidosis and overall clinical
status. As he tolerated dialysis well without recover of his
urine output, ranging from 100 - 400 cc daily, he was
transitioned to a tunneled HD catheter for chronic
administration of hemodialysis. He did well on a MWF dialysis
schedule and discharged with a plan to continue on this schedule
for longterm.
Of note, Hepatitis B and C serologies suggestive no history of
hepatitis C and immunity to Hepatitis B. He also had a PPD that
was < 2 mm induration.
.
SEDATION: The patient was initially sedated with propofol
following admission to the MICU to avoid to avoid worsening his
rhabdomyolysis. However, the patient was weaned off his
propofol and self-extubated the day following admission.
#PNEUMOMEDIASTINUM: The patient was evaluated by both Thoracic
Surgery and ENT for his pneumomediastinum. Thoracic surgery
performed bronchoscopy and endoscopy and noted no tear from the
carina all the way up to the cricoid. ENT noted some bruising
of his left lateral laryngeal wall (possible site of tear) and
thought that the pneumomediastinum was likely [**1-3**] a traumatic
intubation prior to admission at the OSH followed by bagging,
causing air to track down his mediastinum. The patient was
started on an empirical 7 day course of Unasyn and followed with
serial physical exams. Chest Xray from [**5-15**] showed radiographic
resolution of pneumomediastinum.
#LEUKOCYTOSIS: Patient's WBC was elevated at 17.9 at admission,
but quickly normalized following admission. His leukocytosis
was likely [**1-3**] stress demargination. Patient was treated with
Unasyn for 7 day course as prophylaxis for mediastinitis. He
again developed a WBC late in his hospitalization and was
evaluated for infectious causes with a negative CXR, urinalysis,
urine culture and blood culture. His WBC count trended down
over the course of his stay on the medical service without
further concern for infection.
#DEPRESSION: Patient was followed by psychiatry and social work
during his hospitalization. He was started on hydroxazine 25 mg
Q6H PRN for anxiety. Patient will be discharged to medical
facility.
#HYPERTENSION: On admission, the patient was transiently
hypertensive to the 170s, felt to be secondary to volume
overload and discomfort. Renal has been performing ultra
filtration in an effort to decrease intravascular volume and
started on labetalol 200 mg [**Hospital1 **] for further control.
As patient did not have existing hypertension prior to his toxic
insult he was not felt to be at high risk for developing end
organ damage and permissive blood pressures to the 160s were
felt resonable as he was likely to further improve with ongoing
dialysis. He did had a NCHCT to evaluate for evidence of PRES
syndrome given his nausea and vomitting that developed late in
his hospitalization, but there was no radiographic evidence of
demylenation. His nausea and headache resolved with further
dialysis treatments.
At this juncture, he will continue on labetalol for renovascular
hypertension.
NAUSEA/ABDOMINAL PAIN: On [**2193-5-18**] the patient developed nasuea
with vomitting, given his persistent hypertension a central
cause was explored and no radiographic evidence of PRES syndrome
was identified. The patient's symptoms were felt to be related
to uremia secondary to 48 hours without dialysis. The patient
resumed dialysis on [**2193-5-20**] per his usual schedule with
improvement in his symptoms.
It was also thought around [**2193-5-18**] that the patient could have
developed pancreatitis given elevated lipase in setting of
Carbamazepine re-initiation. His home Carbamazepine was
subsequently held. This medication should be avoided in the
future. His abdominal symptoms and nausea resolved with
conservative measurements.
TRANSITIONAL ISSUES
- He will need to establish with a primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 111891**]n with repeat LFTs and CK on outpatient basis to
trend to normalization as psychiatric discharge
-MWF dilaysis
-monitor urine output
-full code
- Contact: Father Dr. [**Known firstname **] [**Known lastname 111892**] [**Telephone/Fax (1) 111893**], [**Telephone/Fax (1) 111894**].
Medications on Admission:
Zyprexa 5mg daily
Tegretol 200mg [**Hospital1 **]
(pt states both meds are from prescriptions he received after
his
hospitaliztion)
Discharge Medications:
1. Calcium Carbonate 500 mg PO QID:PRN heartburn/indigestion
2. Docusate Sodium (Liquid) 100 mg PO BID
3. HydrOXYzine 25 mg PO Q6H:PRN anxiety
hold for sedation, RR<10
4. OLANZapine 5 mg PO HS
5. Pantoprazole 40 mg PO Q24H
6. Artificial Tear Ointment 1 Appl BOTH EYES QID:PRN dry eyes
7. Labetalol 300 mg PO BID
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary:
- acute oliguric renal failure secondary to rhabdomyolysis
- mood disorder NOS with suicide attempt
- rhabdomyolysis
- pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were transferred to [**Hospital1 18**] after overdosing on cough syrup in
an attempt to kill yourself. As a result, you have injured your
kidneys badly and require hemodialysis. You also had
pneumomediastinum from a traumatic intubation, which has
resolved. We also think that you developed briefly pancreatitis
from your home medication (tegretol), which you should not take
any more.
Overall, you had a complex hospital course. You will need to
remain on dialysis as your kidneys are still failing. You will
be discharged to a psychiatric facility for further therapy.
Followup Instructions:
You should establish care with a primary care physician after
psychiatric discharge.
You should also establish care with a nephrologist (kidney
doctor).
If you need assistance with finding a doctor, please call
1-[**Telephone/Fax (1) 70946**]
ICD9 Codes: 5845, 2762, 2760, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1428
} | Medical Text: Admission Date: [**2155-6-5**] Discharge Date: [**2155-6-10**]
Date of Birth: [**2118-8-30**] Sex: M
Service: MEDICINE
Allergies:
Shellfish
Attending:[**First Name3 (LF) 13256**]
Chief Complaint:
tylenol overdose, ALF, ARF
Major Surgical or Invasive Procedure:
none
History of Present Illness:
36 year old man with h/o headaches transferred on [**2155-6-5**] with
ALF and ARF. Patient took approximately 9g of tylenol over the
course of a day for a headache. Unintentional. Afterward
experienced abdominal pain and N/V. Went to an OSH were he was
found to have Acute liver failure (AST >15,000 and ALT>7,000)
and acute renal failure. NAC was started and he was transferred
here for transplant evaluation. Patient was initially in the
SICU where NAC was continued and his LFTs and renal function
have been improving so he is being called out to the
[**Doctor Last Name **]-[**Doctor Last Name **] service.
Past Medical History:
-Hx recurrent UTIs (in his teens-college yrs; none since age 19)
- Recurrent headaches accompanied by vomiting
Social History:
Active smoker. Drinks 10-12 drinks/week. Smoked marijuana in
college, no active drug use. Never used cocaine or IV drugs.
Family History:
No family history of kidney or liver disease
Physical Exam:
Admission exam
VITALS: 98.0, 180/94, 72, 16, 98% RA, UOP >2L so far today
GENERAL: WDWN man in NAD
HEENT: Left eye hemorrhage (stable per pt), PEERL, EOMI, no
icterus
NECK: Supple, no carotid bruits, no JVD
LUNGS: CTAB
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly
EXTREMITIES: WWP, no edema
NEUROLOGIC: A&Ox3, CN II-XII intact, strength and sensation
intact, no asterixis
Discharge exam
Vitals: 98.5 152/104 77 20 98%ra
GENERAL: pleasant, well appearing man in NAD
HEENT: Left eye hemorrhage (stable per pt), PERRL, EOMI, no
icterus
NECK: Supple, no carotid bruits, no JVD
LUNGS: CTAB
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no organomegaly
EXTREMITIES: WWP, no edema
NEUROLOGIC: A&Ox3, CN II-XII intact, strength and sensation
intact, no asterixis
Pertinent Results:
Admission labs
[**2155-6-5**] 02:30PM BLOOD WBC-4.5 RBC-5.00 Hgb-13.3* Hct-40.2
MCV-80* MCH-26.6* MCHC-33.1 RDW-14.5 Plt Ct-156
[**2155-6-5**] 02:30PM BLOOD PT-33.6* PTT-27.5 INR(PT)-3.3*
[**2155-6-5**] 02:30PM BLOOD Glucose-147* UreaN-52* Creat-5.9* Na-139
K-4.8 Cl-97 HCO3-22 AnGap-25*
[**2155-6-5**] 02:30PM BLOOD ALT-7947* AST-[**Numeric Identifier 83953**]* AlkPhos-116
TotBili-4.5*
[**2155-6-5**] 02:30PM BLOOD Albumin-3.9 Calcium-7.4* Phos-5.0* Mg-1.7
[**2155-6-5**] 02:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-15
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2155-6-5**] 02:34PM BLOOD Type-[**Last Name (un) **] Temp-36.7 pO2-64* pCO2-36
pH-7.35 calTCO2-21 Base XS--4 Comment-GREEN TOP
[**2155-6-5**] 02:34PM BLOOD Lactate-5.0*
Discharge labs
[**2155-6-10**] 07:14AM BLOOD WBC-6.3 RBC-4.01* Hgb-10.3* Hct-31.5*
MCV-79* MCH-25.7* MCHC-32.7 RDW-16.4* Plt Ct-156
[**2155-6-10**] 07:14AM BLOOD PT-14.7* PTT-28.7 INR(PT)-1.4*
[**2155-6-10**] 07:14AM BLOOD Glucose-87 UreaN-23* Creat-2.0*# Na-143
K-2.9* Cl-111* HCO3-24 AnGap-11
[**2155-6-10**] 07:14AM BLOOD ALT-903* AST-84* LD(LDH)-305* AlkPhos-118
TotBili-2.5*
[**2155-6-10**] 07:14AM BLOOD Albumin-3.0* Calcium-7.7* Phos-3.9 Mg-1.6
[**2155-6-6**] 10:28AM BLOOD Lactate-1.4
CXR [**6-5**]: No acute cardiopulmonary process
RUQ U/S [**6-5**]: The liver is normal without focal or textural
abnormality. Color and spectral Doppler evaluation of the main,
left, and right portal veins demonstrate patency with
hepatopetal flow. The gallbladder is normal without wall
thickening or gallstone. The common duct measures 4 mm and
there is no intra- or extra-hepatic bile duct dilatation. The
visualized portion of the pancreas is unremarkable. The
pancreatic tail is obscured by overlying bowel gas. Mild
splenomegaly is present with the spleen measuring 13.8 cm.
Bilateral kidneys are normal without hydronephrosis or stone.
The right kidney measures 12.6 cm and the left kidney measures
12.1 cm. The bladder contains a Foley and is collapsed. The
aorta is of normal caliber throughout. The visualized portions
of the inferior vena cava appear normal. IMPRESSION: Mild
splenomegaly. Patent portal veins. Normal-appearing kidneys.
TTE [**2155-6-6**]: 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 65%). 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
mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
Brief Hospital Course:
Mr [**Known lastname **] is a 36yoM with h/o headaches who presents s/p
accidental tylenol overdose with ALF and ARF.
.
# Acute liver failure: Secondary to tylenol toxicity. He
presented with elevated Tbili to 4.5, INR that would peak at
3.3, ALT ~7,000, AST ~15,000, LDH 3,800. He was started on NAC
per protocol. Fortunately, he did well, and all his labs trended
down. NAC was stopped after 4 days. A transplant work-up was
done, but will likely be unnecessary. By discharge, his INR was
1.4, alt/ast were < 1000, t bili normalizing. He has no PCP, [**Name10 (NameIs) **]
was encouraged Finished NAC on [**2155-6-9**]. LFTs/coags have been
downtrending. As he has no PCP [**Name Initial (PRE) 81010**] (he is working on
getting one closer to his home), we arranged f/u in liver clinic
for now.
.
# Acute renal failure: Likely secondary to ATN from renal
hypoperfusion (from vomiting), and direct tylenol toxicity. His
creatinine was 5.9 on admission, peaked at 7.3, and he was
discharged w/ a creatinine of 2.0. No renal replacement therapy
was required. Urine output remained good during this time. He
was advised to stay hydrated, and to avoid NSAIDs, tylenol, and
other nephrotoxins.
.
# Hypertension: Patient denies a prior history of hypertension,
therefore is likely due to acute illness and renal failure. As
his blood pressure was as high as 180's/110's, and we wanted to
avoid further kidney injury, he was started on labetolol 200mg
PO BID. He tolerated this well, and will continue on it for now.
He will establish care w/ a PCP to monitor HTN, and if it
resolves he can stop. If he continues to have HTN, once [**Last Name (un) **]
resolves, likely he should be switched to a different [**Doctor Last Name 360**]
given he is a young, active male, and a beta-blocker would not
be first line therapy.
.
# CODE STATUS: full (confirmed)
# EMERGENCY CONTACT: [**Name (NI) 21206**] [**Name (NI) **] ([**Telephone/Fax (1) 111903**]
================================================
TRANSITIONAL ISSUES
# no new medications, herbals, supplements without consent of a
doctor
# no alcohol for time being
# no tylenol, NSAIDs, or OTC meds without consent of a doctor
# monitor blood pressure in outpatient setting. Wean off
labetolol as tolerates, or change to different class once [**Last Name (un) **]
resolves
# should have repeat chem 10, PT/PTT/INR, LFTs within 1 week. Pt
given script for this. Will establish new PCP, [**Name10 (NameIs) **] has liver
clinic f/u arranged
Medications on Admission:
none
Discharge Medications:
1. Labetalol 200 mg PO BID
hold for SBP < 100 or HR < 60
RX *labetalol 200 mg 1 Tablet(s) by mouth [**Hospital1 **] (twice a day) Disp
#*60 Tablet Refills:*0
2. Outpatient Lab Work
chem 7, ALT, AST, total bilirubin, Alk phos, INR, CBC
Fax results to: Dr [**First Name (STitle) **] [**Name (STitle) 111904**]
Fax: ([**Telephone/Fax (1) 4409**]
Phone: ([**Telephone/Fax (1) 89943**]
Discharge Disposition:
Home
Discharge Diagnosis:
- acetaminophen toxicity
- acute liver injury
- acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr [**Known lastname **],
It was a pleasure taking care of youat [**Hospital1 18**]. You were admitted
with acetaminophen (tylenol) toxicity. For this, you were given
medications, and you improved.
It is very important that you DO NOT: take tylenol, advil,
ibuprofen, naproxen, herbal medications, supplements, or ANY
other medication without the express consent of your doctor.
Also, do not drink any alcohol. Eat a healthy, well balanced
diet.
You will need follow up, and labs drawn, by your new PCP.
The following changes have been made to your medications:
** START labetolol (blood pressure control)
Followup Instructions:
It is recommended that you establish care with a Primary Care
Physician within the next week. If you need assistance finding a
PCP outside the [**Name9 (PRE) 86**] area, your local hospital or healthcare
center can be a resource. If you are looking for a PCP in the
[**Name9 (PRE) 86**] area or need further assistance please call the [**Hospital1 18**]
Find-A-Doc line at ([**Telephone/Fax (1) 29108**]. We are able to assist you
between the hours of 8:30 AM- 5:00 PM Monday through Friday.
Department: LIVER CENTER
When: WEDNESDAY [**2155-6-18**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 5845, 4019, 3051, 2768 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1429
} | Medical Text: Admission Date: [**2159-6-13**] Discharge Date: [**2159-6-19**]
Service: UROLOGY
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is an 84-year-old
Russian female who was transferred from the [**Hospital3 4527**]
Hospital with a history of fever times five days. The
patient has a history of non-insulin-dependent diabetes
mellitus and hypertension. There is a questionable history
of renal stones times 20 years. The patient was initially
evaluated at [**Hospital6 4620**] where a CT scan
demonstrated large left renal pelvis staghorn stone with
emphysematous changes associated with the stone in the renal
pelvis. The patient continues to have low grade temperatures
despite overnight intravenous antibiotic treatment. At the
time of presentation to the [**Hospital1 188**], the patient did have decreased oral intake, fatigue
and left-sided abdominal pain. She denied vomiting and had
been taking Motrin at home for pain control. She was
hemodynamically stable at the time of presentation. She had
been receiving intravenous Cipro from the previous hospital.
PAST MEDICAL HISTORY:
1. Non-insulin-dependent diabetes mellitus.
2. Hypertension.
PAST SURGICAL HISTORY: Polypectomy approximately 20 years
ago.
MEDICATIONS:
1. Atenolol 25 mg p.o. q. day.
2. Avandia 2 mg p.o. b.i.d.
3. Norvasc 5 mg p.o. q. day.
4. Lasix 40 mg p.o. q. day.
ALLERGIES: Glucophage and Glucotrol.
PHYSICAL EXAMINATION ON ADMISSION: On admission the vital
signs were as follows: Temperature 100.8 degrees, pulse 78,
blood pressure 162/50, respirations 20, oxygenation 94% on
room air. The patient appeared to be in mild distress. She
was moderately obese. Her HEENT examination revealed a clear
oropharynx with extraocular movements intact. Her lungs were
clear to auscultation bilaterally. There was no
costovertebral angle tenderness, however, there were palpable
masses. Cardiac examination: Regular rate and rhythm, no
murmurs, rubs or gallops. Her abdominal examination was
soft, non-tender, non-distended obese with normoactive bowel
sounds. There was no rebound tenderness nor guarding. There
were no masses palpable. Extremities: Warm, full range of
motion, no clubbing, cyanosis or edema. Neuro: Grossly
intact.
LABORATORY ON ADMISSION: The patient had a set of labs from
the outside hospital which revealed a white blood cell count
of 12.0 with 86% segs. Her BUN was 44, creatinine 1.9,
hematocrit 29.0. Her blood sugar was 280.
RADIOLOGY: A CT scan from the [**Hospital3 4527**] Hospital
demonstrated large staghorn calculus approximately 2.2 x 1.5
cm with emphysematous changes of the collecting system.
There were also perinephric inflammatory changes. There was
no ureteral dilatation. There was no air in the renal
parenchyma. The CT scan repeated at [**Hospital1 190**] revealed persistent emphysematous changes
associated with a large renal pelvis stone.
HOSPITAL COURSE: After appropriate consent was obtained, the
patient was emergently taken to surgery whereby an open stone
extraction was performed. A left percutaneous nephrostomy
tube was placed along with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**] and a Foley
catheter. She was extubated in the Post Anesthesia Care Unit
and was discharged to the floor in stable condition.
Postoperatively, the patient remained afebrile and had an
uneventful hospital course. She was treated with intravenous
ciprofloxacin and metronidazole for her cultures which showed
coagulase negative Staphylococcus and E. coli. On
postoperative day one the patient's Foley catheter was
removed and she was able to tolerate a regular diet. On
postoperative day two her percutaneous nephrostomy tube was
clamped and was subsequently removed on postoperative day
three. Her pain was well controlled. She diuresed
appropriately and she was evaluated for rehabilitation
placement on postoperative day four.
CONDITION AT DISCHARGE: Good.
DISCHARGE STATUS: To a short term rehabilitation center
where she will be able to regain her baseline level of
functioning.
DISCHARGE DIAGNOSES:
1. Left emphysematous pyelonephritis.
2. Non-insulin-dependent diabetes mellitus.
3. Hypertension.
[**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8916**]
Dictated By:[**Last Name (NamePattern1) 26023**]
MEDQUIST36
D: [**2159-6-18**] 19:20
T: [**2159-6-18**] 19:18
JOB#: [**Job Number 52167**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1430
} | Medical Text: Admission Date: [**2103-4-20**] Discharge Date: [**2103-4-26**]
Date of Birth: [**2018-2-14**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Renal Cell carcinoma
Major Surgical or Invasive Procedure:
[**2103-4-20**]: Left laparoscopic radical nephrectomy and Laparoscopic
paraaortic lymph node dissection with Dr [**Last Name (STitle) 3748**]
Caval thrombectomy and reconstruction with Dr [**Last Name (STitle) 816**]
History of Present Illness:
This patient currently lives in [**Location 4194**] and presented several
weeks ago with left testicular swelling. Ultrasound eventually
led to an abdominal ultrasound, which showed a large left renal
mass and a tumor thrombus into the cava, but below the hepatic
veins. Per outpatient note, he denied hematuria, frequency,
nocturia, or dysuria. He denies weight loss, night sweats,
chills, change in appetite. He has fairly chronic constipation,
but is able to move his bowels.
He also complains of some vague chronic right shoulder pain,
right knee pain. He will be admitted following surgery to be
done by Dr [**Last Name (STitle) 3748**] and Dr [**Last Name (STitle) 816**].
Past Medical History:
Radical prostatectomy 10 years ago,
hypertension controlled with medications, cataract surgery [**07**]
years ago, left hernia repair 20 years ago
Social History:
Live is [**Country 4194**], He is a retired IRS tax collector from [**Country 4194**].
No tobacco, social alcohol, no drug use. He exercises and
performs yoga three times per week. He walks 20 minutes on a
treadmill several times per week.
Family History:
negative for prostate, kidney, or bladder cancer.
Physical Exam:
VS: 98.7, 94, 110/47, 12, 96% 4L (post op)
General: Alert, responsive
Card: RRR
Lungs: CTA bilaterally
Abd: Soft, non-distended, appropriately tender to plapation,
incisions/dressings; C/D/I
Extr: No edema
Pertinent Results:
On Admission: [**2103-4-20**]
WBC-6.6 RBC-3.60* Hgb-10.3* Hct-31.0* MCV-86 MCH-28.6 MCHC-33.2
RDW-13.6 Plt Ct-302
PT-12.9 PTT-26.9 INR(PT)-1.1
Glucose-143* UreaN-27* Creat-1.7* Na-139 K-4.3 Cl-111* HCO3-22
AnGap-10
ALT-52* AST-136* AlkPhos-50 TotBili-0.3
Calcium-8.3* Phos-4.0 Mg-2.5
On Discharge: [**2103-4-26**]
WBC-7.2 RBC-3.53* Hgb-10.1* Hct-30.3* MCV-86 MCH-28.6 MCHC-33.4
RDW-13.8 Plt Ct-320
Glucose-96 UreaN-46* Creat-2.0* Na-140 K-3.7 Cl-107 HCO3-22
AnGap-15
ALT-26 AST-72* AlkPhos-58 TotBili-0.5
Calcium-7.6* Phos-2.8 Mg-2.2
Brief Hospital Course:
85 y/o male who underwent Left laparoscopic radical nephrectomy
and laparoscopic para-aortic lymph node dissection with Dr
[**Last Name (STitle) 3748**] and Caval thrombectomy and reconstruction with Dr [**Last Name (STitle) 816**]
for Renal cell carcinoma with tumor extension into the left
renal vein and inferior vena cava. During the surgery, the large
left renal tumor was seen emanating out of the left
retroperitoneum. The renal vein which
contained the tumor thrombus as it coursed over the aorta was
removed. As well, an adrenalectomy was performed. Once the
kidney was removed, Dr [**Last Name (STitle) 816**] was able to remove the tumor
thrombus by transecting the left renal vein. It was removed in
its entirety in one piece. Please see both operative notes for
surgical detail. The patient tolerated the procedure without
complication. He was transferred to the SICU.
The patient had a mild ileus, with emesis, and a KUB showing
dilated loops of bowel. NGT was placed with 700 cc removed.
However on POD 3 he self d/c'd the NGT, but it was not replaced
as his abdominal exam had improved greatly. Sips were started
and diet advanced slowly with good tolerance.
He had an initally lower urine output, this improved daily, 1 -
1.5 liters daily.
He did have fever to 101.4 on POD 3. Urine culture was no
growth. Blood culture remained pending on day of discharge but
was no growth to date.
The patient was transferred to [**Hospital Ward Name 121**] 10, and he remained on Dr
[**Last Name (STitle) 15283**] service, and followed by urology team.
He was evaluated by PT who thought he should be discharged with
home PT. Follow up appointments have been arranged.
Medications on Admission:
MVI,ASA,Metamuzil,Prilosec,Propafenonine,Rhythmol
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Propafenone 150 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
3. Propafenone 150 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Prilosec 10 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Micardis 80 mg Tablet Sig: One (1) Tablet PO QD ().
9. Psyllium Packet Sig: One (1) Packet PO QOD ().
Discharge Disposition:
Home
Discharge Diagnosis:
Left Renal cell cancer with tumor extension into the left renal
vein and inferior vena cava.
Discharge Condition:
Stable/Good
A+Ox3
Ambulatory with PT/assistive devices
Discharge Instructions:
Please call Dr [**Last Name (STitle) 15283**] office at [**Telephone/Fax (1) 673**] for fever, chills,
nausea, vomiting, diarrhea, increased abdominal pain, inability
to take or keep down food, fluids or medications.
Monitor the incision for redness, drainage or bleeding
You will also be following up with Dr [**Last Name (STitle) 18846**] office
No heavy lifting
Drink enough fluids to keep the urine light yellow in color
Followup Instructions:
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2103-5-3**] 9:30;
[**Hospital **] Medical Office Building, [**Last Name (NamePattern1) **]
DR. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3752**] Date/Time:[**2103-5-10**] 2:15.
[**Hospital Ward Name 516**]
Completed by:[**2103-4-27**]
ICD9 Codes: 5859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1431
} | Medical Text: Admission Date: [**2166-9-22**] Discharge Date: [**2166-9-25**]
Date of Birth: [**2090-5-28**] Sex: F
Service: NEUROLOGY
Allergies:
tobramycin
Attending:[**First Name3 (LF) 2927**]
Chief Complaint:
unresponsive episodes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 76yo W with a history of atrial fibrillation, chronic
obstructive pulmonary disease, squamous cell carcinoma (s/p
radiation and chemotherapy), chronic trach/[**First Name3 (LF) 282**] dependent who
developed acute unresponsiveness on [**2166-9-21**]. She was
recently discharged from the [**Last Name (un) 1724**] ICU approximately one week or
so ago where she was hospitalized for pneumonia/pneumonitis.
During this hospitalization, she was trach'd/[**Last Name (un) 282**]'d and
transferred to [**Hospital3 **] for vent weaning. The
patient happened to be seen at [**Last Name (un) 1724**] on the afternoon of
[**2166-9-21**] by the on call neurologist. These are his first
impressions:
"This morning in rehab she had been fine, alert and
communicating with her husband through lip [**Location (un) 1131**] and writing.
Suddenly at 11:45 a.m. her head slumped to one side and eyes
rolled upward. She arrived in the emergency room at 12:06. On
arrival, she was unresponsive. A stroke burst page was
activated. Noncontrast head CT was negative. CT angiogram was
negative. Because of multiple risks (recent tracheostomy, chest
tube and [**Location (un) 282**] placement, INR 3 yesterday, and NIH stroke score of
greater than 25), she was not felt to be a tPA candidate. I
examined her immediately after the head CT, prior to MRI. At
that time, she had no response to voice or sternal rub. There
was no withdrawal of the limbs to nailbed pressure, although if
a limb was raised passively, she could hold it in place. There
was no clear asymmetry of strength. There was no meningismus.
The right pupil was 7 mm, left 5 mm, both sluggishly reactive.
Corneal reflexes were present bilaterally. Oculocephalic
responses were absent, although there were occasional
spontaneous eye movements to both the right and left. There were
some weak blinking movements of the eyelids, but no other
spontaneous motor activity. The exam raised a concern for
nonconvulsive seizure. She was given lorazepam 1 mg IV prior to
the MRI. MRI of the brain showed no acute infarction or other
obvious structural lesion. On arrival in the emergency room,
again she was given another milligram of lorazepam IV and I
recommended a loading dose of IV phenytoin."
Following her load of phenytoin, the patient did not receive her
complete 1gm dose of IV phenytoin because after the first 500mg,
she became hypotensive to the 70/43. Dilantin was stopped. This
also occurred in the setting of having received ativan as noted
above. She was aggressively fluid resuscitated and transferred
to the intensive care unit. At that time, the neurologist once
again had the pleasure of examining the patient. These were his
impressions at the time:
"When I reexamined her at 2:15 p.m., she could open eyes
spontaneously and look to voice. She followed a few simple
commands including closing the mouth, opening the eyes and
sticking out the tongue. She made weak attempts to grip with
both the right and left hands. She appropriately shook her head
no when asked if her name was [**Doctor First Name **] but weakly nodded to [**Known firstname **].
She could bend her knees to command. Pupils were 6 mm on the
right, 5 mm on the left, each constricting by 1 mm with light.
Eye movements were full. Corneal reflexes were symmetric. More
detailed sensory testing was not possible. There was no clear
facial weakness. The tongue was midline. Strength appeared
symmetric without clear weakness. Reflexes were 2+ and
symmetric in the biceps,
brachioradialis and patellar tendons, 1+ at the Achilles
tendons. Plantar stimulation produced withdrawal bilaterally.
Sensory exam was limited in the limbs, although she appeared to
feel nailbed pressure in all 4 limbs."
Later that day, [**Known firstname **] became more alert, in the setting of
initiating dilantin TID dosing. Overnight, she did well. This
morning, the patient was noted to be more drowsy and
unresponsive. The precise story is unclear. The patient's family
today report that she was more "anxious" but that in fact she
did become more "unresponsive". She also did complain of some
chest/stomach discomfort that was initially thought to be
cardiac in nature. She received some nitroglycerin which dropped
her blood pressures, and ultimately required more fluid boluses.
Her EKG and cardiac enzymes were normal. Later, they thought
that perhaps it might have been related to problems with [**Name2 (NI) 282**]
tube feeds. Her [**Name2 (NI) 282**] feeds were stopped and she received a CT
scan of her abdomen/pelvis which only showed evidence of
pancreatic ductal dilatation without free fluid or
intraperitoneal air. Her "responsiveness" also subsequently
improved throughout the course of this day. Since this OSH was
not able to check an EEG, she was ultimately transferred to the
[**Hospital1 18**] for EEG monitoring and further work up for possible NCSE.
Review of Systems: As mentioned above in the HPI. The patient's
family reports that she has had some tremors in the past week
which they recognize as possibly related to seizures (?). These
were mainly of her lower extremities. Otherwise, they deny any
fevers, dysuria, pain complaints, difficulties with diplopia,
dizziness.
Past Medical History:
1. Squamous cell lung carcinoma diagnosed in [**Month (only) 116**]. Status post
chemotherapy and radiation, reportedly completed in [**Month (only) 205**]. Course
complicated by radiation pneumonitis which has required multiple
steroid tapers.
2. COPD, on home oxygen for 2 years.
3. Atrial fibrillation, on anticoagulation with Coumadin. Also
on amiodarone/diltiazem for rate control
4. Recent pneumonia and pneumothorax, with a most recent
admission to [**Hospital3 **] from [**8-30**] to [**9-12**].
During that admission, she had placement of a chest tube,
tracheostomy on [**9-9**] and [**Month (only) 282**] tube placement [**9-10**].
5. Hypothyroidism.
6. Anemia of chronic disease.
7. Hypertension.
8. Herpes zoster, reportedly involving the right eye and face
early this year.
Social History:
Strong family support system, married. Never smoker, non
alcoholic
Family History:
Positive for "grand mal" seizures in her grandson
Physical Exam:
ADMISSION PHYSICAL EXAM:
Physical Exam:
Vitals: AF, 109/56, 67, 96%, 19
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx, tracheostomized
Neck: Supple, no masses or lymphadenopathy
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: Thin, [**Month (only) 282**] in place, soft, NT/ND, no masses or
organomegaly noted.
Extremities:warm and well perfused
Skin: Multiple erythematous/purple bruises over bilateral upper
and lower extremities.
Neurologic:
-Mental Status: Alert, oriented to [**2166-10-6**]. She speaks
without a PMV and literally whispers. Her eyes tend to remain
closed when she is not interactive, but will quickly open her
eyes when you call her name. Her language is fluent without
naming errors or paraphasias.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 6-4mm and brisk.
III, IV and VI: EOM are intact and full, sustained nystagmus on
right lateral gaze
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, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis noted. In general, she moves all extremities well.
Symmetric proximal muscle weakness (4 to 4+/5) prominently in
deltoids, triceps, iliopsoas.
-Sensory: No deficits to light touch throughout
-DTRs: [**Name2 (NI) 20772**] throughout
Plantar response: Mute
-Coordination: No intention tremor
-Gait: Not tested
DISCHARGE PHYSICAL EXAM:
Vitals: 97.8, 99/54, 65, 16, 98% on CPAP
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx, tracheostomized
Neck: Supple, no masses or lymphadenopathy
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: Thin, [**Name2 (NI) 282**] in place, soft, NT/ND, no masses or
organomegaly noted.
Extremities:warm and well perfused
Skin: Multiple erythematous/purple bruises over bilateral upper
and lower extremities.
Neurologic:
-Mental Status: Alert, oriented to [**2166-9-13**] but not the
date. She intermittently thinks she is at a hospital. She
speaks without a PMV and whispers. Her eyes tend to remain
closed when she is not interactive, but will quickly open her
eyes when you call her name. Her language is fluent without
naming errors or paraphasias. She is able to follow commands.
-Cranial Nerves:
I: Olfaction not tested.
II: L pupil 6->3mm and R pupil 5->3mm, both mildly sluggish.
III, IV and VI: EOM are intact and full, sustained nystagmus on
right lateral gaze
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, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis noted. In general, she moves all extremities well.
Symmetric proximal muscle weakness (4 to 4+/5) prominently in
deltoids, triceps, iliopsoas.
-Sensory: No deficits to light touch throughout
-DTRs: [**Name2 (NI) 20772**] throughout
Plantar response: Mute
-Coordination: No intention tremor
-Gait: Not tested
Pertinent Results:
ADMISSION LABS:
[**2166-9-22**] 08:45PM BLOOD WBC-4.5 RBC-2.88* Hgb-8.9* Hct-28.0*
MCV-97 MCH-31.0 MCHC-31.9 RDW-16.2* Plt Ct-200
[**2166-9-22**] 08:45PM BLOOD PT-43.8* PTT-40.2* INR(PT)-4.5*
[**2166-9-22**] 08:45PM BLOOD Glucose-108* UreaN-10 Creat-0.3* Na-141
K-4.0 Cl-103 HCO3-30 AnGap-12
[**2166-9-22**] 08:45PM BLOOD ALT-52* AST-25 LD(LDH)-277* CK(CPK)-22*
AlkPhos-56 TotBili-0.3
[**2166-9-22**] 08:45PM BLOOD CK-MB-2 cTropnT-<0.01
[**2166-9-23**] 04:03AM BLOOD CK-MB-2 cTropnT-<0.01
[**2166-9-22**] 08:45PM BLOOD Albumin-3.2* Calcium-8.3* Phos-2.8 Mg-1.7
[**2166-9-22**] 08:45PM BLOOD Phenyto-16.1
DISCHARGE LABS:
[**2166-9-25**] 02:11AM BLOOD WBC-3.9* RBC-3.03* Hgb-9.7* Hct-28.9*
MCV-95 MCH-32.1* MCHC-33.7 RDW-16.4* Plt Ct-205
[**2166-9-25**] 07:48AM BLOOD PT-33.3* INR(PT)-3.3*
[**2166-9-25**] 02:11AM BLOOD Glucose-98 UreaN-15 Creat-0.5 Na-141
K-3.7 Cl-103 HCO3-33* AnGap-9
[**2166-9-23**] 11:16PM BLOOD Calcium-8.3* Phos-2.4* Mg-2.0
[**2166-9-24**] 04:34PM BLOOD Type-MIX pO2-35* pCO2-57* pH-7.42
calTCO2-38* Base XS-9
IMAGING:
CXR [**2166-9-23**]: FINDINGS: No previous images.
There is substantial scoliosis with degenerative change
involving the thoracic spine, convex to the right, which makes
it somewhat difficult to properly evaluate the heart and lungs.
The right lung and visualized portion of the left lung are clear
without evidence of vascular congestion. Opacification at the
left base most likely reflects atelectasis and effusion. Right
subclavian catheter extends to the mid-to-lower portion of the
SVC.
TTE [**2166-9-24**]: Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF 65%). 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 ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
KUB [**2166-9-24**]: IMPRESSION: No evidence of obstruction or ileus.
Brief Hospital Course:
This is a 76yo W with a history of squamous cell carcinoma of
the lung, atrial fibrillation on coumadin, history of radiation
pneumonitis who was recently tracheostomized and gastrostomized
and doing well in rehabilitation who had an acute episode of
unresponsiveness concerning for seizure, transferred here for
EEG monitoring.
.
# Neuro: While here on [**9-24**] she had another episode of
unresponsiveness after having been given haldol for ICU
delirium. She was on continuous EEG monitoring, which showed no
seizure activity. Therefore, her unresponsiveness episodes are
more likely related to medications or metabolic issues and not
seizure activity. She should not receive haldol in the future.
We used seroquel as needed instead, which did not cause pt to
have unresponsiveness episodes. She was put on AEDs at the OSH,
so it is possible that if she was having seizures before we
aren't seeing them because they are now controlled. When she
arrived, we stopped her dilantin and increased her keppra to
750mg [**Hospital1 **]. Her MRI (which was brought in by pt's son on CD) was
unremarkable. Given her lung cancer we consider leptomeningeal
carcinomatosis as a possible cause of her unresponsiveness
episodes, however this is extremely unlikely to cause
intermittent unresponsiveness. We were unableto obtain an LP
while she was here because her INR was persistently elevated
(likely in part because of interaction with dilantin), and we
felt it was too dangerous to reverse her anticoagulation. At
some point in the future, if she becomes more persistently
unresponsive while also being more medically stable, it may be
worth considering an LP.
# Cardiovascular: we cotinued her home diltiazem and amiodarone
for rate control. She did have some episodes of atrial
fibrillation while being monitored on telemtery with some [**1-16**]
second pauses, which were asymptomatic. This will need to be
further monitored in the future. We continued her on her home
simvastatin for primary prevention. When she got here, her INR
was supratherapeutic, reaching a peak of 4.7. Her coumadin was
held and when she left her INR was 3.3. She will need her
coumadin restarted once her INR drifts lower.
# Optho: pt with hx of open angle glaucoma, followed by Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 91057**] ([**Telephone/Fax (1) 91058**]), s/p iridotomies bilaterally, not
on any eye drops per pt and Dr. [**Last Name (STitle) 91057**], who on admission was
noted to have bilaterally dilated and minimally reactive pupils,
new since last exam in [**Month (only) 116**]. We consulted optho for concern of
open angle glaucoma crisis (she was alert and conversant with no
neurological reason for the eye findings), but they found normal
pressure in both eyes. Optho felt that her eye findings were
secondary to ipratropium nebs given at the OSH, and surely
enough, the next day (after not having gotten ipratropium at our
institution) her eyes were smaller and more reactive.
# Pulmonary: She was able to be off of CPAP through her trach
for almost 24 hours, but became very tired and so we decided to
keep her on CPAP at night at least to prevent fatigue from WOB.
She was continued on PRN albuterol but not ipratropium as above.
Her sputum culture grew GNRs, but pt was asymptomatic, and this
was from a culture taken on arrival. We decided not to treat,
but if she has any issues in the future, she may need
antibiotics.
# CODE: full - confirmed with patient and family, contact
daughter: [**Telephone/Fax (1) 91059**]
PENDING RESULTS:
Sputum Culture speciation [**2166-9-23**]
BCx x2 [**2166-9-23**]
Final read of EEG from [**Date range (1) **], however prelim reads by an
attending epileptologist showed no seizure activity.
TRANSITIONAL CARE ISSUES:
Patient will need her INR followed and her coumadin restarted
when her INR drifts down further. Her vent weaning will need to
be continued while at rehab.
Medications on Admission:
Nitroglycerin tablet sublingual 0.4 mg p.r.n. as needed for
chest pain
potassium chloride 20 mEq once
citalopram p.o. 10 mg daily
atorvastatin p.o. 30 mg at bedtime,
amiodarone p.o. 100 mg daily
quetiapine p.o. 12.5 mg q. 6 hourly PRN
haloperidol tablet p.o. 0.5 mg q. 8 hourly PRN
Bactrim suspension p.o. 20 mL every Monday, Wednesday, Friday
Florastor p.o. 250 mg b.i.d.
risperidone p.o. 0.25 mg [**Hospital1 **] PRN
prednisone p.o. 30 mg daily
lansoprazole sublingual 30 mg daily,
diltiazem p.o. 60 mg q.i.d.
AccuNeb 1 neb q. 4 hourly p.r.n.,
DuoNeb 1 neb q. 6 hourly p.r.n.
Keppra 500 mg IV q. 12 hourly
Dilantin IV 100 mg t.i.d. and
Discharge Medications:
1. acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
2. citalopram 20 mg Tablet [**Hospital1 **]: 0.5 Tablet PO DAILY (Daily).
3. atorvastatin 10 mg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY
(Daily).
4. amiodarone 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
5. risperidone 1 mg/mL Solution [**Hospital1 **]: 0.25 mg PO BID (2 times a
day) as needed for agitation.
6. quetiapine 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2 times a
day) as needed for agitation.
7. prednisone 10 mg Tablet [**Hospital1 **]: Three (3) Tablet PO DAILY
(Daily).
8. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
9. diltiazem HCl 60 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4
times a day).
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation every four (4) hours as
needed for shortness of breath, wheezing.
11. heparin (porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: 5,000 units
Injection TID (3 times a day).
12. simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas/bloating.
13. levetiracetam 100 mg/mL Solution [**Last Name (STitle) **]: Seven [**Age over 90 1230**]y
(750) mg PO BID (2 times a day).
14. nystatin 100,000 unit/mL Suspension [**Age over 90 **]: Five (5) ML PO QID
(4 times a day) as needed for thrush.
15. nitroglycerin 0.4 mg Tablet, Sublingual [**Age over 90 **]: One (1)
Sublingual twice a day as needed for chest pain.
16. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Age over 90 **]:
6-8 Puffs Inhalation Q6H (every 6 hours) as needed for
wheezing/respiratory distress.
17. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
18. Florastor 250 mg Capsule [**Age over 90 **]: One (1) Capsule PO twice a
day.
19. Bactrim 400-80 mg Tablet [**Age over 90 **]: One (1) Tablet PO Mon, Wed,
Fri: or can give 20mL suspension Mon, Wed, Fri.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]
Discharge Diagnosis:
Medication side effect
Atrial fibrillation
COPD
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
NEURO EXAM: AAOx2 (knows place, year and month, but not date), R
pupil reactive 5->3mm, L pupil 6->3mm; moves all 4 extremities
Discharge Instructions:
Dear Ms. [**Known lastname 4135**],
You were seen in the hospital for suspected seizures that caused
you to become unresponsive. While here, you were monitored with
continuous EEG monitoring which showed no seizures even when you
had an episode of unresponsiveness while here. Therefore, we
think that your unresponsive episodes are related to medications
or medical issues and are not seizure-related.
We made the following changes to your medications:
(The below changes are those made to your transfer meds, not
home meds):
1) We STOPPED your HALOPERIDOL.
2) We STOPPED yout DUONEBS because the ipratoprium was effecting
your pupils.
3) We STOPPED your DILANTIN because it was interacting with your
coumadin.
4) We DECREASED your SEROQUEL to 12.5mg twice a day as needed
for agitation.
5) We INCREASED your KEPPRA to 750mg twice a day. This can
likely be tapered then stopped once you are more medically
stable.
6) We STARTED you on TYLENOL 325-650mg every 6 hours as needed
for fever or pain.
7) We STARTED you on SUBCUTANEOUS HEPARIN injections, 5,000
units three times a day to prevent DVTs. You can stop this
medication once you are no longer chronically in bed or your INR
is therapeutic.
8) We STARTED you on SIMETHICONE 80mg four times a day as n
eeded for gas pains.
9) We STARTED you on NYSTATIN SUSPENSION 5mL four times a day as
needed for thrush.
10) We STARTED you on ALBUTEROL INHALER, 6-8 puffs every 6 hours
as needed for wheezing/respiratory distress when on CPAP.
11) We STARTED you on a HEPARIN FLUSH 2mL intravenously in your
PICC line as needed to flush the line. This medication can stop
once you no longer need your PICC.
Please continue to take your other medications as previously
prescribed.
If you experience any of the below listed Danger Signs, please
contact your doctor or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospitalization.
Followup Instructions:
We recommend that you follow-up with your [**Hospital6 2561**]
neurologist within the next 1-2 months.
If you would prefer to make an appointment with one of our
neurologists you can call [**Telephone/Fax (1) 2756**] and be connected to our
appointment line.
ICD9 Codes: 2930, 496, 2449, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1432
} | Medical Text: Admission Date: [**2120-6-17**] Discharge Date: [**2120-6-25**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
worsening shortness of breath
Major Surgical or Invasive Procedure:
percutaneouos aortic valve replacement (CoreValve)
pacemaker placement
History of Present Illness:
This [**Age over 90 **] year old patient with a history of prior CABG has been
experiencing fatigue and severe shortness of breath with minimal
activity, which is new over the last few months. He denies any
symptoms occurring at rest. He denies any chest pain. He denies
claudication, orthopnea, pnd, lightheadedness or lower
extremity edema. He was seen by Dr. [**Last Name (STitle) 59323**] who referred him
for an echocardiogram. This revealed worsening of his aortic
stenosis. He was seen and [**Last Name (STitle) 6349**] and was deemed appropriate
for TAVI/CoreValve placement.
NYHA Class:II
Past Medical History:
PMH:
CAD, s/p inferior, posterior MI,
s/p CABG x 4 in [**8-/2113**](SVG/OM, Diag, PLB, and LIMA to LAD)
Pancreatitis post CABG
S/P Cholescystectomy in [**10/2113**]
S/P cataract extraction OD
S/P right carpal tunnel release
S/P right knee arthroscopy
S/P Upper GI scope with gastric biopsy, esophageal biopsy, and
balloon dilatation in [**4-/2116**]
H/O diverticulosis
H/O GIB S/P right hemicolectomy (17 units of blood)
H/O right carotid bruit
H/O NSVT
Hypertension
Hyperlipidemia
Chronic renal failure
Mitral regurgitation
Depression
Insomnia
Hearing impaired
Polymyalgia rheumatica- on Prednisone
Arthritis
BPH s/p TURP
Past Surgical History:
S/P Cholescystectomy in [**10/2113**]
S/P cataract extraction OD
S/P right carpal tunnel release
S/P right knee arthroscopy
s/p TURP
s/p R hemicolectomy
s/p CABGx4 (SVG/OM, Diag, PLB, and LIMA to LAD) [**8-25**]
Social History:
SOCIAL HISTORY: Pt lives alone independently in a [**Doctor Last Name **] house in
NH. He plans to stay with his daughter, [**Name (NI) **] after discharge.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 37190**] (dtr)[**Telephone/Fax (1) 82471**]
[**Doctor First Name **] (dtr-in-law) [**Telephone/Fax (1) 82472**]
Lives with: lives alone
Occupation: retired GE tester (jet engines)
Tobacco: 1/2ppd x 15yrs - quit 60yrs ago
ETOH: none
Family History:
Longevity (sisters x 2 deceased age [**Age over 90 **])
Physical Exam:
ADMISSION EXAM
Pulse: 65
B/P: 146/65
Resp: 18
O2 Sat:
Temp: 97.1
General: Alert hard of hearing pleasant elderly gentleman in NAD
at rest, spleaking comfortably.
Skin: Color pale pink, turgor fair. No ulcerations, no lesions.
HEENT: Normocephalic, anicteric. Oropharynx moist. Conjunctiva
pale pink. Lower partials.
Neck: Neck supple, trachea midline. Bilat carotid bruit vs.
referred murmer. JVD.
Chest: Well healed sternal incision. No obvious deformity.
Heart: RRR. V/VI murmer throughout
Abdomen: soft, nontender, nondistended, (+)bowel sounds all quad
Extremities: No hair growth below knees. Trace pedal edema
bilat.
Neuro: Alert and oriented, mildly anxious. Gross FROM. OOB, gait
steady.
Pulses: [**12-24**]+ palpable peripheral pulses throughout
DISCHARGE EXAM
VITALS: Temp current: 98.7 HR: 75-95 RR: 18 BP: 126-147/60s O2
Sat: 100% RA
General: resting comfortably in bed, NAD
HEENT: Oropharynx moist.
Neck: Neck supple.
Chest: Well healed sternal incision. No obvious deformity. Skin
[**Month/Day (2) 1994**] from tape removal center chest, dressing not removed for
exam. Lungs CTA bilaterally with good air entry.
Heart: RRR, paradoxical split S2.
Abdomen: soft, nontender, nondistended, (+)bowel sounds all
quad.
Well healed surgical scar.
Extremities: No hair growth below knees. No pedal edema. Small
(nickel-sized) right groin hematoma, mildly TTP. Palpable DP
pulses.
Neuro: Alert and oriented, mildly anxious. Gross FROM. OOB, gait
steady.
Skin: Color pink, skin warm and dry. Heels and sacrum intact.
Pertinent Results:
Admission labs
[**2120-6-17**] WBC-7.8 RBC-3.19* Hgb-11.2* Hct-31.4* MCV-99* MCH-35.1*
MCHC-35.7* RDW-16.3* Plt Ct-189
PT-13.7* PTT-22.6 INR(PT)-1.2*
Glucose-121* UreaN-34* Creat-1.5* Na-143 K-4.7 Cl-109* HCO3-26
AnGap-13
Albumin-4.0
Calcium-9.0 Phos-2.9 Mg-2.0
%HbA1c-5.7 eAG-117
ALT-18 AST-37 CK(CPK)-29* AlkPhos-40 TotBili-0.9
CK-MB-3 proBNP-2320*
Discharge labs:
[**2120-6-25**] WBC-9.4 RBC-2.78* Hgb-9.2* Hct-27.6* MCV-99* MCH-33.1*
MCHC-33.3 RDW-15.8* Plt Ct-240
PT-13.5* PTT-25.0 INR(PT)-1.2*
Glucose-92 UreaN-29* Creat-1.4* Na-142 K-4.1 Cl-108 HCO3-24
AnGap-14
Calcium-8.4 Phos-2.5* Mg-1.9
proBNP-2338*
Imaging
ECG: ([**6-17**])
Sinus rhythm. Right bundle-branch block. Left anterior
fascicular block.
Inferolateral lead ST-T wave changes are primary and
non-specific. Since the previous tracing of [**2120-5-17**]
inferolateral lead ST-T wave changes appear less prominent.
.
ECHO ([**6-18**])
PRE VALVE DEPLOYMENT The left atrium is dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. A patent foramen ovale is present. A
left-to-right shunt across the interatrial septum is seen at
rest. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. There is moderate
regional left ventricular systolic dysfunction with severe
inferior, inferolateral, and inferoseptal hypokinesis. The
remaining myocardial segments are mildly, globally depressed.
The right ventricle displays mild global free wall hypokinesis.
The descending thoracic aorta is mildly dilated. There are
simple atheroma in the descending thoracic aorta. There are
three aortic valve leaflets. The aortic valve leaflets are
severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). Mild to moderate ([**12-24**]+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is more significant calcification of the base
of the posterior mitral leaflet and posterior mitral annulus.
Mild to moderate ([**12-24**]+) mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion.
.
POST VALVE DEPLOYMENT At initail deployment, the patient
developed near cardiac arrest with right ventricular akinesis.
The aortic valve was quickly replaced and epinephrine was given
with resolution of right ventricular failure. The right
ventriclular function then returned to the pre-deployment state.
The mitral regurgitation was worsened and severe immediately
after this event but after valve replacement returned to
baseline (mild to moderate). The aortic valve and supporting
structure is in situ. The leaflets can be seen moving. The
maximum gradient across the valve was 7 mmHg with a mean of 4
mmHg. There is mild aortic regurgitation with two paravalvular
jets seen.
.
ECG ([**6-18**])
Sinus rhythm with atrial sensed and ventricular paced rhythm.
Since the
previous tracing of the same date ventricular paced rhythm is
now present.
TRACING #2
.
CXR ([**6-18**])
A CoreValve is in place. The left-sided pacemaker with the leads
terminating at right atrium and right ventricle is noted. Lungs
are essentially clear. Heart size and mediastinal silhouette are
stable. There is no pleural effusion or pneumothorax noted.
.
ECHO ([**6-20**])
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. Overall left ventricular systolic
function is moderately depressed (LVEF= 35 %) secondary to
jypokinesis of the inferior septum, inferior free wall, and
posterior wall. The right ventricular free wall is
hypertrophied. Right ventricular chamber size is normal. with
borderline normal free wall function. An aortic CoreValve
prosthesis is present. A paravalvular aortic valve leak
(trace-to-mild) is probably present. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse. Mild to
moderate ([**12-24**]+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
.
CXR ([**6-20**])
IMPRESSION: Very satisfactory postoperative situation. Permanent
pacer with two intracavitary electrodes in unremarkable
position. No pneumothorax identified.
.
ECHO ([**6-25**])
The left atrium is moderately dilated. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. There is mild regional left ventricular
systolic dysfunction with basal inferoseptal, inferior, and
inferolateral akinesis. Right ventricular chamber size and free
wall motion are normal. An aortic CoreValve prosthesis is
present and appears well-seated. The transaortic gradient is
normal for this prosthesis. Mild (1+) aortic regurgitation is
seen (probably paravalvular). The mitral valve leaflets are
mildly thickened. Moderate (2+) mitral regurgitation is seen.
Moderate [2+] tricuspid regurgitation is seen. There is no
pericardial effusion.
.
Compared with the prior study (images reviewed) of [**2120-6-20**],
left ventricular systolic function appears similar. Left
ventricular ejection fraction may have been slightly
underestimated in the prior report. Estimated pulmonary artery
systolic pressure is now higher. Mitral regurgitation is now
more prominent. Tricuspid regurgitation is now more prominent.
.
ECG ([**6-25**])
Ventricular paced rhythm at a rate of 80 beats per minute. No
diagnostic
change compared to previous tracing.
Brief Hospital Course:
Pt is a [**Age over 90 **]yo M with a PMH significant for critical AS, CABG x4
and MR [**First Name (Titles) **] [**Last Name (Titles) 82473**] for percutaneous aortic valve
replacement with CoreValve device.
#1 Severe symptomatic aortic stenosis s/p CoreValve [**6-18**]:
At initail deployment, the patient developed near cardiac arrest
with right ventricular akinesis. The aortic valve was quickly
replaced and epinephrine was given with resolution of right
ventricular failure. The right ventriclular function then
returned to the pre-deployment state. The mitral regurgitation
was worsened and severe immediately after this event but after
valve replacement returned to baseline (mild to moderate).
Perioperative permanent pacemaker placed following occlusion of
RCA, has right BBB and paced beats. ECHO shows good valve
placement and mild perivalvular leak. One unit PRBC given post
procedure for low hct. Pt will need aspirin and Plavix for a
total of 3 months and will follow up with Dr. [**Last Name (STitle) **] and [**First Name4 (NamePattern1) 1022**]
[**Last Name (NamePattern1) 32655**] NP for routine post procedure care.
.
#2 Complete Heart Block during CoreValve placement: common
occurance in patients with right bundle branch block. A
[**Company 1543**] DDD pacemaker model Sensia SEDR01,
serial number [**Serial Number 82474**]. One week wound check and
interrogation occurred while pt was still hospitalized and pt
will need to f/u every 6 months for a pacemaker check.
#3 CAD: s/p CABG x 4 ([**2112**]). Bypass graft angiography
demonstrates the vein graft to the obtuse marginal and the LIMA
to LAD to be patent, however during CoreValve procedure the RCA
graft was TO. Pt had no significant chest pain during
hospitalization and was discharged on home aspirin, plavix,
metoprolol and Lipitor.
.
#4 Chronic Systolic Dysfunction: EF 35%. Appeared euvolemic at
discharge.
Had not been on ACEi [**1-24**] AS and [**Last Name (un) **]. Would consider starting low
dose ACEi as outpatient. Started Lasix 20 mg PO for inc TR
gradient.
.
# Diarrhea. Possibly due to antibiotics and bowel regimen. No
fever or leukocytosis. Resolved at discharge.
.
# Skin [**Last Name (un) 1994**]. Likely secondary to prednisone. Mild serosanguinous
oozing at site. Wound nurse [**First Name (Titles) 6349**] [**Last Name (Titles) 1994**] and wrote
recommendations to VNA for dressing.
.
#. Polymyalgia Rheumatica: On chronic steroids at home,
continued in hospital.
.
#. CKD: baseline creatinine 1.5. Increased to 1.6, possibly
secondary to intravascular depletion from diuresis/diarrhea. Pt
will have his labs rechecked as an outpatient.
Medications on Admission:
atenolol 25mg daily
aspirin 81mg daily
lipitor 10mg QOD (every other am)
prednisone 10mg daily
tamulosiin SR 0.4mg qevening
multivitamin 1 tab daily
fish oil capsule 1000mg twice a day
systane lubricant eye drops 1gtt TID
Discharge Medications:
1. Outpatient Lab Work
Please check Chem-7 and CBC on Thursday [**6-27**] with results to [**First Name5 (NamePattern1) 1022**]
[**Last Name (NamePattern1) 32655**] at [**Telephone/Fax (1) 32656**] fax and [**Telephone/Fax (1) 79809**] phone
2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
1.5 Tablet Extended Release 24 hrs PO once a day.
Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*2*
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO QODHS (every
other day (at bedtime)).
5. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Aortic Stenosis
Acute Systolic Dysfunction, no ACE/[**Last Name (un) **] [**1-24**] acute kidney injury
Hypertension
Anemia
Complete heart block
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You had a percutaneous replacement of your aortic valve with a
CoreValve bioprosthetic valve. You will need to take asprin and
Plavix for 3 months to prevent blood clots around the valve. Do
not stop taking aspirin and Plavix unless Dr. [**Last Name (STitle) **] tells you it
is OK to do so. You also needed a pacemaker after the procedure
for a slow heart rhythm, you will need to see Dr. [**Last Name (STitle) 11250**] and
an electrophysiology doctor [**First Name (Titles) **] [**Location (un) 3844**] to have the
pacemaker checked every 6 months. No lifting more than 5 pounds
with your left arm or lift your left arm over your head for 6
weeks. There are no activity restrictions for your right arm.
You can shower when you get home. You needed a blood transfusion
for anemia, your blood count is better now. You heart is
slightly weaker now than before. You need to watch your salt
intake and take all of your medicines daily. Information
regarding your medicines and diet was discussed with you before
discharge.
Weigh yourself every morning, call Dr.[**Last Name (STitle) 11250**] if weight goes
up more than 3 lbs in 1 day or 5 pounds in 3 days.
.
We made the following changes to your medicines:
1. Stop taking Atenolol, take metoprolol instead to lower your
heart rate and help your heart pump better
2. Start taking plavix every day to prevent blood clots on the
new valve.
Followup Instructions:
Department: CARDIAC SERVICES
When: THURSDAY [**2120-7-18**] at 3:00 PM
With: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
You will have an Echocardiogram at the same time as this appt.
.
PCP
Name: AUNG,THET H
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 77486**]
Phone: [**Telephone/Fax (1) 77350**]
Appointment: Thursday [**2120-6-27**] 11:30am
Completed by:[**2120-6-29**]
ICD9 Codes: 4241, 5849, 4240, 4280, 412, 5859, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1433
} | Medical Text: Admission Date: [**2112-5-2**] Discharge Date: [**2112-5-6**]
Date of Birth: [**2044-4-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine / Nitroglycerin / Lopressor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
exertional chest pain
Major Surgical or Invasive Procedure:
CABG x 4 (Lima>LAD, SVG>diag, SVG>OM2, SVG>PDA) [**5-2**]
History of Present Illness:
67 yo M with history of MI and multiple stents, admitted with
exertional chest pain, cath showed 3VD. Referred for surgery.
Past Medical History:
Type 2 IDDM
CAD s/p IMI and multiple PCI??????s to the LCX and LAD
Hypertension
Polypectomy
Presumed embolic stroke [**2098**], on long term plavix without
residual deficits
S/P tonsillectomy
S/P Appendectomy
Bilateral cataracts
Diabetic retinopathy
S/P surgical repair of a right ankle fracture
Social History:
He is married with no children. He works part-time in financial
planning. He does not smoke and occasionally has an alcoholic
drink.
Family History:
no family history of premature CAD
Physical Exam:
NAD HR 68 RR 18 BP 148/82
Lungs CTAB anteriorly
Heart RRR
Abdomen benign
Extrem warm, no edema, no varicose veins
Pertinent Results:
[**2112-5-6**] 05:30AM BLOOD WBC-8.2 RBC-3.08* Hgb-9.3* Hct-27.8*
MCV-90 MCH-30.3 MCHC-33.6 RDW-16.7* Plt Ct-185
[**2112-5-2**] 11:56AM BLOOD WBC-9.6# RBC-2.89*# Hgb-8.2*# Hct-25.6*#
MCV-89 MCH-28.5 MCHC-32.2 RDW-17.6* Plt Ct-141*
[**2112-5-2**] 11:56AM BLOOD Neuts-85.9* Bands-0 Lymphs-10.6*
Monos-3.2 Eos-0.2 Baso-0.1
[**2112-5-6**] 05:30AM BLOOD Plt Ct-185
[**2112-5-6**] 05:30AM BLOOD Glucose-219* UreaN-21* Creat-1.1 Na-145
K-3.6 Cl-105 HCO3-28 AnGap-16
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 95489**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 95490**] (Complete)
Done [**2112-5-2**] at 7:35:21 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
Division of Cardiothoracic [**Doctor First Name **]
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2044-4-25**]
Age (years): 68 M Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: TEE for hemodynamic instability post cardiac surgery
ICD-9 Codes: 780.2, 440.0
Test Information
Date/Time: [**2112-5-2**] at 19:35 Interpret MD: [**Name6 (MD) 928**]
[**Name8 (MD) 929**], MD, MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 929**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW02-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 40% to 45% >= 55%
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV cavity size. Moderate regional LV
systolic dysfunction. Mildly depressed LVEF.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: No thoracic aortic dissection.
AORTIC VALVE: No AR.
MITRAL VALVE: No MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications. The patient appears
to be in sinus rhythm.
Conclusions
No atrial septal defect is seen by 2D or color Doppler. The left
ventricular cavity size is normal. There is moderate regional
left ventricular systolic dysfunction with Inferior wall
hyopokinesis in the mid to apical segments.. Overall left
ventricular systolic function is mildly depressed (LVEF= 40-45
%). Right ventricular chamber size and free wall motion are
normal. No thoracic aortic dissection is seen. No aortic
regurgitation is seen. No mitral regurgitation is seen. There is
no pericardial effusion.
Impression: No obvious causes for increasing pressor or inotrope
requirements. Wall motion abnormality noted in this study was
seen in TEE earlier in the day, but appears slightly worse.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD,
Interpreting physician [**Last Name (NamePattern4) **] [**2112-5-3**] 13:51
Brief Hospital Course:
He was taken to the operating room on [**2112-5-2**] where he
underwent coronary artery bypass graft, please see operative
report for further details. He was transferred to the ICU in
critical but stable condition. He was initially hypotensive with
decreased cardiac index requiring mutiple drips, but they were
weaned to off on POD 1. He was weaned from sedation, awoke
neurologically intact and was extubated without difficulty. He
was transferred to the floor POD 2, and he had short burst of
atrial fibrillation that was treated with beta blockers and one
dose of amiodarone. He remained in sinus rhythm and his beta
blockers were titrated. He was gently diuresed towards his
preoperative weight. Physical therapy worked with him for
strength and mobility. He was ready for for discharge home with
services on POD 4.
Medications on Admission:
atenolol 25", lisinopril 20", asa 325', plavix 75', mvi,
protonix 20', norvasc 10', lipitor 10', humalog ss, lantus 30',
zetia 10", nitrostat prn, renexa 1g".
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Protonix 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*
7. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
8. Atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
9. Zetia 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
10. Lantus 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime.
Disp:*qs qs* Refills:*2*
11. Humalog 100 unit/mL Solution Sig: sliding scale
Subcutaneous four times a day: please continue with sliding
scale as prior to admission .
Disp:*qs qs* Refills:*2*
12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD s/p CABG
CAD s/p MI '[**94**], CVA (embolic) '[**98**], stent LAD '[**94**] & 91',
polypectomy, b/l cataracts, DM, DM retinopathy, htn, s/p
tonsillectomy, appy, ankle fx repair.
Discharge Condition:
Good.
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please check blood sugars before meals and bedtime, please
continue with lantus and sliding scale insulin but if BG > 200
please follow up with primary care physician
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) 838**] 1 week
Dr [**Last Name (STitle) 120**] in 2 weeks
Dr. [**Last Name (STitle) **] 4 weeks
Wound check [**Hospital Ward Name 121**] 6
Scheduled appt
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], MD Phone:[**Telephone/Fax (1) 8645**] Date/Time:[**2112-6-21**] 4:00
Completed by:[**2112-5-6**]
ICD9 Codes: 9971, 4111, 412, 4019, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1434
} | Medical Text: Admission Date: [**2116-3-4**] Discharge Date: [**2116-3-23**]
Date of Birth: [**2054-11-6**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
Fatigue, Chills
Major Surgical or Invasive Procedure:
Percutaneous Liver Drainage
History of Present Illness:
61 y/o M with hx of DM, hyperlipidemia and memory loss presents
today with one week of generalized fatigue, poor PO intake and
chills.
Per patient and daughter, patient noted profound fatigue and
frequent chills over last three days. He hasn't been able to
eat, and hasn't taken any of his medications. Denies dysuria,
cough, chest pain, shortness of breath, diarrhea, abdominal
pain, neck pain. Taken by his daughter to his PCPs office, there
he was noted to be sluggish, dyspneic, tachycardic in clinic and
has a FSG of 455, on repeat 525.
.
In the ED, initial vitals were T 99.8, HR 127, BP 127/58, R 50
and 100% 10L NRB. He was noted to have a glucose of 411 and an
anion gap of 20. His troponin was 0.15 and EKG demonstrated
sinus tach with < 1mm STD laterally. He received a full dose
aspirin for possible ACS and tylenol for fever. He was given 6L
NS, and started on an insulin gtt at 3 units/hr.
Past Medical History:
DM2 - on metformin/glyburide
Hyperlipidemia
Memory Loss
Social History:
Patient was born in [**Location (un) 4708**] and came to the US in [**2085**]. He has
an eigth grade education. He did construction work in [**Location (un) 4708**]
and in the US worked in parking and transportation. He smokes 5
cigarettes a day. Never been a drinker
Family History:
Mother had dementia, beginning in her fifties
Physical Exam:
ADMISSION EXAM:
VITALS:T 95.4, HR 81, BP 108/51, RR 18, 100/3L
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd, no carotid
bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l, shallow breaths
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps. Slow mentation, but
AAO x 3
Pertinent Results:
Admission Labs: [**2116-3-4**]
CBC: WBC-13.5*# RBC-4.76 Hgb-12.8* Hct-37.7* MCV-79* MCH-26.9*
MCHC-34.1 RDW-13.9 Plt Ct-168
Diff: Neuts-86.3* Lymphs-6.4* Monos-4.6 Eos-0.0 Baso-0.2
Coags: BLOOD PT-15.1* PTT-20.2* INR(PT)-1.3*
Chemistries: Glucose-411* UreaN-24* Creat-2.1* Na-132* K-3.7
Cl-92* HCO3-20* AnGap-24*
.
Labs on Discharge:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
10.2 3.06* 8.1* 24.1* 79* 26.6* 33.6 18.7* 393
UreaN Creat
20 2.4*
ALT:15, AST:19, Alk Phos: 214
.
Microbiology:
Blood Culture ([**3-4**]): SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STREPTOCOCCUS ANGINOSUS (MILLERI)
GROUP
|
CLINDAMYCIN----------- S
ERYTHROMYCIN----------<=0.25 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
Anaerobic Bottle Gram Stain (Final [**2116-3-5**]):
GRAM POSITIVE COCCI IN CHAINS.
Aerobic Bottle Gram Stain (Final [**2116-3-5**]):
GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
Liver Abscess Culture:
GRAM STAIN (Final [**2116-3-9**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final [**2116-3-15**]):
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. SPARSE GROWTH.
ANAEROBIC CULTURE (Final [**2116-3-13**]):
BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH.
BETA LACTAMASE POSITIVE.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2116-3-10**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
.
Chest X-ray ([**3-4**]): Single AP view of the chest demonstrates low
lung volumes. There is no pleural effusion, focal consolidations
or pneumothorax. The hilar and mediastinal silhouettes are
unremarkable. The heart is of normal size. Pulmonary vasculature
appears prominent.
.
TTE ([**3-9**]):
The left atrium is normal in size. 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 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. No masses or vegetations are seen on
the aortic valve. The mitral valve appears structurally normal
with trivial mitral regurgitation. There is no mitral valve
prolapse. No mass or vegetation is seen on the mitral valve.
Trivial mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: No vegetations or clinically-significant regurgitant
valvular disease seen (adequate-quality study). Normal global
and regional biventricular systolic function.
.
CT Chest ([**3-6**]):
1. Multifocal peripheral nodular opacities in the upper lobes,
could represent early multifocal pneumonia. Bibasilar
atelectasis, also suspicious for superimposed infection.
2. 1.5 cm multilobulated slightly hyperdense nodule in the
right upper lobe, while this could be part of the infectious
process, concern is raised for underlying neoplasm such as
bronchioloalveolar carcinoma (BAC) based on the morphology and
attenuation. Recommend repeating CT chest after antibiotic
treatment to ensure clearance and to rule out underlying
neoplasm.
3. 2.8-cm hypodensity in the right hepatic lobe, incompletely
assessed without IV contrast. Differential diagnosis includes
hepatic cyst versus intrahepatic abscess. Consider right upper
quadrant ultrasound for further evaluation.
.
Abdominal Ultrasound ([**3-7**]):
1. Heterogenous, predominantly hypoechoic lesion within the
right lobe of the liver with ill-defined margins and no
vascularity is identified. This lesion can't be classified as a
cyst or hemangioma (two of the more common benign lesions of the
liver) based on this study. Wide differential diagnosis remains
including neoplasm. Triple phase MRI or CT can be pursued for
further evaluation as clinically indicated.
2. Splenomegaly.
.
MR [**Name13 (STitle) **] ([**3-8**]):
1. No evidence of acute intracranial abnormality. Please note,
no contrast
could be given due to low GFR.
2. Multiple focal FLAIR hyperintensities are present within the
supratentorial brain most consistent with the sequela of chronic
small vessel ischemic disease.
3. Bilateral mastoid sinuses demonstrate fluid/mucosal
thickening. Please
clinically correlate.
.
MR spine ([**3-8**]):
1. No evidence of epidural abscess or discitis. Please note no
contrast was given due to a low GFR.
2. Minimal degenerative changes with moderate neural foraminal
narrowing at L3-L4 due to facet arthrosis bilaterally.
3. On the scout image, there is partial imaging of a
heterogeneous signal
mass within the liver. Please see recent abdominal ultrasound
for further
details.
.
TEE ([**3-9**]):
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. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque to 42 cm from the incisors. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. No masses or vegetations
are seen on the aortic valve. The mitral valve leaflets are
structurally normal. No mass or vegetation is seen on the mitral
valve. Mild (1+) mitral regurgitation is seen. No
vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
IMPRESSION: Mild mitral regurgitation with structurally normal
valve. No 2D echo evidence for endocarditis identified.
.
MRI Pelvis ([**2116-3-10**]):
1. Normal hip joints. No evidence of osteomyelitis, or joint
effusion. No evidence of abscess.
2. Mild symmetric bilateral adductor muscle edema, and mild
edema about the greater trochanters, tracking along the tensor
fascia lata, and iliotibial band, and bilateral gluteal muscles.
Findings are nonspecific, but could represent myositis, possibly
associated with patient's severe illness.
3. Diverticulosis.
4. Mild degenerative change at the sacroiliac joints, and pubic
symphysis.
.
Liver Ultrasound ([**2116-3-13**]):
IMPRESSION: Residual abnormal echotexture involving an extensive
portion of the right lobe is likely related to residual
inflammation in the hepatic parenchyma. A CT of the abdomen and
pelvis is recommended to better delineate the extent of the
abnormality and may help to determine a possible cause.
.
MRI Abdomen w/o Contrast ([**2116-3-18**]):
1. Right hepatic abscess, minimally changed in size compared to
the ultrasound [**2116-3-13**], though comparison is difficult
given the difference in technique. More fluidic pockets
measuring up to 2.5 cm each may benefit from more medial
repositioning of the drain.
2. Findings highly suggestive of sigmoid diverticulitis with a 7
cm stretch of abnormally thickened sigmoid colon. MRI of the
pelvis from eight days prior demonstrated edema and possible
intramural abscess associated with the sigmoid colon. Further
evaluation with CT is recommended to evaluate the extent of
inflammation and serve as a baseline study for future exams.
.
CT Pelvis: Sigmoid diverticulosis with mild wall thickening and
fat stranding appears improved from prior MRI suggesting
resolving diverticulitis.
.
CT Abdomen:
1. Allowing for differences in technique, right hepatic abscess
is unchanged with drain located within the lateral portion of
the abscess. Assessment is limited due to absence of intravenous
contrast.
2. Small-to-moderate right pleural effusion with associated
atelectasis.
3. Left basilar nodularity and pleural thickening which could
reflect atelectasis or previously described infectious process.
Brief Hospital Course:
61 year-old male with history of non-insulin dependent DM,
hyperlipidemia and memory loss who presented with one week of
fatigue, chills and poor PO intake.
.
# Sepsis/Liver Abscess: Blood cultures on admission grew
Streptococcus anginosus. Liver ultrasound demonstrated a 6 x 9
cm lesion, which was drained at bedside by IR, and found to be
an abscess growing Strep anginosus and B. fragilis. Started on
ceftriaxone/metronidazole. MRCP demonstrated diverticulitis
which is likely etiology of bacteremia and subsequent abscess.
No endocarditis by TEE. Dental exam normal. MRCP [**3-18**]
demonstrated size of abscess unchanged compared to initial
ultrasound on admission. CT Abd did indicate drain in place. The
patient was evaluated by Hepatobiliary surgery service given the
lack of resolution of hepatic abscess. It was determined that
likely cause of abscess persistence was that his drain was not
being appropriately flushed, accounting for the slow resolution
of abscess visualized on CT. The patient will follow-up with
Infectious Disease and Hepatobiliary Surgery as an outpatient.
It is very important to continue TID drain flushes as specified
in treatments and freq. Plan is for a 4 week (starting [**2116-3-23**])
course of the ceftriaxone and flagyl. He will need weekly
monitoring labs drawn which are specified in treatments and
frequency of PAGE1. ID and Transplant Surgery appts have been
scheduled.
.
#. [**Last Name (un) **]/Likely ATN: Baseline Cr unknown. Creatinine trend up to
3.7 during ICU course. Believed to be secondary to ATN in
setting of septic shock given history and muddy brown casts in
sediment. Renal ultrasound was normal. Creatinine gradually
improved with good urine output. Creatinine at the time of
discharge was 2.4. BUN/Cr will be drawn weekly as part of aABX
monitoring. Pt scheduled for outpatient nephrology f/u at [**Hospital1 18**].
.
# Hypoxemic Respiratory Failure: On hospital day two, patient
became acutely hypoxic, likely from flash pulmonary edema and
was intubated. On [**3-12**], the patient was weaned from the
ventilator and extubated without complication. His respiratory
status continued to improve with diuresis (likely post-ATN). He
was ultimately weaned off oxygen and remained stable on RA
throughout hospital course
.
# Hypertension: Pt has no documented history of HTN and was not
on an anti-hypertensive regimen. On admission he was
hypertensive following fluid resucitation to 180s. He was slowly
started on regimen of hydralazine, amlodipine, and metoprolol
which has kept systolics in 130's. Pt will need PCP f/u and
possible medication titration.
.
# Hip pain: On admission, patient complained of hip pain. MRI
pelvis was obyained to rule out infection. This showed mild
symmetric bilateral adductor muscle edema, mild edema at greater
trochanters. Ortho was consulted and recommended pain control
for trochanteric bursitis.
.
# DM: Held home metformin and glyburide at presentation give
[**Last Name (un) **]. Patient was initiated on lantus and insulin sliding scale,
which was slowly uptitrated during the course of his hospital
stay. At the time of discharge, the patient was taking 41 U
lantus each night, with 3 U pre-prandial humalog. The patient's
insulin requirement may decrease as his infection resolves; his
blood sugars will need to be monitored closely and his insulin
downtitrated. Pt and his family will need insulin dosing and
administration teaching.
.
# Outstanding Labs: None
.
# Transitions of Care:
--DRAIN CARE: aspirate the right flank percutaneous drain,
record output, then vigorously flush drain with 10cc NS TID.
Aspirate all contents again and record the difference of NS
flush minus drain output.
--QID fingersticks on the patient in rehab, given ongoing
insulin titration. We suspect insulin requirement will decrease
--Check CBC with differential, BUN/Cr, LFTs weekly given pt on
long term antibiotics. Please fax results to [**Telephone/Fax (1) 1419**]
(Infectious Disease Clinic at [**Hospital1 18**])
--Patient will follow-up with Hepatobiliary surgery in 1 week.
At this time, determination will be made regarding further
imaging and need for drain to remain in place.
--Patient will follow up with Infectious Disease and Nephrology
in [**2-6**] weeks time.
--Pt will need PCP f/u after rehab stay for BP check and
monitoring of his diabetes treatment regimen
FULL CODE ON THIS ADMISSION
Medications on Admission:
# Glyburide 2.5 mg daily
# Metformin 850 mg [**Hospital1 **]
# ASA 81 mg daily
# Pravastatin 20 mg qHS
# Memantine 10 mg [**Hospital1 **]
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours): Last day: [**2116-4-20**].
4. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig:
Two (2) grams Intravenous Q24H (every 24 hours): Last day:
[**2116-4-20**].
5. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. memantine 10 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Humalog 100 unit/mL Solution Sig: Three (3) units
Subcutaneous three times a day: Please take just before meals.
8. Outpatient Lab Work
Please check CBC with differential, BUN/Cr, LFTs weekly. Please
fax results to [**Telephone/Fax (1) 1419**].
9. hydralazine 25 mg Tablet Sig: One (1) Tablet PO every six (6)
hours.
10. Lantus 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous at bedtime.
11. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO
three times a day.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**]
Discharge Diagnosis:
Primary Diagnoses:
-Strep Anginosus Bacteremia
-Liver Abscess
-Respiratory Failure
-Acute Kidney Injury
-Diverticulitis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname **],
.
It was a pleasure taking care of you here at [**Hospital1 771**]. You were admitted to the intensive
care unit with an infection in your blood and in your liver.
You were started on antibiotics for these infections and
administered aggressive intravenous fluid. You were placed on
the ventilator for a short period of time in order to remove
fluid from your lungs. When you were able to breathe comfortably
on your own, you were transferred to the medical [**Hospital1 **]. Here,
your symptoms improved significantly over the following days
with continued antibiotics. You underwent further studies to
determine a source of your blood and liver infections. It
appears as though your infections may have originated from a
condition called diverticulitis in your bowel.
.
You will continue on antibiotics for several more weeks. You
will follow-up closely with the infectious disease specialists,
hepatobiliary surgeons, and kidney specialists in the coming
weeks. The liver drain will remain in place until you follow-up
with the surgeons. At the time of this appointment, they will
evaluate whether this drain may be removed and determine the
need for further imaging.
.
Please START the following medications:
CEFTRIAXONE (to be continued through [**2116-4-20**])
FLAGYL (to be continued through [**2116-4-20**])
AMLODIPINE
METOPROLOL
HYDRALAZINE
LANTUS
HUMALOG
.
Please STOP the following medications:
METFORMIN
GLYBURIDE
.
If you experience any symptoms that concern you after leaving
the hospital, please call your primary care doctor or return to
the emergency room as soon as possible.
.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD
Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2116-3-26**] 8:30
[**Last Name (NamePattern1) **], [**Hospital **] Medical Building [**Location (un) **]
[**Location (un) 86**], [**Numeric Identifier 718**]
.
Name: [**Last Name (un) **]-[**Hospital1 **],MYECHIA
Location: [**Hospital 3578**] COMMUNITY HEALTH CENTER
Address: [**Hospital1 3579**], [**Location (un) **],[**Numeric Identifier 3580**]
Phone: [**Telephone/Fax (1) 3581**]
Appointment: Tuesday [**2116-3-24**] 12:30pm
.
Department: WEST [**Hospital 2002**] CLINIC
When: WEDNESDAY [**2116-4-1**] at 9:00 AM
With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
.
Department: INFECTIOUS DISEASE
When: TUESDAY [**2116-4-7**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: INFECTIOUS DISEASE
When: FRIDAY [**2116-5-8**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 27625**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: TRANSPLANT CENTER
When: THURSDAY [**2116-3-26**] at 8:30 AM
With: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD [**Telephone/Fax (1) 673**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
ICD9 Codes: 5845, 3051, 5859, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1435
} | Medical Text: Admission Date: [**2185-11-29**] Discharge Date: [**2185-12-13**]
Date of Birth: [**2117-5-22**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Morphine Sulfate / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
Left hip infection
Major Surgical or Invasive Procedure:
[**2185-11-30**]: I&D Left hip with VAC placement
[**2185-12-2**]: I&D Left hip with VAC placement
[**2185-12-3**]: PICC placement
[**2185-12-6**]: I&D Left hip with primary closure and incisional VAC
placement
[**2185-12-9**]: VAC change at bedside
[**2185-12-13**]: VAC change at bedside
History of Present Illness:
Mr. [**Known lastname **] is a 68 year old man who underwent a girdlestone of
his left hip [**10-23**] due to infection. He was placed on Nafcillin
per Infectious Disease. He presented to the orthopaedic surgery
clinic in follow up and was found to have purulent drainage from
his left hip. He was then admitted for further care.
Past Medical History:
CVA [**2180**] with L hemiparesis
LLE DVT [**2180**]
CAD s/p stents X3 10yrs ago with MI
HTN
Hypercholesterolemia
LLE venous stasis
Left hip ORIF [**3-/2185**]
Left hip girdleston [**10/2185**]
Social History:
From rehab
Family History:
n/a
Physical Exam:
Upon admission
Alert and oriented
Cardiac: Regular rate rhythm
Chest: Lungs clear bilaterally
Abdomen: Soft non-tender non-distended
Extremities: LLE staples intact, +draiage, + odor, sensation
intact to LLE
Pertinent Results:
[**2185-12-13**] 04:37AM BLOOD WBC-5.4 RBC-3.33* Hgb-9.9* Hct-30.1*
MCV-90 MCH-29.7 MCHC-32.9 RDW-16.4* Plt Ct-645*
[**2185-12-10**] 04:39AM BLOOD Hct-29.5*
[**2185-12-9**] 10:20AM BLOOD WBC-4.4 RBC-3.22* Hgb-9.8* Hct-29.6*
MCV-92 MCH-30.3 MCHC-32.9 RDW-17.2* Plt Ct-525*
[**2185-12-8**] 06:16PM BLOOD Hct-24.5*
[**2185-12-8**] 04:01AM BLOOD WBC-6.1 RBC-2.67* Hgb-8.3* Hct-24.9*
MCV-93 MCH-31.0 MCHC-33.2 RDW-17.6* Plt Ct-527*
[**2185-12-8**] 12:45AM BLOOD WBC-5.8 RBC-2.86* Hgb-8.9* Hct-26.8*
MCV-94 MCH-31.2 MCHC-33.3 RDW-17.5* Plt Ct-500*
[**2185-12-7**] 07:00AM BLOOD WBC-4.7 RBC-3.10* Hgb-9.3* Hct-28.7*
MCV-93 MCH-30.1 MCHC-32.4 RDW-17.7* Plt Ct-479*
[**2185-12-6**] 02:54PM BLOOD WBC-4.2 RBC-3.23* Hgb-10.0* Hct-30.1*
MCV-93 MCH-30.9 MCHC-33.1 RDW-17.7* Plt Ct-432
[**2185-12-6**] 05:57AM BLOOD WBC-7.1 RBC-3.12* Hgb-9.5* Hct-28.8*
MCV-92 MCH-30.6 MCHC-33.2 RDW-17.8* Plt Ct-424
[**2185-12-5**] 03:18AM BLOOD WBC-5.3 RBC-3.09* Hgb-9.4* Hct-28.9*
MCV-94 MCH-30.6 MCHC-32.7 RDW-18.4* Plt Ct-487*
[**2185-12-4**] 07:30AM BLOOD WBC-6.9 RBC-3.15* Hgb-9.9* Hct-29.8*
MCV-95 MCH-31.6 MCHC-33.4 RDW-18.4* Plt Ct-409
[**2185-12-3**] 05:11AM BLOOD WBC-8.5 RBC-3.13* Hgb-9.7* Hct-28.4*
MCV-91 MCH-31.2 MCHC-34.3 RDW-18.9* Plt Ct-411
[**2185-12-2**] 04:18PM BLOOD WBC-7.3 RBC-3.27* Hgb-10.2* Hct-30.1*
MCV-92 MCH-31.1 MCHC-33.8 RDW-19.3* Plt Ct-441*
[**2185-12-2**] 05:04AM BLOOD Hct-29.6*
[**2185-12-2**] 12:46AM BLOOD WBC-6.7 RBC-3.42*# Hgb-10.5* Hct-30.5*
MCV-89 MCH-30.7 MCHC-34.5 RDW-19.5* Plt Ct-386
[**2185-12-1**] 11:55AM BLOOD Hct-28.9*
[**2185-12-1**] 11:55AM BLOOD Hct-28.9*
[**2185-12-1**] 07:55AM BLOOD Hct-27.8*
[**2185-12-1**] 03:46AM BLOOD WBC-8.0 RBC-2.73*# Hgb-8.4*# Hct-25.2*
MCV-92# MCH-30.9 MCHC-33.5# RDW-20.2* Plt Ct-480*
[**2185-12-1**] 12:37AM BLOOD Hct-23.2*
[**2185-11-30**] 08:50PM BLOOD WBC-10.0# RBC-2.18*# Hgb-6.5*# Hct-21.7*#
MCV-99* MCH-29.8 MCHC-30.0* RDW-21.3* Plt Ct-777*
[**2185-11-30**] 05:37PM BLOOD WBC-6.4 RBC-3.23* Hgb-9.9* Hct-31.7*
MCV-98 MCH-30.7 MCHC-31.2 RDW-20.4* Plt Ct-650*
[**2185-11-30**] 09:51AM BLOOD WBC-7.5 RBC-2.85* Hgb-8.7* Hct-27.7*
MCV-97# MCH-30.5 MCHC-31.3 RDW-21.3* Plt Ct-698*#
[**2185-11-30**] 08:50PM BLOOD Neuts-60.7 Lymphs-25.3 Monos-5.5 Eos-8.4*
Baso-0.1
[**2185-11-30**] 09:51AM BLOOD Neuts-63.1 Lymphs-19.1 Monos-4.8
Eos-12.7* Baso-0.3
[**2185-12-13**] 04:37AM BLOOD Plt Ct-645*
[**2185-12-9**] 10:20AM BLOOD Plt Ct-525*
[**2185-12-8**] 04:01AM BLOOD Plt Ct-527*
[**2185-12-8**] 12:45AM BLOOD Plt Ct-500*
[**2185-12-6**] 02:54PM BLOOD Plt Ct-432
[**2185-12-6**] 05:57AM BLOOD Plt Ct-424
[**2185-12-6**] 05:57AM BLOOD PT-13.7* PTT-33.3 INR(PT)-1.2*
[**2185-12-5**] 03:18AM BLOOD Plt Ct-487*
[**2185-12-2**] 12:46AM BLOOD PT-14.2* PTT-29.6 INR(PT)-1.2*
[**2185-11-30**] 08:50PM BLOOD Plt Smr-VERY HIGH Plt Ct-777*
[**2185-11-30**] 05:37PM BLOOD Plt Ct-650*
[**2185-11-30**] 09:51AM BLOOD PT-14.1* PTT-31.3 INR(PT)-1.2*
[**2185-12-13**] 04:37AM BLOOD ESR-65*
[**2185-12-13**] 04:37AM BLOOD UreaN-7 Creat-0.8 K-3.6
[**2185-12-12**] 04:04AM BLOOD K-3.5
[**2185-12-11**] 08:36AM BLOOD K-3.2*
[**2185-12-10**] 04:39AM BLOOD K-3.3
[**2185-12-9**] 10:20AM BLOOD Glucose-89 UreaN-6 Creat-0.7 Na-137 K-4.2
Cl-105 HCO3-25 AnGap-11
[**2185-12-8**] 06:16PM BLOOD K-3.6
[**2185-12-8**] 04:01AM BLOOD Glucose-96 UreaN-6 Creat-0.7 Na-135
K-2.8* Cl-101 HCO3-26 AnGap-11
[**2185-12-6**] 05:57AM BLOOD Glucose-79 UreaN-6 Creat-0.8 Na-139 K-3.3
Cl-104 HCO3-26 AnGap-12
[**2185-12-6**] 05:57AM BLOOD Glucose-79 UreaN-6 Creat-0.8 Na-139 K-3.3
Cl-104 HCO3-26 AnGap-12
[**2185-12-6**] 01:59AM BLOOD Glucose-84 UreaN-7 Creat-0.7 Na-137 K-3.5
Cl-104 HCO3-25 AnGap-12
[**2185-12-4**] 07:30AM BLOOD Glucose-85 UreaN-5* Creat-0.8 Na-137
K-3.2* Cl-105 HCO3-22 AnGap-13
[**2185-12-3**] 05:11AM BLOOD Glucose-109* UreaN-5* Creat-0.8 Na-136
K-3.5 Cl-105 HCO3-24 AnGap-11
[**2185-12-2**] 12:46AM BLOOD Glucose-100 UreaN-7 Creat-0.8 Na-139
K-3.5 Cl-108 HCO3-24 AnGap-11
[**2185-12-1**] 06:23PM BLOOD K-3.5
[**2185-12-1**] 07:55AM BLOOD K-3.7
[**2185-12-1**] 03:46AM BLOOD Glucose-111* UreaN-12 Creat-0.6 Na-141
K-3.7 Cl-108 HCO3-24 AnGap-13
[**2185-12-1**] 04:46AM BLOOD CK(CPK)-93
[**2185-11-30**] 08:50PM BLOOD ALT-5 AST-12 LD(LDH)-312* CK(CPK)-51
AlkPhos-106 Amylase-51 TotBili-0.5
[**2185-11-30**] 09:51AM BLOOD ALT-5 AST-14 AlkPhos-127* TotBili-0.4
[**2185-12-1**] 11:55AM BLOOD CK-MB-4 cTropnT-0.03*
[**2185-12-1**] 04:46AM BLOOD CK-MB-NotDone
[**2185-11-30**] 08:50PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2185-12-13**] 04:37AM BLOOD Albumin-2.4*
[**2185-12-8**] 12:45AM BLOOD Calcium-7.9* Phos-2.7 Mg-1.8
[**2185-12-7**] 07:00AM BLOOD Calcium-8.2* Phos-3.5 Mg-1.9
[**2185-12-6**] 05:57AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.0
[**2185-12-3**] 05:11AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.8
[**2185-12-2**] 04:18PM BLOOD Calcium-8.2* Phos-3.7 Mg-2.0
[**2185-12-2**] 12:46AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.2
[**2185-12-1**] 11:55AM BLOOD Mg-2.4
[**2185-12-1**] 03:46AM BLOOD Calcium-7.8* Phos-3.8 Mg-1.8
[**2185-11-30**] 05:37PM BLOOD Calcium-9.1 Mg-2.3
[**2185-12-13**] 04:37AM BLOOD CRP-91.4*
[**2185-11-30**] 09:51AM BLOOD CRP-35.3*
[**2185-11-30**] 08:50PM BLOOD EDTA Ho-HOLD
Brief Hospital Course:
Mr. [**Known lastname **] presented to the [**Hospital1 18**] on [**2185-11-29**] via direct admit
from orthopaedic clinic due to a left hip infection. He was
admitted, prepped, and consented for surgery. On [**2185-11-30**] he
went to the operating room for an I&D of his left hip with VAC
placement. He tolerated the procedure well, was extubated,
transferred to the recovery room and then to the floor. On the
floor he became poorly responsive with systolic blood pressure
in the 80's, and his VAC with a large amount of bloody drainage.
He was transfused with 2 units of packed red blood cells due to
acute post operative anemia. He was given narcan with some
response, but a code was called. He was transferred to the ICU
for further care. On [**2185-12-1**] he was again transfused with
3units of packed red blood cells due to acute post operative
anemia. On [**2185-12-2**] he was started on Cipro in addition to
Nafcillin due to gram negative rods for the OR culture. On
[**2185-12-3**] a new PICC line was placed for long term antibiotics.
On [**2185-12-6**] he again returned to the operating room for an I&D
with wound closure and placement of an incisional VAC. On
[**2185-12-8**] he was transfused with 2 units of packed red blood
cells due to acute post operative anemia. On [**2185-12-9**] he had
his VAC changed at the bedside. On [**2185-12-13**] his VAC was again
changed at the bedside.on day of dc his wound was seen by dr
[**Last Name (STitle) **] and felt it looked good Throughout his stay his
potassium had to be repleated due to low levels. He was started
on daily dose of potassium. Physical therapy follow throughout
his hospital stay to improve his strength and mobility. The
rest of his hospital stay was uneventful with his lab data and
vital signs within normal limits, and his pain controlled. He
is being discharged today in stable condition.
Medications on Admission:
[**Last Name (un) 1724**]: atenolol 100'', Fioricet prn, Diovan 80'', [**Doctor First Name **] 60'',
Flonase 0.05% [**Hospital1 **], Lasix 20'', Hydral 50 QID, Lipitor 40',
Norvasc 5'', Plavix 75', Darvocet 100 prn, Triamcinolone [**Hospital1 **]
rashes (cream only)
Discharge Medications:
1. Outpatient Lab Work
Please draw weekly CBC, BUN/Cr, LFT's, and fax results to Dr.
[**First Name (STitle) 1075**] at [**Telephone/Fax (1) 432**].
2. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: One (1) 2gm
Intravenous Q4H (every 4 hours) for 2 weeks: End date [**2185-12-20**].
3. Ciprofloxacin 400 mg/40 mL Solution Sig: One (1) 400mg
Intravenous Q24H (every 24 hours) for 6 weeks: Start date
[**2185-12-2**] end date [**2186-1-13**].
4. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Ferrous Gluconate 300 (35) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
14. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
15. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for sleep.
16. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
17. Cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a
day) as needed.
18. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
19. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H
(every 4 hours) as needed for pain, temps.
20. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
21. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
22. Hydrocortisone 0.5 % Ointment Sig: One (1) Appl Topical TID
(3 times a day) as needed for rash.
23. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea/vomiting.
24. Hydromorphone 2 mg/mL Syringe Sig: One (1) Injection Q4H
(every 4 hours) as needed for pain.
25. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
Highgate Manor
Discharge Diagnosis:
Left hip infection
Acute post operative anemia
Discharge Condition:
Stable
Discharge Instructions:
Continue activity as tolerated WBAT left leg
Continue your medications as prescribed by your doctor
You may apply a dry sterile dressing daily or as needed for
drainage or comfort
If you notice any increased redness, drainage, or swelling, or
if you have a temperature greater than 101.5 please call the
office or come to the emergency department.
You were started on daily KCL as your potassium was quite low.
Continue to have your Postassium checked frequently
Physical Therapy:
Activity: As tolerated
Left lower extremity: Full weight bearing
Treatments Frequency:
Staples/Sutures may be removed 14 days after surgery or at
follow up appointment
VAC change every 3 days. VAC is an incisional VAC
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in 2 weeks, please call
[**Telephone/Fax (1) 1228**] to schedule that appointment.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2185-12-16**]
9:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2185-12-13**]
ICD9 Codes: 2851, 2768, 4019, 412, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1436
} | Medical Text: Admission Date: [**2151-6-23**] Discharge Date: [**2151-6-29**]
Date of Birth: [**2096-3-23**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Ongoing headaches since his ICH
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
55 y RHM, originally from the [**Country 13622**] Republic. His son
acted as an interpretor, since the patient only speaks Spanish.
On Monday [**6-21**] he had a left frontal headache which started at
8
am after he had dropped his children off to summer camp. He also
experienced chest tightness and abdominal pain (otherwise the
rest of his systems review was negative). He vomited twice at
[**Hospital 487**] Hospital (query whether it may have happened after he
received morphine). Pt was trf here for a second opinion.
Past Medical History:
MH: HTN, diagnosed with type 2 Diabetes Mellitus 8 months ago,
thyroid surgery for a nodule of unknown signigance
Social History:
SH: On disability due to a neck injury, related to his previous
factory work. He has 4 children and has a supportive wife.
[**Name (NI) **] has smoked for over 30 y, and has a 15 y pack history. His
alcohol intake is minimal.
Pt is originally from Domician Republic and primarily speaks
Spanish
Family History:
noncontributory
Physical Exam:
HEENT: No cx LNs, thyroidectomy scar, moist mucosal membranes
CVS: S1+2, no added sounds, JVD not raised, no peripheral edema
Resp: good air entry B/L
GI: soft, non-tender, normal BS
Neurological Examination
Mental Status: as interpreted by Mr [**Known lastname 79217**] son, he was
oriented in time, person and place, however, he said that his
head hurt too much to answer anymore questions
Cranial Nerves
I & VIII not formally assessed
II, III, IV, VI - left temporal visual field defect. Conjugate
EOMS restricted in the lateral gaze B/L, no nystagmus. PERRL.
Fundi: no papilledema
V - all divisions in tact to soft touch and cold
VII - left facial asymmetry
IX, X - palate elevates to the midline
[**Doctor First Name 81**] - SCM B/L [**4-5**]
XII - normal tongue movements
Arms and Legs MRC grading out of 5)
Arms
sh abd sh add elb fl elb ext interos str thumb abd
R 5 5 5 5 5 5
L -5 5 5 5 4 +4
Legs
hip fl hip ext knee fl knee ext pl fl dorsifl
R 5 5 5 5 5 5
L 5 5 5 5 5 5
All reflexes (B,T,S,K,A) +2 B/L, plantars downgoing B/L
Sensation in tact to soft touch, cold and pinprick in all
dermatomes in the arms and legs.
Proprioception in tact in the toes and thumbs B/L
Finger to nose ataxia noted in the left hand
Pertinent Results:
[**2151-6-23**] 11:20PM PT-12.5 PTT-24.8 INR(PT)-1.1
[**2151-6-23**] 11:20PM PLT COUNT-293
[**2151-6-23**] 11:20PM WBC-8.4 RBC-4.48* HGB-14.2 HCT-41.3 MCV-92
MCH-31.7 MCHC-34.4 RDW-13.3
[**2151-6-23**] 11:20PM CALCIUM-7.1* PHOSPHATE-1.1* MAGNESIUM-2.2
[**2151-6-23**] 11:20PM estGFR-Using this
[**2151-6-23**] 11:20PM GLUCOSE-178* UREA N-8 CREAT-0.5 SODIUM-141
POTASSIUM-3.0* CHLORIDE-110* TOTAL CO2-22 ANION GAP-12
Brief Hospital Course:
Pt was transferred from [**Hospital 8050**] hospital with Right lobar ICH
most likely secondary to HTN. Pt is primarily Spanish Speaking.
Pt c/o of HA. Pt admitted, HCT images from [**Last Name (un) 11560**] uploaded
into the system. Pt stablized. HTN managed with Metoprolol,
Clonidine Patch, Lisinopril. Pt continued to c/o HA tx with
morphine and oxycodone was some improvement. Pt with right sided
weakness with slight improve on day of transfer. Pt d/c to [**Hospital1 1501**].
Medications on Admission:
ASA 81 mg
Simvastatin 40 mg QDay
Clonidine patch
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QMON (every Monday).
Disp:*4 Patch Weekly(s)* Refills:*2*
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Right lobar intracerebral hemorrhage secondary to HTN
Discharge Condition:
Stable
Discharge Instructions:
Continue to be compliant with medications
F/U with Physicians including PCP [**Name Initial (PRE) 176**] 1 month, Neuro with Dr.
[**Last Name (STitle) 78537**]
Followup Instructions:
DR [**Last Name (STitle) **] (Neuro)Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2151-8-18**] 1:00pm
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 1675**] [**Last Name (NamePattern1) 23**] 8 [**Hospital Ward Name 516**]
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
ICD9 Codes: 431, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1437
} | Medical Text: Admission Date: [**2173-12-2**] Discharge Date: [**2173-12-7**]
Date of Birth: [**2120-11-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Elective admission for flexible bronchoscopy with bilateral lung
lavage
Major Surgical or Invasive Procedure:
Flexible bronchoscopy with bilateral lung lavage
History of Present Illness:
53M h/o pulmonary alveolar proteinosis (PAP) diagnosed in
[**9-/2173**], DM2, HTN, dyslipidemia, admitted to MICU for closer
monitoring after undergoing bilateral lung lavage, each with 13L
NS for PAP, for which he was intubated. Pt's R lung lavage was
performed on [**2173-12-2**], and his L lung lavage was performed on
[**2173-12-6**]; each procedure was uncomplicated. After his second
lavage, pt was briefly hypotensive to SBP 80's, placed on
neosynephrine and IVF, but was quickly weaned off pressors.
.
PAP had been diagnosed in [**10-7**] after pt presented with
increasing SOB, pleuritic CP, and hypoxemia, during which time
he underwent wedge resection of the RML and RLL confirming PAP
on pathology. Flow cytometry to check for hematologic
malignancy was negative.
.
ROS: Unable to be performed given pt sedated, intubated.
Past Medical History:
# HTN
# Diabetes mellitus type II
# Hypercholesterolemia
# Obesity
# Erectile dysfunction s/p prostate surgery [**2168**]
# Umbilical herniorrhaphy [**2165**]
Social History:
# Personal: Originally from [**Male First Name (un) 1056**], but has been living in
[**Location (un) 86**] for 18 years. Married to second wife for 18 years; two
children from his first marriage.
# Professional: Currently unemployed; previously worked as a
custodian.
# Substance use: Denies tobacco use, alcohol, or drugs.
Family History:
# Mother, died 77: CVA associated with DM and HTN
# Father, died 80: Prostate cancer
# Siblings (7 brothers, 5 sisters): DM, HTN, CAD
Physical Exam:
VS: T 97.2, BP 125/75, HR 71, O2sat 99 on AC/Vt 600x RR 14, PEEP
5, FiO2 1.0
ABG: pH 7.46, pCO2 39, pO2 138, HCO3 29
General: Intubated
HEENT: NCAT
Neck: No JVD noted, supple, no TMG
Chest: CTAB on anterior and lateral exam
CV: RRR, S1 and S2 WNL, no m/r/g
Abd: Obese, ND, NT, BS+, no masses or hepatosplenomegaly
Ext: No c/c/e, warm, good pulses
Pertinent Results:
Admission labs:
.
[**2173-12-2**] 08:04PM GLUCOSE-127* UREA N-12 CREAT-0.6 SODIUM-142
POTASSIUM-3.5 CHLORIDE-109* TOTAL CO2-25 ANION GAP-12
[**2173-12-2**] 08:04PM CALCIUM-8.1* PHOSPHATE-4.4# MAGNESIUM-1.8
[**2173-12-2**] 08:04PM WBC-17.6* RBC-3.37*# HGB-10.6*# HCT-31.4*
MCV-93 MCH-31.6 MCHC-33.9 RDW-13.2
[**2173-12-2**] 10:33PM HCT-35.3*
[**2173-12-2**] 08:04PM PLT COUNT-356
[**2173-12-2**] 09:40AM NEUTS-59 BANDS-0 LYMPHS-30 MONOS-4 EOS-0
BASOS-2 ATYPS-5* METAS-0 MYELOS-0
.
Imaging:
.
CHEST (PORTABLE AP) [**2173-12-2**] 9:32 PM
.
1. Standard position of NG and ET tube.
2. Significant increase in bilateral perihilar and lower lobe
consolidations which might reflect recent bronchoalveolar lavage
in a patient with known alveolar proteinosis. Differential
diagnosis might include pulmonary edema, although it is less
likely. Close followup would be recommended.
.
CHEST (PORTABLE AP) [**2173-12-6**] 7:39 PM
.
Comparison is made with prior study of [**2173-12-3**]. ET tube
is in standard position. There is no pneumothorax. If any, there
is a small left pleural effusion. Cardiomediastinal contours are
unchanged. There are low lung volumes. There has been mild
improvement in the lung aeration, mostly in the left lung base.
Brief Hospital Course:
A/P: 53M h/o PAP, DM2, HTN, admitted for elective whole lung
lavage, performed in two stages, intubated post-procedure, with
quick extubation.
# Pulmonary alveolar proteinosis: R lung lavaged on [**2173-12-2**],
left lung lavaged on [**2173-12-6**]. BAL negative for PCP and fungal
infection, with no organisms noted on Gram stain; cultures
pending on discharge. After procedure, pt's ambulatory O2sat
noted to be 97% on room air.
.
# Fluid overload: After R lung lavage, pt autodiuresed well
after receiving 13L in lavage fluid. Repeat chest x-ray showed
improved pulmonary edema and stable bibasilar opacities and
interstial opacities, likely from underlying disease.
.
# Leukocytosis: Considered [**1-1**] lung procedure. Pt afebrile, BAL
sent from lavage for nocardia and PCP. [**Name10 (NameIs) **] demonstrates no
obvious infiltrate suspicious for PNA. Blood, urine cx sent,
all NGTD. BAL neg culture for bacteria/PCP/fungus. WBC
normalized upon discharge.
.
# Transient Hct drop, hyponatremia: Considered [**1-1**] fluid
received during lung lavage, corrected later upon repeat labs.
.
# DM2: Home regimen of metoformin and pioglitazone held while
inpatient; covered with HISS Q6H.
.
# HTN: Normotensive, and continued on home regimen of valsartan
80mg daily, carvedilol 25mg [**Hospital1 **], ASA 81mg daily. Pt confirmed
that he did not take HCTZ at home, and this was therefore
removed from his medication list on discharge.
.
# GERD: Home regimen of ranitidine 150mg daily and esomeprazole
40mg daily; pt continued on H2 blocker only as inpatient.
.
# Full code
Medications on Admission:
Carvedilol 25mg [**Hospital1 **]
ASA 81mg daily
Valsartan 80mg daily
Pioglitazone 45mg daily
Metformin 1000mg [**Hospital1 **]
Montelukast 10mg daily
Ranitidine 150mg daily
Esomeprazole 40mg daily
Discharge Medications:
1. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
2. Valsartan 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO once a
day.
Disp:*30 Capsule(s)* Refills:*2*
5. Esomeprazole Magnesium 40 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*
6. Pioglitazone 45 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
8. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
# Pulmonary alveolar proteinosis
.
Secondary diagnosis
# Hypertension
# Diabetes mellitus type 2
# Dyslipidemia
Discharge Condition:
Breathing normally on room air. Ambulatory oxygen saturation
97%.
Discharge Instructions:
You were hospitalized so that doctors [**First Name (Titles) **] [**Last Name (Titles) **] out your lungs
with fluid, because you have pulmonary alveolar proteinosis.
After the procedure, we measured the level of oxygen in your
blood while you were walking and it was 97%, indicating that you
were breathing well.
.
You will go home and continue taking the same medications as
before. We have confirmed with the hospital pharmacist as well
as your medical records that you should be taking carvedilol
25mg twice daily. We have also confirmed with you directly that
you do not take hydrochlorothiazide.
.
You have an appointment to see doctors in the [**Name5 (PTitle) 11063**]
Pulmonary clinic (telephone [**Telephone/Fax (1) 10084**]), on [**2173-12-14**] at 11 am.
.
You have an appointment with Dr. [**Last Name (STitle) 2168**], your lung doctor
(tel. [**Telephone/Fax (1) 612**]), to follow up about your lung disease.
.
You should also make an appointment to see your primary care
doctor in one month.
.
If you experience worsening shortness of breath, fever, or any
other symptoms you are concerned about, please call your doctor
and go immediately to the nearest emergency room.
Followup Instructions:
THIS IS YOUR [**Telephone/Fax (1) **] PULMONOLOGY DOCTOR APPOINTMENT:
Date/Time:[**2173-12-14**] 11:00
.
THIS IS YOUR LUNG DOCTOR APPOINTMENT: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2173-12-21**] 12:00
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3749**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2174-1-3**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5465**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2174-1-3**] 11:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2173-12-8**]
ICD9 Codes: 2761, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1438
} | Medical Text: Admission Date: [**2180-3-14**] Discharge Date: [**2180-3-15**]
Date of Birth: Sex:
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is a 32-year-old
male with a history of depression, posttraumatic stress
disorder, chronic alcohol abuse and prior overdoses and
suicide attempts who presents to the MICU on [**2179-3-16**] after
being found down on the ground outside the backbay T station
by EMS. The patient was cyanotic with [**Last Name (un) 6055**]-[**Doctor Last Name **]
breathing. Blood pressure was 110/60, heart rate 130. In
the field, he was subsequently intubated and got 1 mg of
Narcan without any response. Further bystanders who observed
him revealed he was down for approximately 30 minutes with no
obvious signs of trauma. In the emergency department he
received charcoal 75 grams times one. The EKG showed QRS,
which was slightly greater than 100 milliseconds. He was
given bicarbonate for evidence of tricyclic toxicity.
Toxicology screen was positive for tricyclic antidepressants,
cocaine and benzodiazepines. His alcohol level was 78. Head
CT was negative. The patient also received Ativan in the
emergency department and he was started on a propofol drip
overnight while intubated. Chest x-ray was notable for
question of some mediastinal widening. The CT angiogram was
performed, which was negative for evidence of dissection. In
the MICU the patient was stable. He received two liters of
IV fluids and he was extubated the following morning. His
labs overnight were notable for a 10 point drop in his
hematocrit from 42 to 33. He did complain of some right
lower quadrant abdominal pain, which he said was chronic. He
subsequently underwent an abdominal CAT scan to rule out new
bleed, which was negative. He denied any history of GI
bleed, including hematemesis, melena, bright red blood per
rectum. NG lavage and guaiac were negative.
The patient reports that he was trying to overdose/commit
suicide by taking approximately 1400 mg of his Elavil. He
wanted to be admitted to detoxification earlier in the day,
but he was unable to get admitted. He spoke with his
"pastor" prior to taking his pills. He reports that the last
alcohol was just prior to taking the Elavil. Last inhaled
cocaine was approximately two to three days ago. He
currently denies any IV drug abuse. Current complaint is
that of right lower quadrant abdominal pain, which he also
says is chronic. He denies nausea and vomiting. He has had
no bowel movements in approximately two to three days. He
denies chest pain, shortness of breath, fevers, chills,
headache, dizziness, and dysuria. He does complain of
sweats. He is currently contracting for safety and denying
any current suicidal ideation. He states that "wants help."
He also states that "sees a man in the room" consistent with
past symptoms of alcoholic hallucinosis.
PAST MEDICAL HISTORY:
1. Longstanding alcohol abuse with prior detoxification
admissions, prior withdrawn symptoms including hallucinosis
and seizures.
2. History of hepatitis C.
3. History of alcoholism and pancreatitis.
4. Depression.
5. Posttraumatic stress disorder.
6. Peptic ulcer disease/gastritis with prior history of GI
bleed documented by esophagogastroduodenoscopy in [**2176-5-8**].
7. No history of coronary artery disease.
MEDICATIONS:
1. Elavil 200 mg p.o.q.d.
2. Seroquel 150 mg p.o.t.i.d.
3. Neurontin 30 mg p.o.b.i.d.
ALLERGIES: The patient is allergic to PENICILLIN, COMPAZINE,
AND COGENTIN.
SOCIAL HISTORY: The patient lives with his parents, but he
has been homeless for the past week since his mother "kicked
him out." He is on disability for "mental illness."
Tobacco: One pack per day times many years. Currently, he
is using inhaled cocaine, which he last used two to three
days prior to admission. He denies current IV cocaine or
heroin use, although he has used IV heroin in the past. He
has also overdosed on benzodiazepines in the past. He drinks
approximately one half of a quart of hard alcohol per day for
the past twelve years.
PHYSICAL EXAMINATION: Admission physical examination
revealed the following: VITAL SIGNS: Temperature 98.7,
heart rate 98, blood pressure 129/54, respiratory rate 18,
pulse oximetry 94% on room air. GENERAL: The patient is
awake, alert, anxious-appearing with his teeth clenched
during the interview consistent with a dystonic reaction.
The patient also has visible tremor. HEENT: Extraocular
muscles are intact. Pupils equal, round, and reactive to
light. No scleral icterus noted. Neck was supple. No
lymphadenopathy, no JVD. CARDIOVASCULAR: Tachycardia,
normal S1 and S2, no murmurs. LUNGS: Trace wheezes at the
left base. ABDOMEN: Protuberant and soft with mild right
upper quadrant and right lower quadrant tenderness to
palpation. Negative [**Doctor Last Name **] sign. Liver edge is ausculted at
the costal margin. EXTREMITIES: No edema, no asterixis.
LABORATORY DATA: Studies revealed the following: White
blood cell 8.8, hematocrit 34.0, platelet count 221,000,
sodium 135, potassium 3.4, chloride 94, bicarbonate 32, BUN
6, creatinine 0.6, and glucose 134, calcium 8.1, magnesium
1.5, phosphorus 2.6, INR 1.2, fibrinogen 211, reticulocyte
count 2.0, haptoglobin 71, CK 154, troponin less than 0.3,
amylase and lipase within normal limits. ALT 57, AST 55, LDH
178, alkaline phosphatase 60, total bilirubin 0.7, urinalysis
negative. Chest x-ray showed some atelectasis and question
of mediastinal widening. Chest clear to auscultation, no
evidence of aortic dissection, but did reveal some bibasilar
atelectasis versus consolidation. CT of the abdomen was
negative for evidence of retroperitoneal bleeding.
HOSPITAL COURSE: (by system).
#1. TOXICOLOGY: The patient was admitted with presumed
tricyclic overdose based on toxicology screen and evidence on
EKG of QRS widening and an R-wave in lead AVR. The patient
received some bicarbonate in the emergency department. The
EKGs gradually showed resolution of these changes. The
telemetry was normal throughout the rest of his
hospitalization. Repeat EKG on the morning of discharge
showed normal QRS interval. The patient did experience some
dystonic symptoms characterized by jaw clenching throughout
his hospitalization which were attributed either to patient's
recent ingestion of someone else antipsychotics, such as
Haldol and/or a symptom of Amitriptyline overdose itself. The
patient was placed on standing and p.r.n. Valium for
withdrawal prophylaxis, according to a CIWA scale. He was
also put on p.o. and standing Benadryl for dystonic symptoms.
#2. CARDIOVASCULAR: The patient has evidence of conduction
abnormalities on initial EKG consistent with Amitriptyline
overdose. As noted, these resolved later on the admission.
The patient showed no further complications of his overdose.
#3. PULMONARY: Chest x-ray with question of mediastinal
widening concerning for aortic dissection, although followup
CT angiogram was negative. The patient has no symptoms of
shortness of breath or fever to suggest consolidation,
although there was the suggestion of atelectasis versus
consolidation on chest x-ray and chest CAT scan.
#4. GASTROINTESTINAL: The patient did have a history of GI
bleed in the past and was noted to have a 10-point drop in
the hematocrit on the first evening of admission. He was
guaiac negative. NG lavage was negative. CT of the abdomen
was negative for bleeding. The hematocrit, subsequently
stabilized with no evidence of acute bleeding. Stools were
guaiac tested and these were negative.
#5. PSYCHIATRIC: The patient was admitted to overdosing on
tricyclics. The patient had poor recall for the events prior
to his overdose, but denied current suicidal ideation in the
hospital. He was maintained with a 1:1 sitter. He was
willing to be admitted to the Psychiatry Department. His
current antipsychotic regimen of Seroquel 150 p.o.b.i.d. was
held during this admission, as was his Elavil for obvious
reasons.
#6. HEMATOLOGICAL: The patient's hematocrit remained stable
as noted above. Iron studies were drawn and were within
normal limits.
DISCHARGE CONDITION: Stable.
DISCHARGE DIAGNOSIS:
1. Tricyclic antidepressant overdose.
2. Alcohol abuse.
3. History of hepatitis C.
4. Depression.
5. Posttraumatic stress disorder.
DISCHARGE MEDICATIONS:
1. Protonix 40 mg p.o.q.d.
2. Thiamine 100 mg p.o.q.d.
3. Multivitamin one tablet p.o.q.d.
4. Folate 1 mg p.o.q.d
5. Valium 10 mg p.o.t.i.d. until decision to taper for
improvement in withdrawal symptoms.
6. Valium 10 mg p.o./IV q.1h.p.r.n. for CIWA scale greater
than 10.
7. Benadryl 25 mg IV/p.o.q.4 to 6h.p.r.n. for dystonia.
8. Benadryl 50 mg q.6h.to 8h. until [**3-17**] or 9th
and/or resolution of dystonic symptoms such as jaw clenching.
9. CIWA alcohol withdrawal protocol.
10. Neurontin 30 mg p.o.b.i.d.
DIAGNOSIS INSTRUCTIONS:
1. The patient should be kept on a CIWA scale.
2. Standing and p.o. Benadryl can be used for dystonia.
3. Seroquel 150 mg p.o.b.i.d. has been held.
The patient should receive outpatient psychiatric followup
prior to discharge with possible eye toward outpatient
alcohol rehabilitation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 15589**], M.D. [**MD Number(1) 15590**]
Dictated By:[**Last Name (NamePattern4) 4689**]
MEDQUIST36
D: [**2180-3-16**] 15:47
T: [**2180-3-16**] 15:55
JOB#: [**Job Number 15591**]
ICD9 Codes: 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1439
} | Medical Text: Admission Date: [**2166-9-23**] Discharge Date: [**2166-9-27**]
Date of Birth: [**2096-1-31**] Sex: M
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is a 70-year-old
gentleman who was admitted to [**Hospital6 2018**] on [**2166-9-22**] for an elective CABG times two.
PAST MEDICAL HISTORY:
1. Appendectomy.
2. Hypercholesterolemia.
3. BPH.
4. Rheumatic fever.
5. Renal stones.
6. Hiatal hernia.
7. Rheumatoid arthritis.
MEDICATIONS ON ADMISSION:
1. Toprol.
2. Plaquenil.
3. Terazosin.
4. Iron.
5. Aspirin.
6. Simvastatin.
7. Hydrochlorothiazide.
ALLERGIES: The patient has no known drug allergies.
PHYSICAL EXAMINATION ON ADMISSION: The patient was found to
be in no acute distress. Regular rate and rhythm. No
murmurs, rubs, or gallops. The lungs were clear. The
abdomen was benign. The extremities revealed no clubbing,
cyanosis or edema.
HOSPITAL COURSE: The patient was admitted to the hospital on
[**2166-9-23**] and underwent a CABG times two with
saphenous vein graft to OM-I and saphenous vein graft to PDA.
The patient was transferred to the CSRU postoperatively where
he was extubated on postoperative day number zero.
On postoperative day number one, the patient's Swan-Ganz
catheter was removed as well as his chest tubes, and he was
transferred to the floor. The patient did well on the floor
and was seen by physical therapy.
By postoperative day number three, the patient was ambulating
at a level V. However, on postoperative day number three,
the patient developed rapid atrial fibrillation and was
started on Lopressor and Amiodarone. The patient responded
well to this and converted to a sinus rhythm after six hours
of atrial fibrillation.
On postoperative day number four, the patient continued to do
well with physical therapy and was at a level V. He was
discharged to home on postoperative day number four in good
condition on the following medications.
DISCHARGE MEDICATIONS:
1. Lopressor 12.5 mg p.o. b.i.d.
2. Amiodarone taper of 400 mg p.o. t.i.d. times four days;
400 mg p.o. b.i.d. times five days; 400 mg p.o. q.d. times
seven days; 200 mg p.o. q.d. times 14 days.
3. Simvastatin 10 mg p.o. q.d.
4. Percocet 5/325 one to two tablets p.o. q. 4-6 hours
p.r.n.
5. Aspirin 325 mg p.o. q.d.
6. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. b.i.d. times ten days.
7. Lasix 20 mg p.o. b.i.d. times ten days.
8. Colace 100 mg p.o. b.i.d.
FO[**Last Name (STitle) **]P: The patient is to follow-up with Dr. [**Last Name (Prefixes) **]
in four weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 6067**]
MEDQUIST36
D: [**2166-9-27**] 22:14
T: [**2166-9-29**] 09:17
JOB#: [**Job Number **]
ICD9 Codes: 4111, 9971, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1440
} | Medical Text: Admission Date: [**2155-4-5**] Discharge Date: [**2155-4-14**]
Date of Birth: [**2071-7-7**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1115**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
Intubated
Bronchoscopy
History of Present Illness:
83 y/o F PMH CVA/stroke, HTN, [**Hospital 33210**] transferred from Nursing Home
for respiratory distress. Overall limited history. Per ED report
patient has long-standing dysphagia secondary to stroke and
recurrent aspiration PNA. She had one episode of vomiting today
and was hypoxic throughout the afternoon in the 80s and
eventually brought into the ED for evaluation. On the resident
transfer form reports 82% on RA and reported baseline mental
status alert, disoriented and cannot follow simple instructions
and risk alert of aspiration.
.
On arrival to the ED VS 91% NRB, HR 91, BP 126/77, Tm 98.4. Per
report patient's sat's ranged 80-90% on NRB. No ABG done prior
to intubation. She was given 500 cc NS bolus and vancomycin,
levaquin and flagyl for antibiotics (levaquin and flagyl not
signed off on). Tmax 99.4 rectal. Vital on transfer 90s, 121/73
(per report no episodes of hypotension). EKG demonstrated sinus
96, no right heart strain. Patient transferred to MICU s/p
intubation.
.
Patient's family reports patient recently discharged from [**Hospital 2587**] last friday following CVA (recurrent) she has been
somnelent/sleepy at [**Hospital3 2558**] but otherwise no compliants.
Denie history of fever, chills, cough, abdominal pain. They
report that patient's communication is limited but did not
notice any recent changes.
Past Medical History:
- H/O Aspiration PNA - family deny
- H/O right CVA/Stroke/TIA - several, recurrent
- HTN
- HLD
- Dysphagia - family deny
- Right Humeral fracture
- History of depression
Social History:
Lives at [**Location **]. Non-smoker.
Family History:
NC
Physical Exam:
On Admission:
GEN: Intubated and sedated. Not arousable to voice.
HEENT: PERRL, EOMI, anicteric, dryMM, op without lesions,
RESP: Clear to auscultation anteriorly.
CV: RR, + 3/6 systolic ejection murmur
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: Pupils equal and reactive to light.
RECTAL: Full of stool.
.
On Discharge:
VS: 97.6 152/73 60 20 100% RA
GEN: awake, alert, no distress, able to respond in 1-word
answers to repeated prompting (Russian-speaking)
HEENT: PERRL, EOMI, anicteric, dry MM
RESP: right lung clear to auscultation, left lung with rales at
base, good air entry and in no respiratory distress
CV: RR, + 3/6 systolic ejection murmur
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no edema in upper extremities, R PICC line removed, L PIV
in place with no surrounding infiltration
SKIN: no rashes/no jaundice/no splinters
NEURO: awake and alert, as above non-verbal, pupils 4mm and
reactive b/l, EOMI, follows 1-step commands with repeated
prompts, tracks with eyes
Pertinent Results:
On Admission to ICU:
[**2155-4-5**] 01:25AM BLOOD WBC-8.8 RBC-4.91 Hgb-14.1 Hct-43.6 MCV-89
MCH-28.6 MCHC-32.2 RDW-15.2 Plt Ct-343
[**2155-4-5**] 01:25AM BLOOD Neuts-79.0* Lymphs-17.4* Monos-2.5
Eos-0.5 Baso-0.5
[**2155-4-5**] 01:40AM BLOOD PT-11.9 PTT-19.2* INR(PT)-1.0
[**2155-4-5**] 01:25AM BLOOD Glucose-144* UreaN-25* Creat-0.7 Na-139
K-5.2* Cl-104 HCO3-23 AnGap-17
[**2155-4-6**] 02:51AM BLOOD Calcium-7.8* Phos-3.3 Mg-1.8
.
On Discharge from ICU:
[**2155-4-9**] 03:44AM BLOOD WBC-5.4 RBC-3.38* Hgb-10.0* Hct-28.8*
MCV-85 MCH-29.7 MCHC-34.9 RDW-14.9 Plt Ct-202
[**2155-4-9**] 03:44AM BLOOD Neuts-74.3* Lymphs-15.9* Monos-5.1
Eos-4.5* Baso-0.2
[**2155-4-9**] 03:44AM BLOOD PT-11.8 PTT-25.5 INR(PT)-1.0
[**2155-4-9**] 03:44AM BLOOD Glucose-88 UreaN-7 Creat-0.3* Na-138
K-3.5 Cl-106 HCO3-30 AnGap-6*
[**2155-4-9**] 03:44AM BLOOD Calcium-7.8* Phos-2.6* Mg-2.2
.
ABG:
[**2155-4-9**] 11:58AM BLOOD Type-ART pO2-108* pCO2-41 pH-7.44
calTCO2-29 Base XS-3
.
Other pertinent labs:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2155-4-14**] 07:15 6.4 3.96* 11.1* 34.8* 88 28.0 31.8 15.2 329
.
Microbiology:
Blood Culture, Routine (Pending): NGTD
.
Urine Culture:
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMIKACIN-------------- <=2 S <=2 S
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- =>32 R =>32 R
CEFAZOLIN------------- <=4 S <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ =>16 R =>16 R
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S <=16 S
TOBRAMYCIN------------ 8 I 8 I
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
.
Sputum/BAL:
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
.
Respiratory Viral Culture (Final [**2155-4-8**]): No respiratory
viruses isolated.
.
Bronchoscopy:
Airways: The observed trachea and carina were normal. The left
mainstem, LUL, lingula and LLL segments and observed subsegments
were normal with minimal purulent secretions that were easily
suctioned. The right mainstem, RML and RLL were normal in
appearance with minimal to moderate mucous that was easily
suctioned. The respiratory mucosa in the take-off of the RUL was
inflamed and erythematous. The bronchosopce was advanced to the
apical segment of the RUL. A BAL was performed with 90cc of
sterile saline infused and ~40cc of purulent secretions were
aspirated. There were no complications and the patient tolerated
the procedure well with stable oxygenation (SpO2 94-96% on
stable vent settings - FiO2 100%).
General impression: Inflamed, irritated RUL with purulent
secretions aspirated on BAL. Sample sent for bacterial, AFB,
viral and fungal cultures as well as cytology.
.
Imaging:
CTA:
IMPRESSION:
1. No acute pulmonary embolism.
2. Ectasia of the ascending thoracic aorta, without acute
thoracic aortic
pathology.
3. Chronic scarring and fibrosis in the right upper lobe,
minimally in the
right lower and left upper lobe.
4. Bibasal central ground-glass opacities, differential
diagnosis includes
infection, mild edema, or aspiration.
5. ET tube and nasogastric tube are in optimal position.
.
[**4-11**]:
RIGHT UPPER EXTREMITY ULTRASOUND: Grayscale and Doppler son[**Name (NI) **]
of the right internal jugular, subclavian, axillary, brachial,
basilic and cephalic veins was performed. There is a PICC in one
of the right brachial veins. There is non-occlusive thrombus in
the brachial vein extending into the axillary and subclavian
vein. There is occlusive thrombus in the cephalic vein.
.
CXR [**4-10**]:
FINDINGS: Right apical pleural thickening and right hilar
superior displacement is unchanged since [**2155-4-5**]. Right upper,
left lower and lingular opacity have improved since [**2155-4-9**]. A
small left pleural effusion is new. There is no evidence of
pulmonary edema. The cardiac size is normal. Thoracic spine
scoliosis, convex to the left is mild.
IMPRESSION: Improving multifocal consolidation; new small left
pleural effusion.
.
Brief Hospital Course:
MICU Course: 83 y/o F PMH CVA/stroke complicated by dysphagia,
HTN, [**Hospital 33210**] transferred from Nursing Home for respiratory distress
requiring intubation, found to have MRSA pneumonia and urinary
tract infection.
.
ACTIVE ISSUES:
==============
# MRSA pneumonia: patient is at a high risk of aspiration due to
dysphagia secondary to several strokes, her most recent stroke
was 1 week prior to this admission and patient developed
vomiting (likely due to UTI, see below) and likely aspirated.
She required intubation on arrival and was intubated from [**4-5**]
to [**4-8**], had successful extubation. She was found to have
multifocal pneumonia on imaging and treated for HCAP coverage
with vancomycin and cefepime. She had a CTA which ruled out PE
(study performed given high oxygen requirement on first day of
admission). Bronchoscopy was done and showed purulent secretions
in the RUL; FiO2 significantly improved following suction of
secretions. BAL and sputum returned positive for MRSA and
patient was narrowed to vancomycin. She should complete a 2-week
course of vancomycin (last day = [**4-18**]). Upon transfer to the
floor, patient was quickly weaned to room air and did not have
any cough or shortness of breath. She was afebrile and had no
leukocytosis. Speech and swallow initially evaluated patient and
recommended keeping her NPO on maintenance fluids. She was
re-evaluated on [**4-14**] prior to discharge and was found to do well
with honey thickened liquids and pureed solids, which was her
diet at [**Hospital3 2558**] prior to admission. We had an extensive
discussion with the family about goals of care and patient's
functional status and her son decided to make her DNR/DNI; he
additionally said that he would not want to place feeding tubes
to maintain nutrition and would rather feed for comfort. Patient
was seen by palliative care prior to discharge. She was
discharged back to [**Hospital3 2558**] with 4 more days of
antibiotics and updated speech/swallow recommendations.
.
# UTI: urine culture grew two different strains of E. Coli and
presumptive S. bovis. She completed a 3-day course of
ceftriaxone without any symptoms. At time of discharge, she was
afebrile with no leukocytosis.
.
# Catheter-induced upper extremity DVT: pt had PICC line placed
in MICU for antibiotic therapy. She was found to have dependent
edema around right elbow and an U/S was done which found a right
side upper extremity DVT. The PICC line was removed and a
peripheral line was replaced in the other arm. The arm was
elevated and the swelling improved. Anticoagulation was not
initiated given many recent strokes, including one 1 week prior
to admission, and increased risk of intracranial hemorrhage.
Coumadin would not be a good option for patient given poor
nutritional state and initiating lovenox at this time seemed to
outweigh the benefits. This was discussed with the family in the
larger context of goals of care for the patient.
.
# H/O CVA/Stroke: patient has had recurrent CVAs this year with
baseline poor functional status, largely non-verbal. A goals of
care discussion was held with the patient's son and his wife
given recurrent aspiration pneumonia and dysphagia. The son
wished to make patient DNR/DNI. He had never discussed her
end-of-life wishes prior to her cognitive impairment but
believes she would not want any aggressive or invasive measures.
Given her dysphagia and nutritional status we discussed with the
family options for feeding. They expressed that she would not
have wanted a feeding tube or NG tube for feeding. Pt was
maintained on maintenance fluids and prior to discharge, was at
baseline swallowing (puree solids and honey thickened liquids).
The son said that in the event the patient's swallowing
capabilities worsened, he would like to feed for comfort and
accept the aspiration risks. Patient should have repeat swallow
evaluation at [**Hospital3 2558**]. She is currently on full dose ASA
which was continued.
.
# Constipation: Required disimpaction on admission and had
subsequent large BM. Continued bowel regimen with senna, colace,
and miralax.
.
INACTIVE ISSUES:
================
# HLD: Continued lipitor.
.
# Depression: continued Remeron 30 mg qhs.
.
TRANSITION OF CARE:
===================
# Goals of care - would continue to discuss with family the
larger goals of care for patient and whether risk of aspiration
pneumonia and possibility of recurrent hospitalizations is
consistent with these goals. [**Name (NI) **] son is now processing the
decline of his mother's health and decided to make DNR/DNI on
this admission. As above, he additionally expressed that he
would not want to feed her invasively with a feeding tube or NG
tube, and that if her swallowing capacity were to decline he
would want to feed for comfort and to accept aspiration risk. We
did not specifically address whether he would like to consider
no longer re-hospitalizing her though this is something he will
think about. Our palliative care team evaluated the patient
prior to discharge and will contact son to continue discussing
goals of care. Recommend social work support to help the son
think through end of life issues, consideration of a do not
hospitalize order and consideration of transition to hospice
care.
Medications on Admission:
- Diet - puree, honey-thick liquids
- Colace [**Hospital1 **]
- Remeron 30 mg qhs
- Senna qhs
- Lipitor 40 mg qd
- ASA 325 mg qd
- Bisacodyl 10 mg supp M-W-F
- Plain yogurt daily
- prn: Tylenol, MOM, [**Name (NI) 20342**] enema
Discharge Medications:
1. atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
5. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Remeron 30 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. Miralax 17 gram Powder in Packet Sig: One (1) PO once a day.
9. doxycycline hyclate 100 mg Tablet Sig: One (1) Tablet PO
twice a day for 4 days: please start on [**4-15**]; last day on [**4-18**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
Aspiration pneumonia
Urinary tract infection
Secondary:
Hypertension
Hyperlipidemia
Recurrent CVAs
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 41617**],
You were admitted to [**Hospital1 18**] with an aspiration pneumonia which
likely occurred when you vomited at home. Your vomiting was
probably caused by a urinary tract infection. You were intubated
for a few days to maintain your breathing and then extubated
successfully. We gave you antibiotics to treat both of your
infections and your improved. You passed the swallow evaluation
prior to discharge. We are providing your facility with
recommendations about your feeding and swallowing. You will also
continue 4 more days of antibiotics when you leave.
You should follow up with your PCP or physician at [**Name9 (PRE) 7137**].
We have made the following changes to your medications:
- START doxycycline 100mg twice daily for 4 more days (last day
= [**4-18**]) for your lung infection
- TAKE senna, miralax and colace to keep your stool soft
Followup Instructions:
Please follow up with your PCP or physician at [**Hospital3 2558**].
Completed by:[**2155-4-14**]
ICD9 Codes: 5070, 2762, 5990, 2859, 311, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1441
} | Medical Text: Admission Date: [**2134-9-27**] Discharge Date: [**2134-10-9**]
Date of Birth: [**2066-11-25**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Abdominal pain.
Major Surgical or Invasive Procedure:
[**2134-9-28**]:
Right hemicolectomy with end ileostomy and mucous fistula.
[**2134-9-30**]:
Cardioversion.
History of Present Illness:
67 year old male was transferred to [**Hospital1 18**] from [**Hospital3 19345**] where he was admitted on [**2134-9-22**] for bilateral UE pain.
Approximately 2 weeks ago he received IM Vidaza for his MDS and
then subsequently developed bilateral upper extremity cellulitis
and blistering at the injection sites. While hospitalized, his
abdomen slowly became more distended and tender. WBC count has
trended upward (12 --> 26). Over the past 24 hrs he was also
found to be in atrial fibrillation and was transferred to [**Hospital1 18**]
this morning for further care. On presentation to the MICU, his
abdomen was markedly distended and tender, and he was intubated
for respiratory distress. OG placed and 200 cc of bile returned.
Past Medical History:
Myelodysplastic syndrome, Carpal tunnel syndrome, COPD.
Past Surgical History:
L knee surgery, back surgery.
Social History:
Retired, used to work for a chemical company. History of
asbestos and other chemical exposure. He has a history of
significant alcohol use, which he stopped approximately seven
years ago. 60 pack year history of tobacco use.
Family History:
Sister - died of scleroderma; Another sister - died of unclear
etiology; Brother - died of EtOH abuse; Daughter with Marfan's;
Two brothers are alive and well; Mother - died of lung cancer;
Father - died in an MVC.
Physical Exam:
97.7 137 (irregular) 142/72 24 97% CMV .6/500/16/5
Intubated, OG tube in place draining bile
PERRL, EOMI, anicteric
Tachycardic, irregularly irregular
Lungs CTAB
Abdomen soft, distended, tympanitic, mildly tender in RUQ and
RLQ without obvious guarding. Fullness on right side of upper
abdomen, ? liver edge. Old supra-umbilical scar well healed. No
hernias.; midline laparotomy wound with steri strips; 4cm area
open wound w dry packing in place at inferior aspect midline
laparotomy wound; +staple erythema underlying steri-strips;
+mucous fistula in RUQ
Bilateral upper extremities with erythema and blistering with
skin sloughing, L>R. LUE with induration but no obvious
fluctuance.
LE warm, trace edema
Rectal: Guiac positive, soft brown stool
Pertinent Results:
[**2134-9-27**] 08:21PM WBC-30.2*# RBC-2.83* HGB-9.7* HCT-29.1*
MCV-103* MCH-34.2* MCHC-33.2 RDW-21.1*
[**2134-9-27**] 08:21PM NEUTS-90.5* LYMPHS-5.6* MONOS-3.5 EOS-0
BASOS-0.4
[**2134-9-27**] 08:21PM PLT COUNT-102*#
[**2134-9-27**] 08:21PM SED RATE-66*
[**2134-9-27**] 08:21PM CRP-188.9*
[**2134-9-27**] 08:21PM GLUCOSE-192* UREA N-71* CREAT-1.1 SODIUM-143
POTASSIUM-4.1 CHLORIDE-112* TOTAL CO2-23 ANION GAP-12
[**2134-9-27**] 08:21PM CALCIUM-8.4 PHOSPHATE-4.4# MAGNESIUM-3.2*
[**2134-9-27**] 08:21PM ALT(SGPT)-40 AST(SGOT)-37 CK(CPK)-141 ALK
PHOS-148* TOT BILI-1.3
[**2134-9-27**] 08:32PM LACTATE-1.5 K+-4.3
[**2134-9-27**] 10:51PM PT-43.7* PTT-40.2* INR(PT)-4.7*
CT abdomen [**2134-9-27**] at LGH showed:
Dilated small bowel loops without a clear transition point.
Several streaks of air in the right colon suspicious for
pneumatosis.
MRI LUE [**2134-9-25**] at LGH showed:
Extensive SC edema which may represent cellulitis. Extensive
edema within the muscles of the posterior compartment of the LUE
may represent myositis. No abscess.
CT abdomen/pelvis [**2134-9-28**] at [**Hospital1 18**] showed:
1. Findings of diffuse small bowel dilatation up to 4.5 cm with
segments of decreased bowel wall enhancement, pneumatosis of the
small bowel and cecum, mesenteric edema, free fluid and celiac
axis origin stenosis concerning for ischemic small and right
sided large bowel.
2. Diverticulosis of the descending and sigmoid colon without
evidence of diverticulitis.
3. Complex small pericardial effusion might represent
hemopericardium.
[**2134-9-28**] 2:10 pm SWAB PERITONEAL.
**FINAL REPORT [**2134-10-4**]**
GRAM STAIN (Final [**2134-9-28**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2134-10-4**]):
ENTEROCOCCUS SP.. SPARSE GROWTH.
DR [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Numeric Identifier 14013**]) REQUESTED SENSITIVITIES TO
DAPTOMYCIN
[**2134-10-2**].
SENSITIVE TO Daptomycin MIC OF 4 MCG/ML, Sensitivity
testing
performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
ANAEROBIC CULTURE (Final [**2134-10-2**]): NO ANAEROBES ISOLATED.
TTE [**2134-9-29**] showed:
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild global left ventricular
hypokinesis (LVEF = 45-50%). 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 ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve, but cannot be fully excluded due to
suboptimal image quality. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is a probable
vegetation on the mitral valve. Mild to moderate ([**12-19**]+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. No masses or vegetations are seen on the tricuspid
valve, but cannot be fully excluded due to suboptimal image
quality. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild global LV hypokinesis. There may be a small
mass on the posterior leaflet of the mitral valve - best seen on
image #45. This appears to move back and forth through the plane
of the valve. It could be a scallop of the mitral valve or an
acoustic artifact or a small vegetation. TEE would help to
clarify, if clinically indicated. Mild to moderate mitral
regurgitation is seen.
TEE [**2134-9-30**] showed:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. A patent foramen ovale is present
with transition of agitated saline bubbles from the right to
left atrium at rest. Overall left ventricular systolic function
is low normal (LVEF 50%) with mild global free wall hypokinesis.
There are simple atheroma in the aortic arch and descending
thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. No masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. No mass or vegetation is seen on the mitral
valve. Mild (1+) mitral regurgitation is seen.
IMPRESSION: No atrial thrombus seen. No vegetation/ abscess
seen. Patent foramen ovale. Low-normal global left ventricular
function.
RUQ US [**2134-10-1**] showed:
Gallbladder sludge without evidence of acute cholecystitis.
CT LUE [**2134-10-1**] showed:
1. Diffuse subcutaneous edema and skin thickening is most
consistent with cellulitis. No subcutaneous emphysema.
2. Fluid along the superficial fascial planes of the biceps and
brachialis muscles. No deeper fluid or organized fluid
collections.
3. Degenerative changes of the left shoulder.
4. Bilateral pleural effusions, with collapse of left lower lobe
and atelectasis of the right lower lobe, incompletely evaluated.
5. Small pericardial effusion. Small ascites. Mild anasarca.
Brief Hospital Course:
On [**2134-9-27**], the patient was admitted to the MICU for
resuscitation. Repeat CT abdomen/pelvis again showed
pneumatosis coli, and on the [**2134-9-28**], he was brought to the
operating theater where necrotic right colon was found and
resected. End ileostomy and delayed mucous fistula with [**First Name4 (NamePattern1) 3924**]
[**Last Name (NamePattern1) **] clamp was performed to expedite the procedure given his
severity of illness. Post-operatively, the patient was admitted
to the SICU on acute care surgery.
On [**2134-9-30**], the patient's platelet count dropped to 40 (from
102 on admission, 200-300 at previous baseline) and prophylactic
heparin SC was held. HIT panel was sent and ultimately returned
negative. Arixtra was started in the interim and later
switched. Echocardiogram showed no vegetations. The patient
was transfused 1 unit platelets. He was extubated with
post-extubation atrial fibrillation with RVR and pulmonary
edema, intractable to diltiazem gtt, improved with metoprolol
boluses, switched to amiodarone gtt. He was re-intubated for
poor protection of airway/lethargy. He was cardioverted with
200J once and has since been in sinus rhythm. On [**2134-10-1**],
amiodarone was switched to oral dose.
On [**2134-10-4**], the patient was weaned to extubation. He passed
speech and swallow evaluation and was started on regular diet,
which he tolerated. On [**2134-10-5**], he was transferred to the
floor.
Following his transfer he continued to make good progress. He
was tolerating a regular diet well with Ensure supplements and
his ostomy was active. The ostomy nurse followed him closely
during his stay as he had a little superficial necrosis and some
skin separation at the mucocutaneous fistula from 8 - 3 o'clock
approx 0.2 cm with minimal depth. There was a 2 cm depth at 3
o'clock with fascia intact. The periphery of the stoma was pink.
His right upper quadrant has a pouch over an area where [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3924**]
[**Last Name (NamePattern1) **] clamp was placed intraop, egressed and removed on
[**2134-10-8**].
He was also followed by the Infectious Disease service as his
initial peritoneal fluid culture was positive for VRE. He was
treated with a course of Daptomycin which ended on [**2134-10-8**] and
he was afebrile with a normal WBC. His left upper arm was
improving and not infected.
The hematologist also followed him closely due to his MDS and
his hematocrit was in the 23-25 range from a baseline of 29. He
received 7 UPC during his hospitalization, the most recent being
on [**2134-10-8**] for a hematocrit of 23 and complaints of fatigue and
lethargy. He also received 2 units of platelets during his stay
for a low count of 40K from a baseline of 100K. He will be
followed by Dr. [**Last Name (STitle) **] as an outpatient next week.
After a long, protracted hospitalization Mr. [**Known lastname **] was
discharged to rehab to increase his mobility and prepare for his
return home.
Medications on Admission:
Oxycodone prn, Trazodone QHS, Ca., Fish oil
Discharge Medications:
1. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for to groin.
2. silver sulfadiazine 1 % Cream Sig: One (1) Appl Topical WITH
EACH DRESSING CHANGE ().
3. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for Wheeze.
5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Necrotic right colon with peritonitis
Respiratory failure
Atrial fibrillation
Acute blood loss anemia
Myelodysplastic Syndrome
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:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-26**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Monitoring Ostomy output/Prevention of Dehydration:
*Keep well hydrated.
*Replace fluid loss from ostomy daily.
*Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
*Try to maintain ostomy output between 1000mL to 1500mL per day.
*If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours.
Please pack inferior aspect midline laparotomy wound with MOIST
to dry dressing [**Hospital1 **]. Thank you.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2134-10-12**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**]
Date/Time:[**2134-10-12**] 2:00
Provider: [**Name10 (NameIs) **] CARE CLINIC Phone:[**Telephone/Fax (1) 2359**]
Date/Time:[**2134-10-19**] 2:30
Completed by:[**2134-10-9**]
ICD9 Codes: 0389, 2851, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1442
} | Medical Text: Admission Date: [**2176-12-13**] Discharge Date: [**2176-12-19**]
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Ativan
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Right visual field cut and confusion.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
88 year old woman with history of HTN initially presenting this
morning with an occipital stroke. Per report she was an active
healthy woman who painted a fence last week. She was brought in
to the hospital this morning after a syncopal episode and acute
onset of neurological deficits and was diagnosed with a large
left PCA territory stroke. She was transferred to [**Hospital1 18**] for
further workup and treatment.
Yesterday morning the patient had 1 episode of desaturations to
80% but had just gotten 1 dose of ativan. They gave her 3L NC
and she bounced back to 90s. At 2am this morning (1 hour ago)
she triggered on the floor for desaturations briefly down to
80%. She was placed on 4L NC then 5L NC and then on a
non-rebreather on which she was sating ~88% and then increased
to 97% when the head of the bed was raised. An ABG and CXR were
normal. Lungs were clear on exam. She was noted to be tachypneic
and hypertensive and in a sinus tach at 95. BPs ranging 175/120,
EKG showed no evidence of right heart strain.
No fever or chills. Denies any current shortness of breath or
cough although cough noted by neurology team this evening. No
witnessed aspiration event.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
hypertension
h/o Shingles in [**2176-10-9**]
Left macular degeneration
hearing loss with hearing aids
Mild cognitive loss
s/p LLE phlebitis in [**2167**]
Varicose veins
Osteoarthritis
s/p Foot surgery in [**2165**]
Social History:
No smoking, ETOH, illicits.
Son and daughter at bedside.
Son is HCP ([**Telephone/Fax (1) 51694**])
Patient lives with her daughter, who previously worked as a
nurse. Complicated social family history.
Family History:
Mom died of colon cancer. Dad died of MI. No h/o strokes.
Physical Exam:
Summary of Neurologic Exam Findings:
Mrs.[**Known lastname 51695**] key exam findings are: Right homonymous
hemianopia, anomia, anterograde amnesia. Please see brief
hospital course for anatomical correlation of these findings and
realtionship to her stroke.
Admission Examination:
96.8 73 150/104 18 96% 2L
Gen: Lying in bed, NAD
HEENT: Normocephalic, atraumatic. Mucous membranes moist.
Neck: Supple
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Abd: +BS soft, nontender
Skin: No rash
Ext: No edema
Neurologic examination:
Mental status:
General: Alert, awake, agitated.
Orientation: Oriented to person, "hospital" (doesn't know which
one). Cannot name month of year.
Attention: Says days of the week forwards but stops after 5
days;
unable to to say days of the week backwards
Executive Function: Follows simple axial and appendicular
commands. Requires step-by-step prompts for complex commands.
Memory: Registration [**4-10**]. Recall 0/3 at 5 minutes.
Speech/Language: When lying down, speech is fluent w/o
paraphasic
(phonemic or semantic) error. When sitting up, however, patient
has significant word substitution and invents words. When asked
to name objects on the stroke card, she makes up words. Then
she
says, "I can't see anything without my roof." Appears
frustrated
by inability to come up with the correct word. Comprehension
seems intact. Unable to read.
Praxis: Able to demonstrate how to brush teeth.
Calculations: Unable to calculate 9 quarters.
Cranial Nerves:
II: Pupils equally round and reactive to light, 2 to 1.5 mm
bilaterally. Dense right visual field cut. Looks at $20 [**Doctor First Name **] in
left visual field and follows it. She also is able to copy the
examiner when shown how to do various parts of the exam (this
was
often done due to difficulty hearing). However, later in the
exam
when testing finger-nose-finger in the sitting position, the
patient was unable to find the examiner's finger regardless of
visual field.
III, IV, VI: Extraocular movements intact without nystagmus.
V1-3: Sensation intact V1-V3.
VII: Facial movement symmetric.
VIII: Significant hearing difficulty throughout exam; examiner
needs to yell for patient to understand.
IX & X: Palate elevation symmetric. Uvula is midline.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius full strength bilaterally.
XII: Good bulk. No fasciculations. Tongue midline, movements
intact.
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor. No pronator drift
Delt; C5 Bic:C6 Tri:C7 Wr ext:C6 Fing ext:C7
Left 5 5 5 5 5
Right 5 5 5 5 5
IP: Quad: Hamst: Dorsiflex: [**Last Name (un) 938**]:Pl.flex
Left 5 5 5 5 5 5
Right 5 5 5 5 5 5
Deep tendon Reflexes:
Biceps: Tric: Brachial: Patellar: Achilles Toes:
Right 1 1 1 1 1
WITHDRAW
Left 1 1 1 1 1
WITHDRAW
Sensation: Intact to light touch throughout. No extinction to
double simultaneous stimulation.
Coordination: Finger-nose-finger limited as patient appears
unable to see the examiner's finger; she is able to touch her
nose with very mild right-sided dysmetria. Heel to shin normal,
RAMs normal.
Gait: Not tested due to pressure-dependent exam.
Pertinent Results:
On admission:
[**2176-12-12**] 09:45PM BLOOD WBC-6.0 RBC-4.44 Hgb-14.0 Hct-40.3 MCV-91
MCH-31.4 MCHC-34.7 RDW-15.7* Plt Ct-148*
[**2176-12-12**] 09:45PM BLOOD Neuts-86.3* Lymphs-9.7* Monos-3.3 Eos-0.4
Baso-0.4
[**2176-12-12**] 09:45PM BLOOD PT-12.4 PTT-28.0 INR(PT)-1.0
[**2176-12-12**] 09:45PM BLOOD Glucose-110* UreaN-10 Creat-0.7 Na-136
K-3.7 Cl-101 HCO3-25 AnGap-14
[**2176-12-13**] 07:40AM BLOOD ALT-18 AST-24 CK(CPK)-106 AlkPhos-73
TotBili-0.4
[**2176-12-12**] 09:45PM BLOOD cTropnT-<0.01
[**2176-12-12**] 09:45PM BLOOD Cholest-223*
[**2176-12-13**] 07:40AM BLOOD Calcium-9.1 Phos-2.3* Mg-1.9 Cholest-241*
[**2176-12-13**] 07:40AM BLOOD %HbA1c-5.7 eAG-117
[**2176-12-12**] 09:45PM BLOOD Triglyc-54 HDL-82 CHOL/HD-2.7
LDLcalc-130*
[**2176-12-13**] 07:40AM BLOOD TSH-3.4
[**2176-12-12**] 09:45PM BLOOD ASA-6.9 Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2176-12-14**] 01:37AM BLOOD Type-ART FiO2-95 pO2-81* pCO2-38 pH-7.46*
calTCO2-28 Base XS-2 AADO2-562 REQ O2-92 Intubat-NOT INTUBA
[**2176-12-14**] 01:34PM BLOOD Lactate-1.3
[**2176-12-14**] 01:34PM BLOOD O2 Sat-92
[**2176-12-12**] 10:30PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.008
[**2176-12-12**] 10:30PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-50 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR
[**2176-12-12**] 10:30PM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE
Epi-0-2
[**2176-12-12**] 10:30PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
MRSA SCREEN (Final [**2176-12-17**]): No MRSA isolated.
CT Head (OSH)
Hypodensity in PCA distribution, not involving brainstem, but
whole of left occipital pole, through inferior temporal lobe and
left hippocampus to temporal pole.
ECG [**2176-12-12**]:
Sinus rhythm. Left axis deviation consistent with left anterior
fascicular block. QRS axis minus 45 degrees. First degree A-V
delay. Delayed R wave transition in the anterior precordial
leads, may be due to left anterior fascicular block but cannot
exclude anteroseptal wall myocardial infarction, age
indeterminate. Clinical correlation is suggested. Possible left
ventricular hypertrophy. Non-specific inferior and lateral ST-T
wave changes. No previous tracing available for comparison.
CTA Neck [**2176-12-13**]:
IMPRESSION:
1. Left occipital infarct.
2. Narrowing of the left PCA P2 bifurcation segment.
Atheromatous disease
involving the left proximal vertebral artery.
3. Small low density right thyroid nodule measuring about 8mm.
Clinical and TFT evaluation advised prior to US.
TTE [**2176-12-14**]:
The left atrium is normal in size. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity is
unusually small. Regional left ventricular wall motion is
normal. Left ventricular systolic function is hyperdynamic
(EF>75%). There is an abnormal systolic flow contour at rest,
but no left ventricular outflow obstruction. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The right ventricular free wall is
hypertrophied. The ascending aorta is mildly dilated. The number
of aortic valve leaflets cannot be determined. The aortic valve
leaflets are moderately thickened. No masses or vegetations are
seen on the aortic valve. Significant aortic stenosis is present
(not quantified). Moderate (2+) aortic regurgitation is seen.
The aortic regurgitation jet is eccentric, directed toward the
anterior mitral leaflet. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is a very
small pericardial effusion.
IMPRESSION: Small LV cavity size with moderate symmetric LVH and
hyperdynamic LV systolic function. Abnormal LVOT systolic flow
contour without frank obstruction. Probable diastolic
dysfunction. Calcified mitral and aortic valve with at least
mild aortic stenosis, moderate aortic regurgitation and mild
mitral regurgitation.
No cardiac source of embolism seen.
CTA Chest [**2176-12-14**]:
IMPRESSION:
1. No pulmonary embolism.
2. Enlarged thoracic aorta as described. No aortic dissection.
3. Liver hypodensities, too small to characterize.
4. Bibasilar atelectasis with trace left effusion.
Abdominal X-ray [**2176-12-15**]:
There is no evidence of obstruction or ileus. There is increased
fecal
material throughout the colon. There are degenerative changes in
the thoracic and lumbar spine.
TTE [**2176-12-16**]:
After intravenous injection of agitated saline, there is prompt
(within one beat) and prominent appearance of saline contrast in
the left heart c/w a right-to-left shunt across the interatrial
septum. The ascending aorta is mildly dilated. The aortic valve
leaflets are moderately thickened. Significant aortic
regurgitation is present, but cannot be quantified. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2176-12-14**], a
right-to-left shunt, likely at the atrial level is now
identified.
Video swallow [**2176-12-16**]:
IMPRESSION: No aspiration. Moderate amount of gastroesophageal
reflux.
Barium swallow [**2176-12-16**]:
IMPRESSION: Ineffective primary peristalsis. Minimal reflux
seen. Possible
small hiatal hernia. No evidence of stricture.
Duplex ultrasound of lower extremities:
IMPRESSION: No evidence of deep vein thrombosis in either leg.
Brief Hospital Course:
Active problems during admission were neurologic (secondary to
left posterior cerebral artery infarction), paroxysmal hypoxic
respiratory failure, hypertension, along with other issues
listed below.
Stroke
Mrs. [**Known lastname 23081**] presented initially with lightheadedness, confusion
and headache followed by dragging of right foot and insensible
speech. CT head at OSH showed left occipital hypodensity
extending into left temporal region. She was seen by neurology
service who recommended CTA head and neck which showed narrowing
of the left PCA P2 bifurcation segment and atheromatous disease
involving the left proximal vertebral artery. She was kept on
aspirin and statin. BP was allowed to autoregulate with goal
SBP 140-180. MI was ruled out with cardiac enzymes. She also
had TTE with bubble study that showed a right to left shunt.
Ultrasound of both lower extremities did not reveal thrombus. In
view of the alternative explanation for this presentation
offered by vertebral disease and the high prevalence of septal
defects in the general population, without evidence of a source
and only in the presence of no other explanation would this be
invoked as causal. Aspirin was changed to Aggrenox prior to
discharge given dyspepsia and superiority in secondary
prevention.
Hypoxic Respiratory Failure
On the day following admission, desaturation to the 80s was
noted and Mrs. [**Known lastname 23081**] was transferred to the ICU for close
monitoring (being transferred back to the floor subsequently)
Most likely positional as patient's O2 saturations apparently
rose quickly after sitting up. CTA was negative for PE. She
had no evidence of CHF on CXR or exam. TTE showed probable
diastolic dysfunction but preserved EF. On [**2176-12-15**], she
desaturated to 80%'s and had to be put on a non-rebreather
briefly. Oxygen saturations remained in high 90%'s on room air
for remainder of hospital stay. A bubble study was performed.
Atrial Septal Defect
Bubble study was consistent with atrial septal defect but it was
felt that her stroke was more likely attributable to vertebral
disease than paradoxical emboli. Cardiology thought that this
was a possible underlying cause of desaturation, but felt that
this was unlikely given the paroxysmal nature of her
desaturations that were more frequent during sleep. This will
need to be followed in rehabilitation, but as an inpatient,
such events did not occur later in the admission. Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], who saw her during this admission, will see her as an
outpatient for further evaluation. Again, we do not attribute
her stroke to this defect.
Thyroid Nodule
Of note, CTA also revealed a small low density right thyroid
nodule measuring about 8 mm. She should get TFT's prior to
ultrasound and this should be followed as an outpatient.
Hypertension
Pt remained hypertensive, reaching systolic 200's. Per neuro,
BP was allowed to autoregulate with goal BP 140-180 systolic.
She was controlled with hydralazine for SBP above 180's.
Lisinopril was restarted at 5 mg, resulting in improved control.
Blood pressure is best lowered gradually in this context, with
uptitration of ACEI most desirable.
Chest Pain
In the ICU, she had episodes of chest pain often precipitated by
food intake. EKG remained unchanged from prior. Cardiac
enzymes were negative. She was put on a Nitro gtt at one point
as she was hypertensive to systolic 190's. She was kept on full
dose aspirin. Given negative cardiac work-up and relation to
food intake intake, GI was consulted.
Dyspepsia
KUB was unremarkable. GI recommended barium esophagram which
showed no strictures but did show ineffective primary
peristalsis, minimal reflux, and possible small hiatal hernia.
GI recommended that pt have outpatient GI appointment if
symptoms continue. If symptoms continue by the time of this
appointment, GI will consider EGD to rule out esophagitis.
Bradycardia
Pt had a few episodes of bradycardia precipitated by po intake
which were attributed to increased vagal tone in the context of
dyspepsia.
Ativan Adverse Reaction
We noted that even taking her home dose of Ativan resulted in
marked sedation. We would suggest avoiding benzodiazepines.
Leg Cramps
Not an active problem during admission.
Medications on Admission:
Lisinopril one tab (dose unknown) PO daily
Lorazepam 0.5-1mg PO daily PRN insomnia, anxiety
Quinine PRN leg cramps
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): Can stop when ambulating
frequently.
4. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for indigestion.
5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
6. hydrocortisone 0.5 % Cream Sig: One (1) Appl Topical TID (3
times a day) as needed for rash .
7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) as
needed for GERD.
9. dipyridamole-aspirin 200-25 mg Cap, Multiphasic Release 12 hr
Sig: One (1) Cap PO DAILY (Daily) for 4 days: After four days,
increase to [**Hospital1 **].
10. dipyridamole-aspirin 200-25 mg Cap, Multiphasic Release 12
hr Sig: One (1) Cap PO BID (2 times a day): Do not start until
four days of once daily dosing is completed.
11. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
Primary
Stroke - ischemic, left posterior cerebral artery
Atrial septal defect
Vertebral stenosis
Secondary
Hypertension
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane). At baseline she has been more independent, but this is
our present recommendation.
She has complete right visual field loss and memory impairment.
She cannot typically encode new memories at present,
particularly when these are episodic or linguistic.
Discharge Instructions:
You came to the hospital after having a stroke. This was of the
back part of your brain and involves brain areas important for
your right visual field (left occipital lobe), along with a
brain region important for memory formation (left hippocampus).
This has occurred in the context of narrowing of a blood vessel
that supplies these regions (vertebral artery). We adjusted your
medications to include an antiplatelet [**Doctor Last Name 360**], Aggrenox. Now that
you are medically [**Last Name (un) 2677**], we feel that you will now benefit from
rehabilitation, where you will adapt to the changes that have
occurred as a result of this stroke. Please attend follow-up
listed below. Please continue to take your medications as
directed.
Followup Instructions:
Please follow-up in stroke clinic.
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2177-1-17**] 10:30
Please follow-up with Cardiology:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
[**2177-1-9**] at 13:00. [**Hospital Ward Name 23**] [**Location (un) **], [**Hospital1 18**] [**Hospital Ward Name 5074**].
Please follow-up with Gastroenterology if your dyspepsia
continues:
[**Last Name (LF) 2643**], [**First Name3 (LF) **] B
Office Phone: ([**Telephone/Fax (1) 2306**]
Office Location: LMOB 8E Department: GI, Medicine Organization:
[**Hospital1 18**]
Please see your primary care doctor (we have not made an
appointment, because you will be at rehabilitation) as soon as
you are discharged from rehabilitation. [**Last Name (LF) **],[**First Name3 (LF) **] L.
[**Telephone/Fax (1) 5294**].
If your primary care doctor would like you to see a cardiologist
again, you could make an appointment to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Hospital1 69**].
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1443
} | Medical Text: Admission Date: [**2179-10-13**] Discharge Date: [**2179-10-22**]
Date of Birth: [**2130-3-25**] Sex: M
Service: NEUROLOGY
Allergies:
Statins-Hmg-Coa Reductase Inhibitors
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
head and neck angiogram.
History of Present Illness:
HPI: 49 yo RHM with a history of HTN, GERD and possible alcohol
abuse, according to his girlfriend [**Name (NI) 1356**], who was contact[**Name (NI) **] by
his son, had an episode of vomiting late last night, which was
not unusual for Mr [**Known lastname 66015**], as he was constantly suffering with
"acid reflux." He then had a headache early this morning, lost
consciousness, and then the EMS arrived, 5 people were required
to hold him down. When his girlfriend saw him in the [**Hospital3 6265**] ER, he was able to identify her, but kept on
perseverating about the time. Since he became combative, [**Hospital3 6265**] ER intubated him by rapid sequence
(vercuronium+succ+etomidate), and they mentioned that his airway
was difficult to intubate. He was transferred by Mediflight to
[**Hospital1 18**] ER, and he was assessed by neurosurgery, who did not feel
that he was a neurosurgical candidate, hence neurology was
consulted.
Past Medical History:
HTN
GERD
Social History:
Has smoked since teenage years, approx 1 ppd.
Drinks several shots of Vodka, Scotch, or pints of beer, family
classified him as a "moderate drinker"
Lives with his son, widowed, has a girlfriend called [**Name (NI) 1356**].
No IVDA
Worked as a manager for [**Company **]
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] TEL: [**Telephone/Fax (1) 17753**]
Brother and HCP is [**Name (NI) 11229**] [**Name (NI) **] [**Telephone/Fax (1) 66016**]
Family History:
Mother died of colorectal ca
Father had HTN and CAD
Physical Exam:
ON ADMISSION:
T-97.7 BP-178/104-->116/74 HR-98
Intubated 600/8/16/100% pulse ox 92-97%
On propofol which was lightened for the neuro exam
Gen: Lying in bed, blood frothing at the OG tube from oral
trauma
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Poor air entry LL zone
aBd: Mild hepatomegaly. +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: With the propofol lightened, he was agitated,
thrashing around, biting his tube
Cranial Nerves:
Pupils 2 mm bilaterally, sluggishly responsive to light.
Fundoscopy normal. Blinks to threat. Dolls head normal. Corneals
in tact bilaterally. Facial excursion normal. Gag in tact.
Motor & Sensory:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
Moves all 4 limbs symmetrially away from noxious stimuli
Reflexes:
2 in the arms +2 patellar, 2 Achilles.
Toes downgoing bilaterally
Coordination: finger-nose-finger normal, heel to shin normal,
RAMs normal.
Physical exam at time of discharge:
VS 98.9F 146/90 70 18 100% RA
MS: much improved since admission. Inattentive, but able to
perform DOW backwards over 35 seconds. Memory: [**3-2**]
registration, 0/3 at 5 minutes, [**1-2**] with cues. Naming - intact
to high frequency, impaired to low frequency objects. Oriented
to self, [**Hospital1 18**], Date (the latter fluctuates). Fluent speech, no
dysarthria. Intact comprehention, significant latency in
responses 5-10 seconds at times. [**Location (un) **] impaired. Follows [**1-1**]
step commands.
CN:
VFF confrontation, EOMi, face symmetric, sensation intact b/l,
tongue midline, palate midline, shoulder shrug intact.
Motor - full strength througout. Reflexes 2+ throughout, except
achilles 1+
FNF intact, HTN intact. Negative romberg, gait is bradykinetic
with impaired planning and head turning.
Left antecubital fossa thrombophlebitis. Right ICA bruit.
Pertinent Results:
Admission Labs:
.
WBC-14.3* RBC-4.29* Hgb-14.7 Hct-43.3 MCV-101* Plt Ct-299
BLOOD Neuts-83.6* Lymphs-13.7* Monos-1.8* Eos-0.4 Baso-0.6
BLOOD PT-12.1 PTT-23.0 INR(PT)-1.0
Glucose-202* UreaN-15 Creat-1.0 Na-143 K-3.8 Cl-105 HCO3-24
AnGap-18
ALT-20 AST-33 LD(LDH)-291* CK(CPK)-328* AlkPhos-70 TotBili-0.5
CK-MB-17* MB Indx-5.2 cTropnT-0.13*
Calcium-9.0 Phos-3.6 Mg-1.9
.
Modifiable Risk Factors for Stroke:
HAB1c:
Chol, TG, HDL, LDL
.
IMAGING:
.
CT HEAD W/O CONTRAST ([**2179-10-13**])
IMPRESSION:
Bilateral temporoparietal layering intraparenchymal hemorrhage
with
surrounding edema. Areas of hemorrhage are stable since the
prior exam, but
the surrounding edema is increased, causing effacement of the
ambient and
right perimesencephalic cisterns. Differential diagnosis (given
lack of
trauma history) includes hypertensive hemorrhage, hemorrhage due
to underlyingmetastases, or venous sinus thrombosis.
.
MRA/V BRAIN W/O CONTRAST ([**2179-10-13**])
IMPRESSION:
1. Large organized hematomas involving the temporoparietal
lobes,
bilaterally, with prominent "hematocrit effect" and relatively
little in the way of associated vasogenic edema. If this
represents layering hemorrhage at the very time of presentation,
this is highly suggestive of either anticoagulation or
underlying coagulopathy.
2. Such a presentation may be occasionally be seen with
underlying amyloid
angiopathy, which might also explain the associated regional
subarachnoid
hemorrhage, related to involvement of the overlying pial
vessels. However,
cerebral amyloidosis would be unusual in a patient of this age,
and there is no evidence of microbleeds, elsewhere.
3. No pathologic or mass-like enhancement around the lesions, or
elsewhere in the brain, to specifically suggest underlying
neoplastic process.
4. No abnormal vessel is associated with the hemorrhages.
5. Lesions demonstrate a rim of apparent restricted diffusion;
however, the
overall appearance makes hemorrhagic transformation of
underlying infarctions quite unlikely. Such an appearance, with
cytotoxic edema, can be seen withhemorrhagic
cortical/subcortical contusions, and trauma could account for
the accompanying subarachnoid hemorrhage; this should be closely
correlated with any other clinical evidence of recent trauma.
6. Unremarkable cranial MRV with no evidence of cerebral venous
thrombosis.
7. Apparent chronic occlusion of the left internal carotid
artery from the
skull base through its terminus, with reconstitution largely via
a robust
posterior communicating artery.
.
ECHO [**10-15**]
The left atrium is dilated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. There is mild
regional left ventricular systolic dysfunction with mid to
distal anteroseptal and apical akinesis. No definite apical
thrombus identified (cannot exclude). Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened. There is no aortic valve stenosis. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**1-1**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
.
CT Head ([**2179-10-15**]):
IMPRESSION:
Essentially unchanged multifocal intraparenchymal hemorrhage
with mass effect and brain parenchyma edema. No new foci of
hemorrhage or hydrocephalus. Bilateral cerebral edema and uncal
herniation, stable.
.
CT Head ([**2179-10-15**]):
IMPRESSION: No significant short-interval changes. Stable
multifocal
intraparenchymal hemorrhage with mass effect and brain
parenchyma edema.
Bilateral cerebral edema and uncal herniation, stable. No new
foci of
hemorrhage or developing hydrocephalus.
.
CT Head ([**2179-10-16**]):
IMPRESSIONS: No change in exam over the last couple of days,
with multifocal intraparenchymal, subarachnoid, and right
subdural hematoma. Diffuse edema with unchanged diffuse sulcal
effacement and mild central herniation.
.
CT Head ([**2179-10-17**]):
IMPRESSION: No significant interval change in intraparenchymal,
subarachnoid, and right subdural hemorrhage.
.
Angiography ([**2179-10-18**]):
Pending
.
EEG ([**2179-10-15**]):
IMPRESSION: This is a moderately abnormal EEG due to the
presence of a
slower than normal background. No focal or epileptiform features
were
seen. This slow background could indicate a moderate
encephalopathy of
toxic, metabolic, or anoxic etiology, or could be seen with
extensive
subcortical disruption of midline or deeper structures. Note is
incidentally made of a slower than normal cardiac rhythm.
.
Transthoracic Echocardiogram ([**2179-10-15**]):
The left atrium is dilated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. There is mild
regional left ventricular systolic dysfunction with mid to
distal anteroseptal and apical akinesis. No definite apical
thrombus identified (cannot exclude). Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened. There is no aortic valve stenosis. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**1-1**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. There is borderline pulmonary
artery systolic hypertension. There is no pericardial effusion.
.
Carotid Duplex ():
pending
.
Carotid Ultrasoune ():
pending
.
Chest x-ray ([**2179-10-13**]):
IMPRESSION: Standard position of supporting and monitoring
devices. Minimal bilateral atelectasis.
[**10-15**] -
IMPRESSION: This is a moderately abnormal EEG due to the
presence of a
slower than normal background. No focal or epileptiform features
were
seen. This slow background could indicate a moderate
encephalopathy of
toxic, metabolic, or anoxic etiology, or could be seen with
extensive
subcortical disruption of midline or deeper structures. Note is
incidentally made of a slower than normal cardiac rhythm.
CT head [**10-15**]:
IMPRESSION:
Essentially unchanged multifocal intraparenchymal hemorrhage
with mass effect
and brain parenchyma edema. No new foci of hemorrhage or
hydrocephalus.
Bilateral cerebral edema and uncal herniation, stable.
Carotid U/S per request from vascular [**10-19**]
IMPRESSION: There is complete occlusion of the left internal
carotid artery.
There is 80% to 99% stenosis within the right internal carotid
artery
[**10-19**] Renal us:
IMPRESSION:
1. No hydronephrosis and no renal mass.
2. No vascular abnormality identified, although the imaging of
the left main
renal artery is technically limited.
CT head [**10-20**]
IMPRESSION:
1. No significant interval change in the bilateral parenchymal
hemorrhages
and scattered foci of subarachnoid hemorrhage.
2. Previously-seen right subdural hematoma is less apparent.
3. No new hemorrhage.
Labs at time of d/c:
CK CK-MB MBIndx cTropnT
[**1021-10-21**] 0.[**10-17**]
[**2179-10-16**] 02:42AM [**Numeric Identifier **] 6 0.5
[**2179-10-15**] 08:38PM [**10-15**] 02:00AM 4943 10 0.2 0.47
[**2179-10-14**] 04:08PM 1701 20 1.2 0.63
[**2179-10-14**] 09:21AM 1561 33 2.1 1.04
[**2179-10-14**] 12:48AM 1268 53 4.2 1.27
[**2179-10-13**] 05:00PM 932 64 6.9 0.81
[**2179-10-13**] 10:20AM 328 17 5.2 0.13
[**2179-10-21**]:
138 103 11 95 AGap=12
-------------[
3.4 26 0.7
CK: 851 MB: 4 Trop-T: 0.18
Ca: 8.8 Mg: 2.1 P: 3.3
Osms:289 TSH:2.9
cbc 11.0/11.9/34/344
ESR 42
CRP 38
[**Doctor First Name **], ANCA - pending
Brief Hospital Course:
Mr. [**Known lastname **] is a 49 yo man w/a history of HTN, GERD, and
significant EtOH use who presented after a headache with a
question of loss of consciousness and fall in the bathroom. He
was transferred to the [**Hospital1 18**] for care after imaging demonstrated
multiple bilateral intraparenchymal hemorhhages in the bilateral
temporal lobes, bilateral temporal and occipital lobe
subarachnoid hemorrhages and a subdural hematoma in the setting
of a subacute anterior wall ST-elevation myocardial infarction.
He was admitted to the stroke service from [**2179-10-13**] to [**2179-10-22**].
.
# NEURO:
A CT scan showed extensive bilateral temporal lobe hemorrhages,
as well as a small subarachnoid and right subdural hemorrhages.
The etiology of these findings is somewhat unclear; however on
further history it was elicited that the patient's son heard a
'thud' upstairs, and then found his father on the floor. It is
possible that he fell, causing a traumatic head injury. The
extent of the hemorrhage suggested some degree of coagulopathy
and, given his reported extensive drinking history, it is
possible that he has an element of platelet dysfunction. It is
likely that a hypertensive episode contributed to the hemorrhage
as well.
.
The patient had multiple repeat head CTs, which showed stable
hemorrhage with some edema and a small amount of uncal
herniation. Neurosurgery was consulted, and mannitol was
started at their recommendation on [**2179-9-15**]. The patient's
clincal examination improved, with increasing orientation,
attention, and naming ability.
.
To investigate source of the bleed, a conventional angiogram was
performed confirming comletely occluded [**Doctor First Name 3098**] and ~ 95% occluded
[**Country **] with collaterals from opthalmic artery on the R and PCA
circulation. Posterior circulation free of flow limiting
stenoses. No evidence of AVM or aneurysm was noted. MRV showed
no venous thrombosis. The etiology of the bleeds remained
unclear, ? hypertensive. Vasculitis etiology was felt to be an
unlikely source, however, given no other etiology, ESR, CRP were
obtained. ESR was 42, CRP was 37. Given this, [**Doctor First Name **] and ANCA
were sent, these were pending at time of discharge. A follow up
with Dr. [**Last Name (STitle) 66017**] [**Name (STitle) 66018**] vasculitic w/up and bleeds was
arranted on [**2179-11-9**].
Given extensive cortical bleeds, he was maintained on seizure
ppx. At time of discharge, his Keppra dose was 750mg [**Hospital1 **], and
should be tapered Q3 days by 500mg per day until completed. EEG
was negative for seizure activity, consistent with
encephalopathy.
Patient's exam improved, however he retained a significant
executive function, attentional and memory deficits. Please see
exam at discharge for details. Follow up with stroke
neurologist, Dr. [**Last Name (STitle) 66017**] from [**Hospital1 18**], should be arranged within
eight weeks of discharged from the rehabilitation facility.
Course was complicated by HAs, combination migranous and tension
in nature. He was treated with Fioricet, with moderate effect.
No sedating medications were used to maintain ability to
asseess mental status.
.
# CVS
STEMI - On admission the patient was noted to have an elevated
troponin, which peaked at 1.27, with corresponding ST segment
elevations in the anterior and lateral leads. Unfortunately,
given his extensive hemorrhage, it was not possible to undergo
further intervention. He was started on metoprolol and a
statin. However, his CK rose significantly on [**2179-10-16**], at
which point the statin was stopped, with subsequent trend
towards normalization of the CK. Patient was started on 81mg
ofASA on [**10-22**]. He will require outpatient cardiology follow
up. He will require another trial of statin or other lipid
lowering [**Doctor Last Name 360**] as an outpatient, given elevated LDL, and severe
carotid disease. Lipid panel showed LDL of 150.
.
Angiography performed as above showed significant stenoses.
Vascualr surgery was consulted for evaluation for CEA. It was
felt that patient should undergo R CEA afteer 4-6 weeks of the
event, once time was alloted for repair of the blood brain
barrier. An appointment with Dr. [**Last Name (STitle) **] at [**Hospital1 18**] has been made.
.
Patient was noted to have significant hypertension. Due to
severe carotid stenosis, his SBP goal was deemed to be
140-165mmHg. This was maintained on Lisinopril, Clonidine and
Metoprolol. Renal US was obtained and ruled out renal artery
stenosis on R, limited view on L.
# RESP
The patient was successfully extubated on [**10-14**], and while
complaining of a headache, was actually fairly interactive, able
to answer basic questions.
Medications on Admission:
HCTZ 25 mg QDay
Lisinopril 5 mg QDay
Atenolol 50 mg QDay
Zantac OTC
ALL: NKDA
Discharge Medications:
1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QWED (every Wednesday).
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO TID (3
times a day).
4. HydrALAzine 20 mg IV Q4H:PRN SBP>160
give if SBP >160 and HR <55
5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. Levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
9. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Folic Acid 1 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 for
constipation.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
13. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**1-1**]
Tablets PO Q6H (every 6 hours) as needed for head ache: avoid >
3g in 24 hrs.
14. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
Primary: Bilateral intraparenchymal temporal hemorrhages,
bilateral subarachnoid hemorrhages and subdural hemorrhages. ST
elevation MI
Secondary: HTN, alcohol abuse, significant smoking history
Discharge Condition:
Mental Status: much improved since admission. Inattentive, but
able to perform DOW backwards over 35 seconds. Memory: [**3-2**]
registration, 0/3 at 5 minutes, [**1-2**] with cues. Naming - intact
to high frequency, impaired to low frequency objects. Oriented
to self, [**Hospital1 18**], Date (the latter fluctuates). Fluent speech, no
dysarthria. Intact comprehention, significant latency in
responses 5-10 seconds at times. [**Location (un) **] impaired. Follows [**1-1**]
step commands.
CN:
VFF confrontation, EOMi, face symmetric, sensation intact b/l,
tongue midline, palate midline, shoulder shrug intact.
Motor - full strength througout. Reflexes 2+ throughout, except
achilles 1+
FNF intact, HTN intact. Negative romberg, gait is bradykinetic
with impaired planning and head turning.
Left antecubital fossa thrombophlebitis. Right ICA bruit.
Discharge Instructions:
You were admitted to [**Hospital1 18**] after a severe head bleed on both
sides of your temples. You required intensive care unit
stabilization and treatment with multiple medications. You also
had a heart attack, STEMI. You underwent an angiogram to
determine the source of your bleed. This did not show a source,
but showed that your carotid arteries were severely occluded,
for which you will require surgery (right side only). At time
of discharge, you had significant impairment in memory,
attention and cognition.
Due to this, you required rehabilitation.
You were started on multiple new medications, please ensure you
take these as prescribed.
Please follow up with all of your schedule appointments
Should you develop severe headaches, worsening inattention, one
sided weakness, vision changes, chest pain, shortness of breath
or any other symptom concerning to you, seek immediate medical
attention.
Followup Instructions:
Please call your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],[**First Name3 (LF) **] F.
[**Telephone/Fax (1) 17753**], to arrange follow up within 1 week of discharge
from the rehabilitation facility
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2179-11-9**] 7:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2179-11-17**] 10:15
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2179-10-22**]
ICD9 Codes: 431, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1444
} | Medical Text: Admission Date: [**2105-12-21**] Discharge Date: [**2106-1-15**]
Date of Birth: [**2062-7-1**] Sex: F
Service: TRAUMA SURGERY
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname **] is a 43 year-old
female involved in a high speed rollover motor vehicle
accident who was unrestrained. The patient was found
unresponsive at the scene and was taken to an outside
hospital where she was intubated, paralyzed and sedated.
condition and was transferred to the [**Hospital1 **]
Hospital for further management. Upon arrival here at the
[**Hospital1 **] the patient was evaluated with multiple
radiological studies, which in summary demonstrated a right
frontal skull and sinus fracture, which was repaired on
[**2105-12-25**]. The patient had a left distal humeral fracture
along with a 1 cm punctate laceration on the lateral
patient was also found to have a C2 to C7 fracture. The
[**Hospital 228**] hospital course has been long and will only be
detailed very briefly in summary.
The patient was transferred to the Intensive Care Unit where
she remained intubated for an extensive period of time. The
patient developed several complications including C-difficile
colitis, which was treated with Flagyl for a complete course
of fourteen days. Repeat stool cultures were negative at the
time of discharge. The patient also developed pressure
ulcers on her chin and occiput due to her [**Location (un) 36323**] collar.
These ulcers were treated initially just conservatively, but
because they did not resolve the patient's collar eventually
had to be custom made by the prosthetic company. The
patient's ulcers were treated with Santyl ointment to the
wounds.
The patient's course was also complicated with thrombocytosis
up to one million. The patient was started on aspirin for
prophylaxis. The patient also had an IVC filter place during
her hospital course, because of immobility. Because of the
patient's inability to adequately wean off the vent, the
patient was trached on the [**1-3**]. The patient
also had a PEG tube placed at that time. Since that time the
patient has been able to get off the vent without any
difficulty and is tolerating trach mask. The patient now has
a Passamuer valve which allows her to speak.
The patient has been extensively followed by physical therapy
and now is able to ambulate with assistance. Her other issue
has been her glycemic control. This patient has a past
medical history significant for very brittle diabetes and
previous to her admission she was on an insulin pump. She
was maintained for most of her hospital course on an insulin
drip in the unit. Over the last week, the drip has been
weaned to off and the patient has been started on Lantus
insulin in increasing doses in order to provide a baseline
glycemic control. The patient has been supplemented with
sliding scale as needed. By the time of discharge the
patient has been off her insulin regimen for almost 48 hours
with adequate glycemic control.
DISCHARGE MEDICATIONS: Aspirin 325 mg po q day, subQ heparin
5000 units b.i.d., Clonidine transdermal patch .2 mg q week,
changed on Thursdays. Prevacid 30 mg once a day. Santal
ointment to the chin also done once a day. Colace 100 mg
b.i.d. Iron sulfate 325 mg once a day. Lantus insulin 50
units subQ q.h.s. Insulin sliding scale, which reads
glucoses from 65 to 125 nothing, 125 to 175 2 units of
regular insulin, 176 to 225 3 units of regular insulin, 226
to 275 5 units of insulin, 276 to 325 6 units of insulin, 326
to 375 7 units of insulin and greater then 376 8 units of
insulin. The patient is also on vitamin C 500 mg twice a day
and zinc 220 mg po once a day.
FOLLOW UP: The patient is to follow up in trauma clinic in
three to four weeks.
DISCHARGE STATUS: Stable.
DISCHARGE DIAGNOSES:
1. Hyperglycemia requiring insulin drip.
2. C-difficile colitis requiring treatment with antibiotics.
3. Thrombocytosis.
4. Deep venous thrombosis requiring placement of an IVC
filter.
5. Right frontal skull and sinus fracture requiring
operative repair.
6. Left open humeral fracture requiring open reduction and
internal fixation.
7. C2 to C7 fracture requiring [**Location (un) 36323**] collar placement.
8. Ventilatory dependence requiring tracheostomy.
9. Inability to swallow requiring placement of PEG.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 02-205
Dictated By:[**Name8 (MD) 4729**]
MEDQUIST36
D: [**2106-1-15**] 08:03
T: [**2106-1-15**] 08:57
JOB#: [**Job Number 36324**]
ICD9 Codes: 5185 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1445
} | Medical Text: Admission Date: [**2174-5-4**] Discharge Date: [**2174-5-20**]
Date of Birth: [**2102-3-31**] Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Thorocentesis
IR guided permatcath [**5-13**]
History of Present Illness:
72yo M with metastatic squamous cell lung CA s/p chemo, XRT,
photodynamic therapy and tumor debulking to obstructing LLL
tumor and pleurodiesis for recurrent Left pleural effusion. In
addition, the patient has a history of AFib, HTN, DMII with
diabetic nephropathy and emphysema. Day prior to admission, he
was sob with climbing stiars. The following night, he presented
with orthopnea and PND associated with dry cough. The patient
admits to mild chest discomfort. He denied any palpitations,
paresthesias, LE edema, hemoptysis.
On arrival of EMS, the patient had SaO2 in 80% on RA which
improved to 90% on 100% NRB. The pateint was given nebs, lasix
in the ED with improvement in sx. He was also given 1 SL nitro
with resolution of chest discomfort.
Past Medical History:
1. Metastatic squamous cell lung CA s/p chemotherapy with
[**Doctor Last Name **]/taxol, photodynamic therapy for obstructing LLL tumor.
2. Recurrent L pleural effusion s/p thoracoscopy with talc
pleurodiesis on [**2174-3-26**].
3. HTN
4. Afib with embolic CVA in [**September 2172**]
5. DMII with nephropathy
6. SCC of skin
7. Emphysema
8. Mild CHF - EF 50-55% by TTE [**9-/2172**], mild regional left
ventricular systolic dysfunction with focal severe hypo/akinesis
of the basal inferior wall and inferior septum. [**1-23**]+ MR.
9. Nephrotic Syndrome by renal biopsy [**9-/2173**]
Social History:
The patient lives with his wife. [**Name (NI) **] is a retired baseball player
and telephone company worker He admits to smoking 60+ pack years
but reports he quit in '[**71**]
He denies any significant alcohol consumption.
Family History:
non contributory
Physical Exam:
In the ED:
VS: 96 119 119/109 20 92% on 5L
Gen: elderly male sitting at 90 degress in no respiratory
distress
HEENT: mm dry, no JVD at 90 degrees, unable to tolerate lying at
any lower angle
Chest: [**Month (only) **]. BS throughout, with rales at left base
CV: tachy, regular rhythm, no murmurs, rubs, gallops
Abd: soft, NT, ND, +BS
Ext: right leg with 1+ edema, no cords, no calf tenderness
Pertinent Results:
[**2174-5-4**] 01:10AM WBC-18.5* RBC-4.25* HGB-11.1* HCT-35.6*
MCV-84 MCH-26.1* MCHC-31.1 RDW-14.9
[**2174-5-4**] 01:10AM PT-24.3* PTT-35.1* INR(PT)-3.7
[**2174-5-4**] 01:10AM GLUCOSE-358* UREA N-59* CREAT-3.0* SODIUM-140
POTASSIUM-5.2* CHLORIDE-105 TOTAL CO2-20* ANION GAP-20
[**2174-5-4**] 07:54PM CK(CPK)-72
[**2174-5-4**] 07:54PM CK-MB-NotDone cTropnT-0.44*
[**2174-5-4**] 10:33PM TYPE-ART PO2-50* PCO2-36 PH-7.41 TOTAL CO2-24
BASE XS-0
[**2174-5-4**] 10:33PM LACTATE-1.8
.
[**2174-5-4**] CXR: - IMPRESSION: 1) Worsening asymmetrical alveolar
pattern, most likely due to worsening pulmonary edema. 2)
Moderate to large loculated left pleural effusion. 3) Stable
abnormal appearance of left hilum and perihilar region, in
keeping with history of lung cancer."
.
[**2174-5-5**] TTE: Conclusions: The left atrium is dilated. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is mildly depressed. Resting regional wall
motion abnormalities include basal to mid
inferior/inferolaterlal hypokinesis. Right ventricular chamber
size and free wall motion are normal. The aortic root is mildly
dilated. The aortic valve leaflets are mildly thickened. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Moderate (2+) mitral regurgitation is seen.
The mitral regurgitation jet is eccentric. There is no
pericardial effusion. Compared with the prior study (tape
reviewed) of [**2172-9-29**], left ventricular systolic function
appears similar and mitral regurgitation appears similar."
.
[**2174-5-6**] Bilateral Lower Extremity Doppler US:
"No DVTs bilaterally.
.
[**2174-5-6**] Non-contrast Chest CT - IMPRESSION: 1. Left lower lobe
consolidation, with air fluid levels concerning for an empyema
vs recent procedure. Clinical correlation is requested. 2.
Moderate sized right-sided pleural effusion. 3. Loculated left
pleural effusion at prior chest tube insertion site. 4. Diffuse
paraseptal emphysematous change bilaterally. 5. Honeycombing and
interstitial air space disease, predominantly within right upper
lobe. Given the acute increase, this most likely represents a
pneumonic infiltrate. Given the asymmetry, congestive heart
failure is less likely. Clinical correlation is requested.
6. Diffuse mediastinal lymphadenopathy consistent with the
patient's history of lung cancer. 7. Atherosclerotic disease.
Brief Hospital Course:
72yo M with squamous cell lung CA s/p chemo, XRT, and
photodynamic therapy, recurrent left pleural effusion s/p
pleurodiesis, CHF, HTN, Afib, Emphysema, who presents with
progressively worsening DOE and hypoxia.
.
PULMONARY - The etiology of the patient's hypoxia was somewhat
unclear. [**Name2 (NI) **] had evidence of both pulmonary edema as well as a
primary pulmonary process. Multiple CT scans noted evidence of
PNA, and possible multilobar PNA. He completed a 10 day course
of Levofloxacin for this. He was admitted to CCU intially for
diuresis, and then to the [**Hospital Unit Name 153**] for further w/u of his pulmonary
process. He was briefly intubated for hypoxia/respiratory
distress s/p extubation in the [**Hospital Unit Name 153**]. He thorough w/u for
infectious etiology of his pulmonary process including right
thoracentesis and brochoscopy which did not show etiology of
these findings. All viral and bacterial cultures returned
negative. PE was felt less likely given his CT findings,
negative LE U/S, and therapeutic INR on Coumadin.
Attempts at aggressive diuresis with IV diuretics were
unsuccessfull given his Cr in the 3's and known renal disease.
His creatinine began to rise with IV diuretics, and he begun on
hemodialysis because of his volume overload and continued
hypoxia. His oxygen requirement continued to decrease to room
air currently.
.
CARDIOVASCULAR:
Coronaries - the patient c/o some atypical chest discomfort
on admission, and was noted to have flat CK's but positive
Troponins as high as 0.5 in setting of ARF. He had new EKG's
with lat STD's and TWI's at low rates, which became more diffuse
at higher heart rates. He has likely CAD based on focal WMA's on
previous and current TTE's. Cardiology was consulted and
recommended medical management of CAD at this time. Pt was
continued on ASA, statin, BB.
Pump - repeat TTE noted stable EF. Pt required hemodialysis
for adequate diuresis. Pt was thought to have a component of
diastolic dysfunction in setting of CAD, as well as Afib when in
RVR.
[**Name (NI) **] - pt presented on Amiodarone but clearly continued to
be in Afib. His rate was slighly elevated in high 90's on
admission, which was controlled with BB. His Amiodarone was
d/c's given his ongoing pulmonary infiltrates and continued Afib
despite Amio. He was anticoagulated with Heparin and then
restarted on coumadin. Goal INR [**2-24**].
.
ARF: The patient has very poor basline renal function, with
significant renal damage by recent renal biopsy. This is thought
be secondary to nephrotic syndrome b/o diabetes. After he was
started on hemodialysis, it was felt that he would likely
require long-term dialysis given his poor baseline. He had an
IR-guided permacath placed for access.
.
ONCOLOGY: After discuss with pt's primary Oncologist Dr
[**Last Name (STitle) 3274**], it was felt that the status of the patient's lung Ca
was unknown. He likely has local recurrence in the location of
his previous treatments, but there is no evidence of current
metastasis. Since his has had an indolent course of tumor
progression and since his mortality is unknown, it was decided
that his lung cancer not preclude treatment of his other medical
issues.
.
DM: patient was placed on ISS. Glipizide was discontinued given
his renal failure.
.
ANEMIA: anemia studies c/w anemia of chronic inflammation, with
no evidence of GIB. He was started on epogen with hemodialysis.
FEN: Cardiac, diabetic diet.
UTI: Patient on 7 day course of Levofloxacin. Attempts to remove
foley were unsuccessful secondary to retention. [**Month (only) 116**] may have
trial of removal in 3 days. Started on flomax.
Medications on Admission:
1. Norvasc 10mg once daily
2. Toprol XL 75mg once daily
3. Amiodarone 200mg once daily
4. Lasix 40mg [**Hospital1 **]
5. Coumdain 5mg QHS
6. Glipizide
7. ASA
.
.
Allergies: Percocet -> N/V
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
7. Insulin Regular Human 100 unit/mL Solution Sig: One (1) unit
Injection ASDIR (AS DIRECTED): per insulin sliding scale
151-200, 4 units
201-250, 6 units
251-300, 8 units
301-350, 10 units
351-400, 12 units.
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
every six (6) hours.
9. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
10. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
12. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
13. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
14. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
15. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H
(every 48 hours) for 2 days.
16. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 4480**] [**Hospital 4094**] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Pulmonary Edema
CHF
Metastatic Lung cancer
Recurrent Pleural effusion
DM
SCC of skin
Emphysema
Nephrotic syndrome
Discharge Condition:
good
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Next Hemodialysis on Monday.
Check INR 3x per week, goal INR [**2-24**].
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D., PH.D.[**MD Number(3) **]: [**Hospital6 29**]
MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2174-6-8**] 10:00
Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] MULTI-SPECIALTY MULTI-SPECIALTY
THORACIC UNIT-CC9 Where: CLINICAL CTR. - 9TH FL. MULTI
Date/Time:[**2174-6-9**] 11:30
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2174-5-20**]
ICD9 Codes: 486, 5990, 5119, 5849 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1446
} | Medical Text: Admission Date: [**2199-5-1**] Discharge Date: [**2199-5-8**]
Date of Birth: [**2121-4-19**] Sex: M
Service: SURGERY
Allergies:
Dilantin / Heparin Agents
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
Juxta-renal abdominal aortic aneurysm.
Major Surgical or Invasive Procedure:
1. Infrarenal tube graft repair of abdominal aortic aneurysm via
retroperitoneal approach.
History of Present Illness:
Pt is a 78 year old man currently admitted for AAA repair who is
recently s/p intraventricular hemorrhage
Past Medical History:
PMHx:
* Seizure disorder (details not available at this time)
* Abdominal aortic aneurysm
* Atrial fibrillation
* Hypertension
* COPD
* CHF
* Pulmonary hypertension
* Benign prostatic hypertrophy
* T2 compression fracture found [**2199-1-7**]
* s/p MRSA baceremia [**2199-1-7**]
* s/p heparin induced thrombocytopenia
* s/p cholecystectomy [**2198-1-7**]
Social History:
Retired from [**Company 2676**], lives in rehab, has son and
daughter-in-law.
Quit smoking 10 years ago, ?4 packs per day for
20 years. No EtOH.
Family History:
Family history: Mother - deceased, stroke. Father - deceased,
MI.
Physical Exam:
Physical exam:
T Afeb HR 88 BP 150/87 RR 14 Sat 96% on RA )
GEN sitting in chair, leaning to the right side, asleep
HEENT NCAT, MMM, OP clear, +~1.5cm skin-colored fleshy,
irregular lesion beneath right eye
Chest CTAB
CVS irregular rhythm, no m/r/g
ABD soft, NT, ND, +BS
EXT no rash, weak distal pulses
Pertinent Results:
[**2199-5-8**] INR 2.6
[**2199-5-7**] 02:20AM BLOOD
WBC-6.2 RBC-3.15* Hgb-9.5* Hct-28.0* MCV-89 MCH-30.3 MCHC-34.1
RDW-16.1* Plt Ct-167
[**2199-5-7**] 02:20AM BLOOD
PT-23.5* PTT-36.1* INR(PT)-2.3*
[**2199-5-7**] 02:20AM BLOOD
Glucose-136* UreaN-25* Creat-1.2 Na-138 K-4.3 Cl-108 HCO3-25
AnGap-9
[**2199-5-7**] 02:20AM BLOOD
Calcium-8.0* Phos-2.0* Mg-2.0
[**2199-5-4**] 08:22AM BLOOD
Lactate-1.0
[**2199-5-2**] 10:22PM BLOOD
Glucose-100 Lactate-2.3* K-3.4* Cl-125*
EVALUATION:
The examination was performed while the patient was seated
upright in the bed on VICU 11.
Cognition, language, speech, voice: Awake, alert, but slow to
respond, limited verbal output, appearing fatigued. He did
follow
one step commands, though inconsistently, with a delay and with
visual cues/modeling. Pt's speech was intelligible and fluent,
but responses were very limited. Vocal quality was breathy,
though the pt could generate adequate voicing with effort.
Teeth: Edentulous
Secretions: Mild amount of thick, clear, sputum was stranding
from the hard palate to the tongue. This was removed with the
Yankauer catheter.
ORAL MOTOR EXAM:
WFL for labial and lingual symmetry and ROM. However, both
labial/buccal tone and tongue strength were diminished. Palatal
elevation was symmetrical. Gag was absent.
SWALLOWING ASSESSMENT:
PO swallowing assessment was completed at bedside with ice
chips,
thin liquids (tsp, cup), purees ( tsp x2), and nectar thick
liquid (tsp, cup). Oral transit was minimally slowed though no
residue was noted. Pt had a difficult time initiating taking any
po's, so feeding was required however he would not open his
mouth
sufficiently to actually allow adequate boluses into his mouth.
Laryngeal elevation appeared adequate to palpation, though he
swallowed multiple times per bolus. He did c/o sensation of
puree
sticking in his throat. Overt coughing was noted with thin
liquids and pt confirmed sensation of aspiration. No further
po's
could be assessed as pt refused any more boluses.
SUMMARY / IMPRESSION:
Pt is demonstrating overt signs of aspiration with thin liquids,
but more significantly is refusing all po's, despite maximal
encouragement. As such, beyond thin liquids the examination was
limited by the pt's fatigue, delayed response time and refusal.
Notes from discharge facility indicate poor po intake has been
an
issue, but the pt was on a full po diet so it appears that he
was
able to advance off of tube feedings. Unclear whether this
decline is related to post op somnolence or possible
toxic-metabolic issues noted per neurology. However, at this
time, I would recommend the pt remain NPO with enteral nutrition
and medications via the PEG. We will plan to re-evaluate pt
later
this week, either [**2199-5-8**] or [**2199-5-9**].
RECOMMENDATIONS:
1. Remain NPO with enteral nutrition and medications via the
PEG.
MR HEAD W/O CONTRAST [**2199-5-4**] 9:13 PM
Interpretation: There are several areas of hyperintensity on the
diffusion weighted images. These are located in the right
frontal and left occipital lobes with questionable involvement
of the left frontal lobe. These areas are hyperintense on FLAIR,
raising the possibility that they may represent T2 shine
through. However, these diffusion findings are new since the
prior MR examination. Therefore, these likely reflect relatively
new ischemia, although they may not be truly acute. There is no
evidence of hemorrhage, edema, masses, or mass effect. The
vessels appear unchanged, with a large right A1, and no
detectable left A1 branch of the anterior cerebral artery.
Impression: Several areas of diffusion abnormality suggesting
recent infarction. No evidence of hemorrhage.
CT HEAD W/O CONTRAST [**2199-5-4**] 2:36 PM
FINDINGS: There is no evidence of hemorrhage, mass effect, or
shift of normally midline structures. Chronic right frontal and
parietal lobe infarctions are again noted. Marked
periventricular white matter hypodensity is again seen most
consistent with chronic microvascular infarctions. The
ventricles are prominent and similar in size and symmetry.
The paranasal sinuses and mastoid air cells are well aerated.
IMPRESSION: No evidence of hemorrhage. Stable prominent
ventricles.
NOTE ADDED AT ATTENDING REVIEW: I agree with the above
interpretation. However, I am concerned that the CTA may suggest
an arteriovenous malformation. There were numerous prominent
vessels, arterial and venous, and no explanation for the
hemorrhage. I discussed this concern with Dr. [**Last Name (STitle) 71522**] at 9:25
pm on [**2199-5-4**].
[**2199-5-1**]
EKG
Atrial fibrillation, mean ventricular rate, 80. Compared to the
previous
tracing of [**2199-4-25**] no major change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
80 0 72 [**Telephone/Fax (2) 71523**]7 55
Brief Hospital Course:
[**5-1**], Pt admitted had a Infrarenal tube graft repair of
abdominal aortic aneurysm via retroperitoneal approach.
Tolerated the procedure well. Had epidural placed for pain
control .L renal cross
clamp time 25 minutes. Argatroban was administered
intra-operatively
Prolong intubation in SICU / requiring pressure support /
metabolic acidosis
On [**5-2**], there was a period of hypotension to 90s/50s requiring
pressor support, but this was transient.
Pt was extubated on [**5-3**].
Pain is currently being managed with Dilaudid PCA and
Bupivacaine epidural. The last morphine dose was at 4:50pm on
[**5-2**]. Epidural DC by pain service
Pt has been somewhat difficult to arouse with limited speech
output and eye rolling during morning rounds [**5-4**], prompting
consult for seizure evaluation from Neurology
CT scan / MRI done - no acute process. Possible AVM. To be
followed as an outpt. Medications adjusted.
Final neurological - toxic-metabolic encephalopathy related to
post-surgical state and sedative medications (Dilaudid) being
used for pain control
Pt received fundaperinox from transition to coumadin for Afib.
Hx of HIT pos. When INR at goal, Fundaperinox was DC'd.
Pt with difficulty swallowing / G tube / pt on TF. Speech and
swallow consult obtained:
BEDSIDE SWALLOWING EVALUATION:
HISTORY: Thank you for referring this 78 year old male admitted
from [**Hospital1 1501**] on [**2199-5-1**] for AAA repair. AAA was diagnosed when pt
was
admitted [**12-12**] s/p right parietal subacute infarction as well as
right intraventricular hemorrhage. Post op, neurology was
consulted as the pt was somnolent with decreased speech output.
Neurology consult reported that the pt may have toxic-metabolic
encephalopathy related to post-surgical state and sedative
medications being used for pain control. PMH includes:
s/p right parietal subacute infarction and right
intraventricular
hemorrhage, Seizure disorder, Abdominal aortic aneurysm, Atrial
fibrillation, Hypertension, COPD, CHF, Pulmonary
hypertension,Benign prostatic hypertrophy, T2 compression
fracture found [**2199-1-7**], s/p MRSA bacteremia [**1-13**], s/p
heparin induced thrombocytopenia, s/p cholecystectomy [**1-12**],(+)
UTI.
We were consulted this admission to evaluate whether pt was able
to swallow safely. We evaluated the pt multiple times last
admission with the last examination being a video swallow study
completed on [**2199-2-7**]. That study revealed a mild-moderate
oropharyngeal dysphagia that worsened over time. After fatigue,
he demonstrated reduced A-P tongue movement, moderate oral
cavity
residue, moderately reduced hyolaryngeal excursion and laryngeal
valve closure, moderate vallecular residue and mild pyriform
sinus residue. Pt was observed to penetrate both thin and
nectar
thick liquids with eventual aspiration of residue of thin
liquids.
Because pt's oral and pharyngeal muscles fatigued so quickly, he
was at risk to aspirate any texture of solid or liquid over the
course of an entire meal. As such, we recommended that the pt
remain primarily NPO at this time with nutrition, hydration, and
medication via PEG.
Per discharge summary from rehab facility, the pt participated
in
speech therapy, had a repeat video swallow study and progressed
to a ground solid, thin liquid po diet while at rehab. However,
his po intake remained poor despite stopping tube feedings and
starting the pt on Megace. However, notes from rehab facility
and
extended care facility indicate the pt was solely on a po diet,
not on tube feedings prior to admission here for AAA repair.
EVALUATION:
The examination was performed while the patient was seated
upright in the bed on VICU 11.
Cognition, language, speech, voice: Awake, alert, but slow to
respond, limited verbal output, appearing fatigued. He did
follow
one step commands, though inconsistently, with a delay and with
visual cues/modeling. Pt's speech was intelligible and fluent,
but responses were very limited. Vocal quality was breathy,
though the pt could generate adequate voicing with effort.
Teeth: Edentulous
Secretions: Mild amount of thick, clear, sputum was stranding
from the hard palate to the tongue. This was removed with the
Yankauer catheter.
ORAL MOTOR EXAM:
WFL for labial and lingual symmetry and ROM. However, both
labial/buccal tone and tongue strength were diminished. Palatal
elevation was symmetrical. Gag was absent.
SWALLOWING ASSESSMENT:
PO swallowing assessment was completed at bedside with ice
chips,
thin liquids (tsp, cup), purees ( tsp x2), and nectar thick
liquid (tsp, cup). Oral transit was minimally slowed though no
residue was noted. Pt had a difficult time initiating taking any
po's, so feeding was required however he would not open his
mouth
sufficiently to actually allow adequate boluses into his mouth.
Laryngeal elevation appeared adequate to palpation, though he
swallowed multiple times per bolus. He did c/o sensation of
puree
sticking in his throat. Overt coughing was noted with thin
liquids and pt confirmed sensation of aspiration. No further
po's
could be assessed as pt refused any more boluses.
SUMMARY / IMPRESSION:
Pt is demonstrating overt signs of aspiration with thin liquids,
but more significantly is refusing all po's, despite maximal
encouragement. As such, beyond thin liquids the examination was
limited by the pt's fatigue, delayed response time and refusal.
Notes from discharge facility indicate poor po intake has been
an
issue, but the pt was on a full po diet so it appears that he
was
able to advance off of tube feedings. Unclear whether this
decline is related to post op somnolence or possible
toxic-metabolic issues noted per neurology. However, at this
time, I would recommend the pt remain NPO with enteral nutrition
and medications via the PEG.
RECOMMENDATIONS:
1. Remain NPO with enteral nutrition and medications via the
PEG.
[**2199-5-7**] No overnight events, neurology signed off- will see as
outpatient. PT/OT continued. REhab screen in process.
[**2199-5-8**]: VSS. No overnight events. Will discharge to rehab with
tubefeeds via Gtube. Patient will follow up with Dr.
[**Last Name (STitle) **] as scheduled. Remains on Coumadin for afib (goal
INR 2.0-3.0)
Medications on Admission:
keppra 1000', toprol 75", albuterol, enalapril 5', megace 400',
NTG prn, prevacid 30', ultram 50 prn, colace 100", senna 1",
warfarin 3 to 5'(for AF)
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution [**Last Name (STitle) **]: One (1) Inhalation
Q6H (every 6 hours) as needed.
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed. ML(s)
3. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Aspirin 325 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
6. Simvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Last Name (STitle) **]: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
8. Levetiracetam 100 mg/mL Solution [**Last Name (STitle) **]: One (1) PO BID (2
times a day).
9. Warfarin 3 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime):
goal [**2-9**] / INR.
10. Tubefeeding orders
Tubefeeding: Start After 12:01AM; Probalance Full strength;
Starting rate: 10 ml/hr; Advance rate by 10 ml q4h Goal rate: 55
ml/hr
Residual Check: q4h Hold feeding for residual >= : 150 ml
Flush w/ 200 ml water q8h
11. Regular Insulin sliding scale
Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Regular
Glucose Insulin Dose
0-65 mg/dL [**1-8**] amp D50
66-120 mg/dL 0 Units 0 Units 0 Units 0 Units
121-160 mg/dL 2 Units 2 Units 2 Units 2 Units
161-200 mg/dL 4 Units 4 Units 4 Units 4 Units
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Manor - [**Location (un) **]
Discharge Diagnosis:
PRIMARY
.
AAA
post operative pro long intubation - hypoxia
hyotension requiring pressure support
hyperchloremic metabolic acidosis 2nd to NS infusion
guiac positive stools
hypokalemia / hypomagnesium
Heparin induced thrombocytopenia
.
SECONDARY
.
AF
seizure disorder
HTN
R. intraventricular bleed
emphysema
T2 compression fx
Post operative transfusion
decrease platelets
post op confusion
Discharge Condition:
stable
Plt 167
Creat 1.2
INR(PT)-2.6
Discharge Instructions:
Division of [**Location (un) **] and Endovascular Surgery
Abdominal Aortic Aneurysm (AAA) Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**6-14**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? 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 incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**2-9**]
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
?????? You should get up every day, get dressed and walk, gradually
increasing 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 (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
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Call Neurology and schedule an appointment, They can be reached
at 617
Provider:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2199-5-23**]
11:15
Completed by:[**2199-5-8**]
ICD9 Codes: 4280, 2762, 2768, 4019, 4589, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1447
} | Medical Text: Admission Date: [**2128-5-24**] Discharge Date: [**2128-5-31**]
Date of Birth: [**2081-11-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
s/p VT Arrest
Major Surgical or Invasive Procedure:
Cardiac Catheterization
ICD placed
History of Present Illness:
46 yo M with no known cardiac hx, smoker, remote drug use, s/p
witnessed collapse/cardiac arrest at work. Pt received CPR
immediately x 8 min; EMS arrived and found him in polymorphic
VT: received 4 shocks in the field and regained consciousness.
Pt was immediately transferred to [**Hospital3 **] where he
went into polymorphic VT, he was shocked an additional 3 times
then went into NSR (no ST changes noted; nl QTc). Pt was started
a Lido bolus + gtt then turned off en-route to [**Hospital1 18**] and amio
loaded w/300mg and started an Amio gtt at 1mg/min by EMS.
Past Medical History:
-Extensive Coccaine addiction, Crack, MJ, no IVDU, sober x3years
-Obesity
Social History:
Currently in the service, lives alone in a half way house.
Parents live in [**Hospital3 **], has a sister in the area. Current
smoker 2ppd, denies ETOH. Extensive Coccaine, Crack, MJ
addiction sober x3 years. No h/o IVDU.
Family History:
mother: h/o "clots"; has a PPM; no h/o SCD; no h/o early CAD; no
h/o arrhythmias
Physical Exam:
99.8 72 98-102/76 15 100% on A/C 650/15/10/0.6 ABG 7.3/41/155
Gen'l: intubated sedated
HEENT: PERRLA; no head trauma
Neck: supple; no bruits; JVP 10 cm
Pulm: CTA anteriorly
CVS: RRR: S1/2; no m/r/g
Abd: obese; + BS; soft; no organomegaly
Ext: no c/c/e
Neuro: sedated; moves extremities spontaneously
Pertinent Results:
Labs:
OSH:
11.1>---<266
43
142 106 12
--------------<181
3.4 23 1.1
Trop I 0.03
ECG: sinus at 78 bpm; nl axis; borderline AV conduction delay;
borderline low voltage limb leads; delayed RWP; Q in V1
Rhythm strips osh: polymorphic VT; no underlying LQT
Bedside TTE: EF 30%; ateroseptal HK to AK
-----------------
[**Hospital1 18**] RESULTS:
.
[**5-24**] ECG:
Sinus rhythm with 1st degree A-V delay Poor R wave progression -
could be due in part positional/ normal variant but clinical
correlation is Suggested for possible prior anteroseptal
myocardial infarction
.
[**5-24**] ECHO:
Conclusions:
Left Ventricle - Ejection Fraction: 25% to 30% (nl >=55%)
The left atrium is normal in size. There is severe regional left
ventricular systolic dysfunction. Resting regional wall motion
abnormalities include anteroseptal and anterior akinesis with
hypokinesis elsewhere (the apex is not well visualized). Right
ventricular chamber size is normal; free wall motion may be
mildly to moderately depressed but is not fully visualized. The
aortic valve leaflets are mildly thickened. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). There is no pericardial effusion.
.
[**5-25**] C. CATH:
COMMENTS:
1. Selective coronary angiography showed a right dominant
system
without flow limiting disease angiographically. The LMCA was
without
disease angiographically. The LAD wrapped around the apex and
was
without flow limiting stenoses. The LCX was filling a large OM1
and Om2
and was without flow limiting stenoses. The RCA was the dominant
vessel
without flow limiting stenoses.
2. Left ventriculography showed severe hypokinesis of the
anterolateral and apical walls. The calculated contrast ejection
fraction was 36%. There was no mitral regurgitation
angiographically.
3. Limited resting hemodynamics showed a borderline pulmonary
artery
pressure (PA mean 21 mmHg). The left and right sided filling
pressures
were minimally elevated (LVEDP 16 mmHg, RVEDP 14 mmHg). The
cardiac
output was normal (CO 6.1 l/min, CI 2.4 l/min/m2). There was no
gradient
across the aortic valve.
.
[**5-27**] ECHO:
Conclusions:
There is mild symmetric left ventricular hypertrophy. The left
ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF 60-70%). No masses or thrombi are seen
in the left ventricle. There is no ventricular septal defect.
The right ventricular cavity is mildly dilated. There is mild
global right ventricular free wall hypokinesis. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2128-5-24**], the left ventricular ejection fraction is markedly
increased.
.
[**5-27**] ECG:
Sinus rhythm. First degree atrio-ventricular conduction delay.
Compared to the previous tracing no major change
.
[**5-28**] ECG:
Sinus rhythm. First degree atrio-ventricular conduction delay.
Diffuse
non-diagnostic T wave flattening. Compared to the previous
tracing of [**2128-5-27**] no major change.
.
[**5-28**] PA &LAT CXR Post ICD:
Tip of the right atrial transvenous pacer lead projects over the
superior cavoatrial junction, not directed anteriorly toward the
right auricle, which is usually seen. Transvenous right
ventricular pacer defibrillator lead is in standard placement,
tip directed towards the anterior right ventricular apex.
Lungs clear. No pneumothorax, pleural effusion, or mediastinal
widening.
.
[**5-29**] CXR post lead revision:
Comparison made with the prior chest from [**Month (only) 116**] the 19. The
position of the two ICD wires remains unchanged and
satisfactory. The satisfactory position is confirmed on the
lateral film. No failure or infiltrates are present.
.
LABS:
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2128-5-30**] 06:05AM 8.6 4.16* 12.8* 36.9* 89 30.8 34.7 13.3
212
[**2128-5-27**] 03:57AM 9.9 4.04* 12.5* 35.4* 88 31.0 35.4* 12.9
163
[**2128-5-26**] 05:03AM 8.9 3.96* 12.5* 35.1* 89 31.5 35.5* 13.4
168
[**2128-5-25**] 05:00AM 17.2* 4.50* 14.4 39.8* 88 32.1* 36.3*
13.3 238
[**2128-5-24**] 11:00PM 18.5* 4.85 15.1 43.5 90 31.1 34.6 13.3
279
.
Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2128-5-30**] 06:05AM 144* 14 1.0 142 4.1 104 27 15
[**2128-5-24**] 11:00PM 148* 15 1.1 141 6.1*1 108 25 14
.
CK(CPK)
[**2128-5-28**] 07:15AM 1079*
[**2128-5-27**] 03:57AM 1622*
[**2128-5-26**] 07:13PM 1450*
[**2128-5-26**] 03:07AM 976*
[**2128-5-25**] 01:00PM 858*
[**2128-5-25**] 05:00AM 662*
[**2128-5-24**] 11:00PM 433
.
CK-MB MB Indx cTropnT
[**2128-5-28**] 07:15AM 4
[**2128-5-27**] 03:57AM 6
[**2128-5-26**] 07:13PM 6
[**2128-5-26**] 03:07AM 6 0.03
[**2128-5-25**] 01:00PM 1
[**2128-5-25**] 05:00AM 11 1.7 <0.01
[**2128-5-24**] 11:00PM 9 0.60
.
Cholest Triglyc HDL CHOL/HD LDLcalc
[**2128-5-25**] 05:00AM [**Telephone/Fax (1) 67069**] 41 4.0 100
.
TSH
[**2128-5-24**] 11:00PM 1.5
.
HEPATITIS HBsAg
[**2128-5-26**] 03:07AM NEGATIVE
.
HIV SEROLOGY HIV Ab
[**2128-5-29**] 04:10PM NEGATIVE
CONSENT RECEIVED
.
HEPATITIS C SEROLOGY HCV Ab
[**2128-5-26**] 03:07AM NEGATIVE
Brief Hospital Course:
Impression:
46 yo M with obesity, smoker, remote h/o cocaine use, presents
s/p rescucitated cardiac arrest secondary to polymorphic VT.
1. Cardiac arrest: polymorphic VT: likely seciondary to ischemia
of the LAD territory based on ECG and bedside echo. D/c amio
gtt, started lidocaine gtt. Pt was loaded with 300mg Plavix
prior to going to C. Cath the following morning from admission.
Cath found clean coronaries. Pt was not contnued on ASA, high
dose statin due to clean coronaries but started on a BB. Pt
continued to have ectopy on [**Last Name (LF) **], [**First Name3 (LF) **] ICD was placed per EP on
[**5-27**]. Leads misplaced and repositioned on [**5-28**], pacer also
firing dysynchronously with a 12beat run of NSVT on [**5-28**]. On
[**5-31**] ICD was tested per EP without complications. CE were cycled
with elevated CK most likely [**2-12**] CPR as Tn-T remained
unremarkable. EKGs also without any evidence of ischemia, no
NSTEMI during his admission. His ASA and statin were d/c'd as
coronaries were clean. He was continued on BB and ACE-I for
better BP and HR control. Pt was to f/u in device clinic within
1 week.
.
2. Resp failure: intub in the field for airway protection. Also
likley LLL infiltrate on CXR. Pt was successfully extubated the
following day without incident. His O2 sats remained well above
95% on RA. He was started on Clinda for presumed aspiration PNA
given prolonged rescusitation in the field. He completed a 7 day
course of clinda.
.
3. Neuro: moved all extremities spontaneously. Full neuro exam
after off sedation/extubated was normal. There was a question of
possible frontol lobe involvement [**2-12**] probable hypoxia given his
inappropriate comments and behavior. Dr. [**First Name (STitle) **] followed the
pt's course since admission and did not feel his behavior was
due to a hypoxic/anoxic insult or due to frontal lobe
involvement. Per Dr. [**First Name (STitle) **] felt behavior was c/w grandiose
personality and character traits rather than a neurological
deficit. However, given issues of non-compliance and pt's
reluctance to comply with medical advice a psych consult was
obtained to further evaluate pt's competency. Per psych, they
called [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 67070**] which agreed that his behavior was at his
baseline. Per psych pt was competent and did not see a reason to
section him. Pt was stable for d/c back to half way house.
.
4. Full code
.
Mother [**First Name4 (NamePattern1) **] [**Name (NI) 67071**]): ([**Telephone/Fax (1) 67072**] (cell)
Sister [**First Name8 (NamePattern2) **] [**Name (NI) 15655**]): ([**Telephone/Fax (1) 67073**] (home)
Medications on Admission:
None
(per EMS/OSH started on Lido gtt, and Amio gtt)
Discharge Medications:
1. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
1.5 Tablet Sustained Release 24HRs PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
VT Arrest
Discharge Condition:
Good
Discharge Instructions:
Please take all your medications and keep all your follow up
appointments.
.
If you have chest pain, shortness of breath, are lightheaded or
dizzy or any other worisome symptoms please call your doctor and
go to the emergency room.
.
Please note the following changes in your medications:
-You were started on Toprol Xl and Lisinopril for your heart
.
You should not drive for 6months after your discharge from the
hospital
Followup Instructions:
You should follow-up in cardiology to check your
pacemaker/defibrillator as follows:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2128-6-4**]
11:30
You should also follow-up with Dr. [**Last Name (STitle) **] in
electrophysiology in [**2-14**] weeks. You should call [**Telephone/Fax (1) 285**] to
make an appointment.
You should also follow-up in behavioral neurology since you had
a cardiac arrest. You can call [**Telephone/Fax (1) 1690**] to make an
appointment.
Completed by:[**2128-6-1**]
ICD9 Codes: 4271, 5070, 4275 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1448
} | Medical Text: Admission Date: [**2189-1-25**] Discharge Date: [**2189-1-28**]
Date of Birth: [**2137-6-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1042**]
Chief Complaint:
hypotension, bradycardia s/p crack/EtOH
Major Surgical or Invasive Procedure:
none
History of Present Illness:
51 yo M with h/o bipolar disorder, schizoaffective disorder,
polysubstance abuse, and HIV who presents with hypotension and
bradycardia s/p crack cocaine and alcohol use. Per pt, had
snorted a large amount of crack at 12 am and drank a [**12-24**] bottle
of alcohol at 12:30 am when he attempted to reenter his group
home and was not allowed. He then began to hear voices in his
head telling him to "kill" himself and that he was a "loser." He
was reportedly noted to be altered and was brought in by EMS for
further evaluation.
In the ED, BP 60/36, HR 52. He was given atropine 1 mg and then
glucagon 5 mg with good response of SBPs from 50s to 110s and HR
from 50s to 70s. One hour later, the pt was noted to be
bradycardic and hypotensive, responding once again to glucagon.
An EKG was notable for a prolonged QTc of 473 msec, FS 94, Cr
elevated to 2.2. Urine tox + cocaine, serum EtOH 227. In the ED,
the pt denied SI and further auditory hallucinations. He was
started on a glucagon drip and transferred to the ICU for
further care.
Currently, the pt complains of a headache, lightheadedness, and
fatigue. He states that he feels as he usually does after doing
a large amount of crack. He denies SI, HI, fevers, cough, SOB,
CP, abd pain, diarrhea, nausea, vomiting, dysuria. Denies taking
any other additional medications beyond prescribed meds, but did
speak vaguely about taking "street methadone" or suboxone.
Past Medical History:
HIV positive
Bipolar disorder - h/o multiple psychiatric admissions
Schizoaffective disorder
Polysubstance abuse
EtOH abuse - no h/o seizures, but h/o withdrawals, ? DTs
HTN
Hepatitis A, B and C
ALL: NKDA
Social History:
The patient has a history of cocaine and heroin use. The
longest time sober was two years. + EtOH abuse. Lives in group
home.
Family History:
Father an alcoholic.
Physical Exam:
T 96.4 BP 89/52 HR 55 RR 13 O2 sat 97% on RA
Gen - sleepy but arousable to voice, follows commands
HEENT - sclerae anicteric, dry MM, neck supple, no LAD, JVD flat
CV - bradycardic, nl s1/s2, I/VI holosystolic murmur over apex
Lungs - expiratory wheezes b/l, no rhonchi or rales
Abd - Soft, NT, ND, normoactive BS
Ext - no LE edema, WWP, mildly tremulous
Skin - no rashes or lesions
Pertinent Results:
[**2189-1-25**] 01:47AM BLOOD WBC-7.8# RBC-3.00* Hgb-13.1* Hct-36.6*
MCV-122*# MCH-43.8* MCHC-35.9* RDW-13.0 Plt Ct-193
[**2189-1-25**] 01:47AM BLOOD Glucose-77 UreaN-53* Creat-2.2*# Na-136
K-3.8 Cl-101 HCO3-18* AnGap-21*
[**2189-1-25**] 03:38PM BLOOD Glucose-121* UreaN-38* Creat-1.0# Na-140
K-4.0 Cl-113* HCO3-20* AnGap-11
[**2189-1-25**] 01:47AM BLOOD ALT-119* AST-152* LD(LDH)-277*
AlkPhos-38* Amylase-23 TotBili-0.3
[**2189-1-25**] 01:47AM BLOOD ASA-NEG Ethanol-227* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2189-1-25**] 03:38PM BLOOD VitB12-817 Folate-GREATER TH
[**2189-1-25**] 01:47AM BLOOD Lipase-17
[**2189-1-25**] 01:47AM BLOOD Albumin-4.2
EKG: sinus bradycardia @ 51 bpm, nl axis, prolonged QTc 478
msec, LVH, TWI III, T wave flattaening aVF, J point elevation
V2-V6
Imaging:
CXR [**2189-1-25**]:
No acute cardiopulmonary process.
Brief Hospital Course:
51 yo M with extesive psych history, polysubstance abuse, and
HTN who presents s/p crack and EtOH ingestion with bradycardia
and hypotension.
.
#) Hypotension/Bradycardia - Likely in setting of post-crack
sympathetic burnout with beta-blocker on board in acute renal
failure. Hypotension and bradycardia have resolved on glucagon
drip.
- Continue glucagon gtt at 5 mg/hr.
- Monitor FS q1h.
- Start D5 1/2 NS @ 125 cc/hr to prevent hypoglycemia.
- Allow pt to take pos.
- Hold all antihypertensives.
- Telemetry monitoring.
- Resolved and was transferred out of ICU.
.
#) Acute renal failure - Per pt, no prior h/o renal dysfunction,
prior Cr in OMR in [**2181**] 0.8 - 1.1. ARF likely pre-renal in
etiology given large intake of crack cocaine and alcohol without
taking fluids or other pos.
- IVFs as above.
- Check pm lytes, BUN, Cr.
- UA negative, consider checking urine lytes in afternoon if Cr
not trending down.
- Resolved after IVF resuscitation.
.
#) Anion-gap metabolic acidosis - AG 17 in setting of uremia and
ingestions. Will continue to monitor closely.
- Resolved with IVF resuscitation.
.
#) Alcohol abuse - Concern for withdrawal and possible DTs.
Currently without significant signs or symptoms of EtOH
withdrawal.
- CIWA q2h, valium 10 mg po prn for CIWA > 10.
- SW, addictions consult.
- CIWA was discontinued after 72 hours, with CIWA 0-1
.
#) Prolonged QTc - of 478 msec. Pt on zyprexa as outpt, concern
for other possible ingestions as well that pt does not report.
- Repeat EKG.
- Continue zyprexa for now while closely monitoring QTc.
- QTc remained stable
.
#) Macrocytic anemia - In setting of EtOH abuse, HAART meds.
Continue to monitor, guaiac stools, check B12, folate.
.
#) Bipolar/schizoaffective disorder - Currently denies SI, but
did have auditory hallucinations to harm himself last pm after
using crack and EtOH.
- Psych consult.
- No need for 1:1 sitter for now.
- Continue cogentin, depakote, zyprexa.
.
#) Hypertension. After resuscitation, patient returned to
baseline high blood pressure. His outpatient regimen was
restarted, and subsequently titrated to a goal blood pressure of
< 140/90. A beta blocker was not resumed due to his overdose and
cocaine abuse. He was discharged on clonidine PO, nifedipine,
and lisinopril.
.
#) Patient was referred by social work to [**Hospital1 **] for rehab/detox
program.
.
#) AIDS. He was continued on his anti-retroviral therapy.
Medications on Admission:
Combivir 150-300 mg 1 tab [**Hospital1 **]
Sustiva 600 mg daily
Cogentin 1 mg [**Hospital1 **]
Depakote 250 mg qam, 500 mg qhs
Zyprexa 20 mg qhs
Trazodone 300 mg qhs prn
HCTZ 25 mg daily
Lopressor 100 mg daily
Protonix 40 mg daily
Ibuprofen 800 mg tid prn
Zestril 20 mg daily
Clonidine 0.3 mg tid
Discharge Medications:
1. Benztropine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*1*
2. Trazodone 100 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime) as needed.
Disp:*90 Tablet(s)* Refills:*1*
3. Efavirenz 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QAM (once a day (in the
morning)).
5. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QHS (once a day (at bedtime)).
6. Lamivudine-Zidovudine 150-300 mg Tablet Sig: One (1) Tablet
PO BID (2 times a day).
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
8. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Olanzapine 10 mg Tablet, Rapid Dissolve Sig: Two (2) Tablet,
Rapid Dissolve PO HS (at bedtime).
12. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*1*
13. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*1*
14. Nifedipine 30 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*1*
15. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
1. Alcohol withdrawal with delirium tremans
2. Cocaine withdrawal
3. Bradycardia
4. Hypotension
5. Hypertension
6. HIV/AIDS
Discharge Condition:
Stable, without tremors or hallucinations
Discharge Instructions:
Please contact your primary care physician if you develop
tremors, anxiety, or hallucinations.
You have a intake appointment at [**Hospital1 **] on Monday, [**2-2**].
Stop drinking alcohol and using crack cocaine.
An appointment has been made with your new primary care
physician.
Stop taking Lopressor (metoprolol).
Followup Instructions:
Provider: [**Name10 (NameIs) 39063**] [**Last Name (NamePattern4) 39064**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2189-3-3**] 2:00
ICD9 Codes: 4589, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1449
} | Medical Text: Admission Date: [**2200-10-1**] Discharge Date: [**2200-10-4**]
Date of Birth: [**2140-1-22**] Sex: M
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 443**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
1. Cardiac catheterization
2. Stenting of the right internal carotid artery
History of Present Illness:
60yo M PMHx CAD s/p CABG and mult PCIs, sCHF, HL, PVD, tobacco
abuse and [**Country **] stenosis who was referred for cardiac
catheterization for chest pain of increasing frequency now s/p
carotid stenting of asymptomatic progressive [**Country **] stenosis.
Regarding his CAD, prior to this admission last cardiac cath
([**2200-4-30**]) w native CADx3, known occluded RCA, patent LIMA/RIMA,
restenosis of the native RCA distal to the touchdown site of the
RIMA, successfully treated with DES. Patient reports that since
[**Month (only) **] he has had recurrence of anginal symptoms, exertional
and progressive. Regarding his extensive PVD, he was recently
found to have progression of known [**Country **] stenosis to 80-99%
range, without associated visual/neurologic symptoms. Patient
initially admitted to [**Hospital1 1516**] service for cardiac cath ([**9-30**]),
which did not demonstrate any significant new disease. On day of
transfer to CCU the patient underwent [**Country **] stenting with 8-6
protege [**Country **] stent, via R femoral artery without any noted
complications. Following the procedure remained hemodynamically
stable without any vagal episodes. He was then transferred to
CCU for further post-procedure monitoring.
.
On arrival to the floor, patient denies any HA, dizziness,
numbness/weakness. Review of symptoms significant for above
complaints as well as chronic claudication.
Past Medical History:
1. CARDIAC RISK FACTORS: -DM, +HLD, +HTN
2. CARDIAC HISTORY:
-CABG: [**2183**] CABG (LIMA-LAD, RIMA-RCA, SVG-D1, SVG-RV branch-
PDA-OM)
-CAD: SVG to OM1 Known occluded, SVG to PDA known occluded, RIMA
to RCA patent, LIMA to LAD patent
-sCHF: EF 45% in [**2197**]
-PCI: RIMA to RCA PTCA [**11/2198**], [**1-/2199**], stent [**4-/2200**]
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
-Right renal artery stenosis
-[**4-/2200**] right brachial pseudoaneurysm s/p radial access for cath
-hyperlipidemia
-PVD with right carotid disease awaiting CEA
-Dyslipidemia
-Tobacco abuse (currently smoking [**11-17**] PPD)
-GERD
-Anxiety/ depression
-Arthritis
-GOUT
-Hypothyroid
Social History:
Lives with: landlord and stepbrother, no girlfriend, and son
[**Name (NI) 6644**].
Occupation: Disabled.
Smokes [**11-17**] PPD for 45 years.
ETOH: Rare ETOH and denies illicit drug use.
Family History:
Mother with MI in her 40??????s
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 98.3 114/84 59 16 99%RA
GENERAL: NAD, comfortable
HEENT: NCAT, PERRL, OP clear
NECK: Supple, JVD 6cm
CARDIAC: nlS1/S2, no m/r/g
LUNGS: Resp unlabored, dry crackles bilaterally, no
wheezes/rales/ronchi
ABDOMEN: Soft, obese, NTND, +BS
EXTREMITIES: R groin cath site c/d/i, non-tender, no bruit
PULSES: Right: DP 1+ PT 1+ Left: DP 1+ PT 1+
.
DISCHARGE PHYSICAL EXAM:
VS: 97.7 125/77 72 14 100%RA
GENERAL: NAD, comfortable
HEENT: NCAT, PERRL, OP clear
NECK: Supple, JVD 6cm
CARDIAC: nlS1/S2, no m/r/g
LUNGS: Resp unlabored, dry crackles bilaterally, no
wheezes/rales/ronchi
ABDOMEN: Soft, obese, NTND, +BS
EXTREMITIES: R groin cath site c/d/i, non-tender, no bruit
PULSES: Right: DP 1+ PT 1+ Left: DP 1+ PT 1+
NEURO: CN's III-XII intact, [**3-20**] motor in all 4 extremities,
intact to light touch throughout, appropriate reflexes, downward
going toes on plantar reflex, no cerebellar signs
Pertinent Results:
ADMISSION LABS:
.
[**2200-10-1**] 05:35PM BLOOD WBC-7.3 RBC-4.48* Hgb-14.0 Hct-41.6
MCV-93 MCH-31.4 MCHC-33.7 RDW-13.2 Plt Ct-222
[**2200-10-1**] 05:35PM BLOOD Plt Ct-222
[**2200-10-1**] 05:35PM BLOOD Glucose-94 UreaN-16 Creat-0.9 Na-137
K-4.5 Cl-101 HCO3-30 AnGap-11
[**2200-10-1**] 05:35PM BLOOD CK(CPK)-218
[**2200-10-1**] 05:35PM BLOOD CK-MB-4 cTropnT-<0.01
[**2200-10-1**] 05:35PM BLOOD Calcium-9.3 Phos-3.3 Mg-2.2
.
PERTINENT LABS:
.
[**2200-10-1**] 05:35PM BLOOD CK-MB-4 cTropnT-<0.01
[**2200-10-2**] 06:45AM BLOOD CK-MB-3 cTropnT-<0.01
[**2200-10-2**] 06:45AM BLOOD ALT-18 AST-17 CK(CPK)-152 AlkPhos-56
TotBili-0.3
.
DISCHARGE LABS:
.
[**2200-10-4**] 09:00AM BLOOD WBC-6.7 RBC-3.83* Hgb-12.0* Hct-36.0*
MCV-94 MCH-31.4 MCHC-33.4 RDW-13.0 Plt Ct-238
[**2200-10-4**] 09:00AM BLOOD Glucose-151* UreaN-15 Creat-0.8 Na-140
K-3.7 Cl-106 HCO3-26 AnGap-12
[**2200-10-4**] 09:00AM BLOOD Calcium-8.8 Phos-2.7 Mg-1.9
.
MICRO/PATH: None
.
IMAGING/STUDIES:
.
C.CATH [**10-1**]:
FINAL DIAGNOSIS:
1. Known two vessel native coronary disease.
2. Patent LIMA and RIMA arterial conduits.
3. 70% stenosis in the proximal right renal artery.
4. 60-70% stenosis in the right iliac.
5. 60% stenosis in the left iliac.
.
Carotid Series Complete [**10-2**]:
IMPRESSION: 70-79% stenosis in the right internal carotid
artery. No
evidence of significant stenosis in the left internal carotid
artery.
.
Renal Artery Doppler [**10-2**]:
IMPRESSION:
1. Findings consistent with right renal artery stenosis.
2. Normal left renal vascular flow.
3. Multiple bilateral exophytic and cortical renal cysts.
.
C.CATH [**10-3**]:
FINAL DIAGNOSIS:
1. Severe [**Country **] stenosis.
2. Successful stenting of [**Country **] with 8-6x40mm Protege carotid
stent.
3. Goal sbp 100-120mmHg
4. Monitor in CCU overnight
5. ASA, plavix
Brief Hospital Course:
60 year old gentleman patient of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 11250**] with
known
CAD, s/p PTCA of RIMA to RCA on [**2198-12-4**], DES after RIMA
touchdown to RCA 6/11, now with recurrent and more frequent
chest pain at rest, had cardiac catheterization that was
unchanged from prior cath, found to have renal artery stenosis
(right). He also has asymptomatic progressive [**Country **] stenosis and
was scheduled for carotid stenting on [**2200-10-3**]. After stenting,
he was transferred to CCU for further management.
.
ACTIVE DIAGNOSES:
.
# Coronary Artery Disease s/p CABG and PCI to RIMA to RCA: Pt
presented with chest pain since 9/[**2199**]. He had coronary
catheterization on [**2200-10-1**] which did not reveal new
occlusion. He was continued on aspirin, plavix, statin, imdur,
morphine and SL nitro. He was instructed not to overuse nitro
tablets as he was doing at home. His imdur dose was increased
from 60 mg to 90 mg daily. Outpatient cardiologist was contact[**Name (NI) **]
regarding the reason of not being on beta blocker or ACEi. He
was not on ACEi because his outpatient cardiologist did not want
to drop his SBP to < 140 given he has severe right ICA stenosis
to avoid possible stroke. He was not on betablocker because of
the same reason in addition to his heart rate being usually in
the 50's. He was discharged with follow-up with his PCP and
cardiologist and with study-related follow-up.
.
# Renal Artery Stenosis: Found on cath to have 70% stenosis in
the proximal right renal artery. Right renal US was done and
showed stenosis as well as multiple bilateral simple exophytic
and cortical renal cysts. No stent was placed and he was
instructed to follow up with his PCP and other outpatient
providers.
.
# Carotid Artery Stenosis: Pt had a carotid US in [**2199**] which
showed right ICA 60-79% stenosis with 1-39% left ICA stenosis.
Repeat in [**7-/2200**] showed critical [**Country **] stenosis of 80-99%. He was
on aspirin 81 mg daily, plavix 75 mg daily, and lovastatin 20 mg
daily as home medications. Repeat carotid US showed 70-79%
stenosis in the right internal carotid artery. In the cath lab
he was found to have significant [**Country **] stenosis with successful
stenting using 8-6x40mm Protege carotid stent. He was monitored
overnight in the CCU with tight blood pressure control and had
an unremarkable clinical course. He was discharged with
study-related follow-up in addition to PCP and cardiology
[**Name9 (PRE) 702**]. He will need to be continued on aspirin and plavix
and should not discontinue either unless told by his
cardiologist.
.
# Peripheral Vascular Disease with Claudication: He describes
having symptoms of vascular claudication on exertion in his legs
and had an ABI of 0.66 right, 0.72 left. On cath he was found to
have 60-70% stenosis in the right iliac and 60% stenosis in the
left iliac. He was continued on aspirin, plavix, and his home
statin. He may benefit from vascular intervention of his PAD in
the future.
.
CHRONIC DIAGNOSES:
.
# Chronic Systolic Congestive Heart Failure: TTE in [**2197**] showed
Dilated LV with apical dyskinesis, septal akinesis and inferior
basilar dyskinesis with EF 45%. on lasix 20 mg every other day.
Imdur 60 mg daily. He was stable without clinical evidence of
CHF exacerbation. We increased his imdur dose to 90 mg daily
which he tolerated well.
.
# Hyperlipidemia: Stable. Continued on home ezetimibe,
gemifibrozil, and statin.
.
# Hypothyroidism: Stable. Continued on home levothyroxine 50 mcg
daily.
.
# GERD: Stable. Continued on home lansoprazole.
.
TRANSITIONAL ISSUES:
# He will need appropriate study follow-up in addition to
regular PCP and cardiology [**Name9 (PRE) 702**]
.
# He will need to be on aspirin and plavix. He should not
discontinue either medication unless told to do so by his
cardiologist.
.
# He may benefit from further vascular intervention to address
his symptoms of claudication.
Medications on Admission:
-albuterol sulfate 90mcg HFA Aerosol Inhaler 1 puff [**2-19**]
times/day prn
-bupropion HCl 75 mg Tablet once a day
-clopidogrel 75 mg Tablet daily
-ezetimibe 10 mg Tablet daily
-furosemide 20 mg Tablet every other day
-gemfibrozil 600 mg Tablet by mouth daily
-isosorbide mononitrate 60 mg Tablet ER 24 hr daily
-lansoprazole 30 mg Capsule (E.C.) daily
-levothyroxine 50 mcg Tablet by mouth daily
-lorazepam 1 mg Tablet by mouth twice a day
-lovastatin 20 mg Tablet by mouth every other day (was on [**Last Name (un) **]
day but developed muscle aches which resolved by decreasing the
dose)
-mom[**Name (NI) 6474**] 50 mcg Spray, Non-Aerosol 2 sprays daily prn
allergies
-morphine 15 mg Tablet by mouth four times per day for chest
pain
-nitroglycerin 0.4 mg Tablet, SL [**11-18**] Tablet(s) SL prn chest pain
-salmeterol 50 mcg Disk with Device one puff daily
-aspirin 81 mg Tablet, (E.C.) by mouth daily - tolerates with
food
-cholecalciferol 400 unit Tablet, Chewable by mouth daily
-omega-3 fatty acids-vitamin E [Fish Oil] 1,000 mg Capsule daily
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
2. bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. furosemide 20 mg Tablet Sig: One (1) Tablet PO QOD ().
6. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
8. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. lovastatin 20 mg Tablet Sig: One (1) Tablet PO every other
day.
11. mom[**Name (NI) 6474**] 50 mcg/Actuation Spray, Non-Aerosol Sig: Two (2)
sprays Nasal once a day as needed for allergies.
12. morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for chest pain.
13. nitroglycerin 0.4 mg Tablet, Sublingual Sig: [**11-18**] Tablet,
Sublinguals Sublingual Q5MIN () as needed for chest pain.
14. salmeterol 50 mcg/dose Disk with Device Sig: One (1) Disk
with Device Inhalation DAILY (Daily).
15. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
16. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
17. omega-3 fatty acids Capsule Sig: One (1) Capsule PO
DAILY (Daily).
18. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 1 months.
Disp:*30 Patch 24 hr(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Carotid artery stenosis, Atypical chest pain,
Coronary artery disease, Peripheral vascular disease
Secondary Diagnosis: Chronic systolic congestive heart failure,
Hypertension, Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Chest pain free.
Discharge Instructions:
It was a pleasure taking care of you during your stay here at
[**Hospital1 18**].
You were admitted for chest discomfort, and a cardiac
catheterization revealed stable coronary artery disease. As
your right internal carotid artery was found to be highly
narrowed, a stent was placed to open up this narrowing. Your
blood pressures were monitored after the procedure in the
cardiac care unit and these remained stable.
The etiology of your chest pain is unclear. [**Name2 (NI) **] should consider
consultation with a gastroenterologist and discuss this with
your cardiologist and PCP.
There were no changes made to your medication regimen.
Please continue to take aspirin and plavix every day without
exception. Do NOT stop taking these medications unless your
cardiologist instructs you to do so.
You should try to stop smoking. Smoking is extremely bad for
your health and is directly related to your heart and widespread
artery disease. We have provided you with a nicotine patch to
help assist you in quitting.
Followup Instructions:
Please report to [**Hospital Ward Name **] 4 on the [**Hospital Ward Name 517**] on [**2200-11-4**]
at 11:00AM to meet with the research team and complete the
registry follow up appointment. If you have any questions,
please call Dr.[**Name (NI) 8664**] office or the cardiology department at
[**Hospital1 18**].
Please follow up with Dr. [**First Name4 (NamePattern1) 11249**] [**Last Name (NamePattern1) 11250**] within one
week.
Please follow up with your PCP to review your chronic medical
issues.
Please discuss Gastroenterology consultation with your medical
providers.
Completed by:[**2200-10-9**]
ICD9 Codes: 2449, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1450
} | Medical Text: Admission Date: [**2160-4-5**] Discharge Date: [**2160-4-19**]
Date of Birth: [**2098-6-12**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11304**]
Chief Complaint:
Hematuria
Major Surgical or Invasive Procedure:
Open debulking radical nephrectomy and renal vein tumor
thrombectomy, [**2160-4-7**], Dr. [**Last Name (STitle) 3748**]
History of Present Illness:
61M w/ incidental L renal mass found during W/U for
brachytherapy for low-grade [**Last Name (STitle) **], now w/ gradually worsening
gross
hematuria for the past several days. He noted clots and
difficulty voiding and was admitted for bladder
irrigation. He was already on the O.R. schedule for
laparoscopic debulking L nephrectomy [**2160-4-7**].
Past Medical History:
PMH: [**Doctor Last Name **] 6 [**Doctor Last Name **] (10-17% of [**1-18**] cores), BPH, NIDDM, HTN,
diverticulosis, umbilical hernia
PSH: none
MED: metformin, amlodipine, HCTZ, MVI, ASA
ALL: NKDA
SOC: 40 pk-y tob (quit age 35); denies EtOH/IVDA
FH: father w/ [**Name2 (NI) **] (died of other causes at age [**Age over 90 **]); negative for
renal/bladder CA
Physical Exam:
Discharge PE:
AVSS
NAD
Abd distended but non tender, passing bowel movements,
Incision C/D/I, no infection
Stool small liquid brown/green
Voids light pink urine
Pertinent Results:
[**2160-4-10**] 07:30AM BLOOD WBC-12.6* RBC-3.20* Hgb-8.2* Hct-24.5*
MCV-77* MCH-25.6* MCHC-33.4 RDW-17.1* Plt Ct-438
[**2160-4-10**] 07:30AM BLOOD Glucose-167* UreaN-16 Creat-1.2 Na-136
K-4.2 Cl-105 HCO3-21* AnGap-14
[**2160-4-5**] 5:50 am URINE Source: Catheter.
**FINAL REPORT [**2160-4-6**]**
URINE CULTURE (Final [**2160-4-6**]): NO GROWTH.
[**2160-4-17**] 06:50AM BLOOD WBC-6.6 RBC-3.47* Hgb-8.8* Hct-27.1*
MCV-78* MCH-25.4* MCHC-32.5 RDW-18.5* Plt Ct-339
[**2160-4-19**] 06:00AM BLOOD PT-30.0* PTT-32.8 INR(PT)-3.1*
[**2160-4-16**] 06:10AM BLOOD Glucose-112* UreaN-14 Creat-1.4* Na-136
K-3.5 Cl-104 HCO3-23 AnGap-13
Brief Hospital Course:
61M w/ low-grade [**Month/Day/Year **] awaiting brachytherapy and locally-advanced
L renal mass w/ collecting system invasion, renal vein thrombus,
and likely metastases, presented w/
gradually worsening gross hematuria. 24F [**Last Name (un) **] catheter placed
and started on CBI, hematuria improved. He then underwent open
debulking radical nephrectomy and renal vein tumor thrombectomy
as scheduled. Please see dictated operative note for details.
The patient was brought to ICU after surgery, tranfused 5U PRBC,
and extubated on POD#1. He received perioperative antibiotic
prophylaxis x24 hours. The patient was transferred to the floor
from the ICU in stable condition. His pain was well controlled
on PCA, hydrated for urine output >30cc/hour, provided with
pneumoboots, SQ heparin, and incentive spirometry for
prophylaxis, and ambulated with physical therapy. With
improvement of creatinine, the patient was restarted on home
medications. His diet was conservatively advanced. On POD2, he
received an additional 1U PRBC transfusion with Hct 21.8,
improved to 24.5. On POD3, epidural then foley was removed. His
oxygen was weaned off with increased ambulation on POD 4. The
patient was discharged in stable condition, tolerating regular
diet, ambulating independently, voiding, passing liquid bowel
movements without fever or abdominal pain, and with pain control
on oral analgesics. On exam, incision was clean, dry, and
intact, with no evidence of hematoma collection or infection.
The patient was given explicit instructions to follow-up in
clinic with Dr. [**Last Name (STitle) 3748**], C diff results pending.
Brief MICU course: Patient was transfered to the ICU on [**2160-4-12**]
for acute respiratory decompensation, tachycardia and fevers.
He was initially started on vancomycin and Zosin for broad
coverage. He was also given PO vancomycin to emperically cover
C. diff. He was started on a heparin drip given the convern for
DVT in the setting of malignancy. His urine culture was
positive with gram negative rods. A CT of the chest revealed
multiple PEs. LENIS were negative. A CT abdomen with contrast
did not reveal an abscess around his recent surgical site. He
stabalized on antibiotics and IV heparin, and was transferred
out of the ICU on room air within two days.
He was transitioned to coumadin, on which he was discharged with
3 mg PO daily. His last INR was 3.1. One day before discharge,
he began to pass some clots per urethra, likely from his episode
of clot retention prior to surgery. UA showed no evidence of
infection. He was discharged in stable condition, ambulating
without assistance, tolerating regular diet, and with his pain
adequately controlled on PO pain meds. He was given
instructions to call his PCP as soon as possible to schedule a
f/u appointment to manage his coumadin and INR.
Medications on Admission:
Metformin, amlodipine, HCTZ, MVI
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H ()
as needed for fever for 2 weeks.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation for 2 weeks.
Disp:*28 Capsule(s)* Refills:*0*
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 2 weeks.
Disp:*40 Tablet(s)* Refills:*0*
6. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
7. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home
Discharge Diagnosis:
Kidney cancer, pulmonary embolism
Discharge Condition:
Stable
Discharge Instructions:
-Please take your coumadin as instructed and call your PCP on
day of discharge to arrange for follow-up appointment so that
your INR can be monitored.
-You may shower but do not bathe, swim or immerse your incision.
-Do not eat constipating foods for 2-4 weeks, drink plenty of
fluids.
-Do not lift anything heavier than a phone book (10 pounds) or
drive until you are seen by your Urologist in follow-up.
-Do not drive or drink alcohol while taking narcotics.
-Resume all of your home medications, except hold NSAID
(aspirin, advil, motrin, ibuprofin) until you see Dr. [**Last Name (STitle) 3748**] in
follow-up.
-Call Dr.[**Name (NI) 11306**] office Monday to schedule a follow-up
appointment and check stool culture results, AND if you have any
questions.
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call Dr. [**Last Name (STitle) 3748**] or go
to the nearest ER.
Followup Instructions:
Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3748**] to arrange for a follow-up
appointment.
Please call your PCP on day of discharge to arrange for a
follow-up appointment and to follow coumadin levels.
Completed by:[**2160-4-19**]
ICD9 Codes: 2762, 2851, 5849, 0389, 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1451
} | Medical Text: Admission Date: [**2121-9-8**] Discharge Date: [**2121-9-15**]
Date of Birth: [**2055-12-25**] Sex: F
Service: TSURG
Allergies:
Diphenhydramine / Phenytoin / Heparin Agents
Attending:[**First Name3 (LF) 4272**]
Chief Complaint:
RUL tumor
Major Surgical or Invasive Procedure:
status post left video-assisted thoracoscopy with wedge
resection
status post right upper lobectomy
status post mediastinal lymph node dissection
status post serratus anterior muscle pedicle flap
anemia requiring blood transfusion
right and left-sided chest tube placements
History of Present Illness:
Ms. [**Known lastname 1169**] is a 65yo female with a history of the right upper
lobe lung cancer status post mediastinoscopy and chemo with XRT
in [**2114**]. She now presents with recurrence in the right upper
lobe, noted after several bouts of pneumonia. She also has a
few small subpleural nodules on the left lung. For this
recurrence she has received neoadjuvant therapy.
Past Medical History:
right frontal lobe tumor (benign)
seizure disorder
DM2
cholelithiasis
legally blind in right eye
s/p craniotomy
s/p carpal tunnel release
Social History:
denies alcohol
stopped smoking in [**2111**]
retired
lives with fiancee
Physical Exam:
On Discharge
Temp 97.1, HR 94, BP 115/59, R20, 95%RA
NAD
RRR
CTA-B; incis: no SOI,
obese, s/nt/nd
no c/c/e
Pertinent Results:
[**2121-9-10**] 10:26AM BLOOD Hct-18.4*
[**2121-9-11**] 05:47PM BLOOD Hct-28.4*
[**2121-9-8**] 04:00PM BLOOD Plt Ct-255#
[**2121-9-12**] 06:43AM BLOOD Plt Ct-83*
Brief Hospital Course:
Ms. [**Known lastname 1169**] was admitted to the Thoracic Surgery service under
the care of Dr. [**Last Name (STitle) 175**]. She was taken to the OR for a left VATS
with wedge resection and RULectomy, with muscle flap and
mediastinal lymph node dissection. She tolerated the procedure
well, please see Dr.[**Name (NI) 14732**] Operative Note for greater detail.
She was transferred to the CSRU. On POD#0 she was extubated and
weaned off [**Doctor Last Name **] drips. She was transferred to the floor on POD#1.
On POD#2, her left chest tube was pulled. Her hematocrit was
18.4 and she was transfued with 3 units of pRBCs with a
post-transfusion hematocrit of 28.4. On POD#4, her epidural was
discontinued. Her platelets were noted to have declined from an
intial level of 255 to as a low as 83. She was placed on
heparin allergy precautions, in case of heparin-induced
thrombocytopenia, and a heparin antibody test was positive on
POD#7.
The remainder of her hospital course was unremarkable. On POD
#7, Ms. [**Known lastname **] JP drain and two right-sided chest tubes were
pulled without incident.
At the time of discharge, Ms. [**Known lastname 1169**] was ambulating, tolerating
a regular diet, had no active respiratory issues, and had good
pain control. Physical therapy recommended rehab placement for
strength and conditioning.
She was discharged to a rehab facility in good condition.
Medications on Admission:
Levothyroxine175mcg daily
Prozac 10mg daily
Dilantin 200mg [**Hospital1 **]
Albuterol
Compazine 10mg prn daily
Nystatin cream
Glyburide 5mg daily
Lovastatin 40mg daily
Folic acid 1mg daily
Protonix 40mg daily
Fosamax 70mg qSat.
Discharge Medications:
1. Levothyroxine Sodium 175 mcg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Fluoxetine HCl 10 mg Capsule Sig: One (1) Capsule PO QD (once
a day).
Disp:*30 Capsule(s)* Refills:*2*
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 INH* Refills:*0*
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Disp:*1 INH* Refills:*2*
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
Disp:*1 INH* Refills:*2*
9. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for PRN.
Disp:*1 1* Refills:*0*
10. Glyburide 5 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
Disp:*30 Tablet(s)* Refills:*2*
11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
12. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*45 Tablet(s)* Refills:*0*
13. Dilantin 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
Disp:*120 Capsule(s)* Refills:*2*
14. Alendronate Sodium 70 mg Tablet Sig: One (1) Tablet PO QSUN
(every Sunday).
Disp:*4 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) **]
Discharge Diagnosis:
status post left video-assisted thoracoscopy with wedge
resection
status post right upper lobectomy
status post mediastinal lymph node dissection
status post serratus anterior muscle pedicle flap
anemia requiring blood transfusion
heparin induced thrombocytopenia
hypokalemia
hypomagnesemia
right frontal lobe tumor(benign)
seizure disorder
diabetes mellitus type 2
legally blind in right eye
cholelithiasis
Discharge Condition:
Good
Discharge Instructions:
If you experience any chest pain, difficulty breathing,
shortness of breath, nausea/vomiting, or fevers/chills, please
seek medical attention.
Followup Instructions:
Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 175**] for a follow-up appointment in [**12-27**]
weeks: [**Telephone/Fax (1) 170**]
Please follow up with your PCP [**Last Name (NamePattern4) **] [**1-28**] weeks
ICD9 Codes: 2851, 496, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1452
} | Medical Text: Admission Date: [**2102-3-23**] Discharge Date: [**2102-3-29**]
Date of Birth: [**2025-2-17**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
V. Fib arrest/ STEMI
Major Surgical or Invasive Procedure:
Intra-aortic Balloon pump removal
Pulmonary intubation
History of Present Illness:
Mr. [**Known lastname 89928**] is a 77 year-old creole-speaking male with PMH of [**Hospital **]
transferred from OSH s/p STEMI c/b Vfib arrest with now with BMS
x 2 to LCX, on pressors with IABP placement. Patient initially
presented to [**Hospital3 417**] Hospital with intermittent chest
pain x 3 days. EKG showed ST depressions in V1-V4 with more
pronounced R:S ratios and minimal ST elevations in II, III, and
aVF concering with an acute posterior STEMI. While in the ED, he
had unwitnessed VT that degenerated to VF arrest. He received
CPR with epi x 1 and shock x 2; he subsequently had return of
sinus rhythm and spontaneous respiration with severe agitation
requiring intubation. Emergent catheterization showed 2 vessel
disease with 40% mid-LAD disease, sequential 90% proximal 70%
distal and 90% ostial RCA lesions and 100% occlusion mid left
circumflex. Overlapping 2.25 x 15mm and 2.5 x 12mm BMS were
placed in the mid circumflex. Wedge pressure was elevated to 17,
PA systolic pressure was elevated to 43; and an aortic ballon
pump was placed to augment his cardiac output. Dopamine was
started during cardiac catheterization because of SBPs in low
70s. He is now admitted to the CCU for further care.
On inital evaluation in the CCU, he is sedated and unresponsive.
Upon weaning sedation and with minial manipulation within the
bed, Mr. [**Known lastname 89928**] become more alert and with his family at the
bedside was able to move all 4 limbs and follow commands.
On review of systems, patient's family endorse that he had
complained of decreased exercise tolerance and leg "heaviness".
His family 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. They deny recent fevers, chills or rigors. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, palpitations, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension
2. CARDIAC HISTORY: none
3. OTHER PAST MEDICAL HISTORY:none
Social History:
Hatian creole speeking man. Works at [**Company **]'s, lives alone but
has visiting nurse.
-Tobacco history:Never
-ETOH: Heavy Drinking, never had sx of withdrawl
-Illicit drugs: Never
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; Son with history of CAD s/p stent.
Physical Exam:
VS: T=95.8 BP=106/71 HR=72 RR=14 O2sat=100% on mechanical
ventilator
GENERAL: Intubated and sedated man.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink.
NECK: Supple, JVP was obscured by instrumentation.
CARDIAC: RR, Infaltion of IABP audible throughout precordium. No
m/r/g. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
ABDOMEN: Soft, No HSM. Abd aorta not enlarged by palpation. No
abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: Ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ DP and PT are doplerable
Left: Carotid 2+ Femoral 2+ DP and PT are doplerable
Pertinent Results:
[**2102-3-23**] 07:30PM WBC-13.1* RBC-3.94* HGB-12.5* HCT-37.6*
MCV-95 MCH-31.8 MCHC-33.4 RDW-12.8
[**2102-3-23**] 07:30PM PLT COUNT-188
[**2102-3-23**] 07:30PM PT-17.0* PTT-61.4* INR(PT)-1.5*
[**2102-3-23**] 07:30PM CALCIUM-7.7* PHOSPHATE-3.9 MAGNESIUM-2.3
[**2102-3-23**] 07:30PM ALT(SGPT)-135* AST(SGOT)-309* LD(LDH)-634*
CK(CPK)-2604* ALK PHOS-74 TOT BILI-0.6
[**2102-3-23**] 07:30PM GLUCOSE-116* UREA N-12 CREAT-1.1 SODIUM-139
POTASSIUM-4.8 CHLORIDE-110* TOTAL CO2-22 ANION GAP-12
[**2102-3-23**] 07:42PM LACTATE-1.8
Cardiac Enzymes:
[**2102-3-23**] 07:30PM BLOOD CK-MB-278* MB Indx-10.7* cTropnT-3.84*
[**2102-3-24**] 10:12AM BLOOD CK-MB-158* MB Indx-3.2 cTropnT-7.48*
[**2102-3-24**] 06:05PM BLOOD CK-MB-94* MB Indx-1.2 cTropnT-5.68*
[**2102-3-25**] 04:45AM BLOOD CK-MB-44* MB Indx-0.5 cTropnT-3.90*
[**2102-3-26**] 04:12AM BLOOD CK-MB-14* MB Indx-0.2
CK trend:
[**2102-3-24**] 10:12AM BLOOD ALT-120* AST-256* CK(CPK)-4866*
[**2102-3-24**] 06:05PM BLOOD CK(CPK)-7966*
[**2102-3-25**] 04:45AM BLOOD ALT-98* AST-222* LD(LDH)-833*
CK(CPK)-8716*
[**2102-3-26**] 04:12AM BLOOD ALT-82* AST-170* LD(LDH)-698*
CK(CPK)-6952*
CAD Risk factors:
lipid panel: tcholesterol 235 TAG 215 HDL 28 LDL 164
HA1C: 5.6
Imaging:
CXR: [**3-23**]
An ET tube terminates 1.2 cm above the carina. There is an
intraaortic
balloon pump which terminates at the level of the carina. A
femoral approach catheter terminates more laterally. A
transesophageal catheter extends to at least the level of the
stomach. The heart size is normal. Central vascular congestion
with mild interstitial edema is present. A slightly lordotic
view limits evaluation at the costophrenic angles, however,
there is suggestion of a left pleural effusion.
CXR: [**2102-3-25**]:
The ET tube, the NG tube, and the femoral approach catheter are
in unchanged position. Intra-aortic balloon pump continues to be
rather low, 8 cm below the aortic root. The minimal degree of
interstitial edema in the left lung has resolved. There is no
change in bilateral pleural effusions. There are no focal
changes to suggest interval development of infectious process
such as pneumonia or aspiration pneumonia.
ECHO: [**2102-3-24**]:
The left atrium is elongated. There is symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with basal inferior and inferolateral (posterior)
akinesis. The remaining segments exhibit compensatory
hyperkinesis (LVEF = 45%). There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial 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.
IMPRESSION: Mild regional left ventricular systolic dysfunction,
c/w inferoposterior infarction. No evidence of mechanical MI
complications. No echocardiographic evidence of low-output state
while on IABP support.
Micro:
sputum culture: [**2102-3-24**]
GRAM STAIN (Final [**2102-3-25**]):
>25 PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS, CHAINS, AND
CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
Brief Hospital Course:
Mr. [**Known lastname 89928**] is a 77 year-old creole-speaking male with PMH of [**Hospital **]
transferred from OSH s/p STEMI c/b Vfib arrest with now with BMS
x 2 to LCX, on pressors with IABP placement.
#. Cardiogenic shock: He was transferred from OSH with
cardiogenic shock (low cardiac index, elevated CVP/ PWP, high
SVR, hypotension) requiring pressors and intra-aortic balloon
pump. Etiology secondary to STEMI (see below) s/p
revascularization with BMS x 2 to left circumflex. During CCU
stay, hemodynamics were monitored with aortic ballon pump,
arterial line, swan ganz catheter and urine output with goal MAP
> 65, UOP 50cc/hr and CVP 12 -14 (higher goal [**2-15**] likely RV
infarct). While on intra-aortic balloon pump, patient maintained
on heparin gtt and monitored for complications. Of note, he did
develop mild thrombocytopenia and symptoms worrying for
progressive limb ischemia with decreased peripheral pulses and
rising CK. As hemodynamics improved dopamine was discontinued
and he was weaned off intra-aortic balloon pump. Echocardiogram
on [**3-24**] while on intra-aortic balloon pump showed EF of 45%,
mild regional left ventricular systolic dysfunction, c/w
inferoposterior infarction. Once hypotension had resolved, he
was started on metoprolol and captopril and was discharged on
[**2102-3-29**].
#. Coronaries: He presented to OSH with STEMI c/b vfib arrest in
emergency department. Emergent catheterization at OSH showed
severe 2 vessel disease with 100% occlusion in left circumflex,
40% mid-LAD disease, sequential 90% proximal 70% distal and 90%
ostial RCA lesions. He received BMS x2 to left circumflex at
OSH, and was transferred to [**Hospital1 18**] for possible intervention on
RCA. Received ASA 325mg, plavix load of 600mg; and was
subsequentially started on ASA 325mg, plavix 75mg, and
atorvostatin 80mg. When cardiogenic shock resolved, patient was
also started on metoprolol succinate 100mg daily and lisinopril
10mg daily. Patient will need further risk factor modification
for secondary prevention with better BP and lipid control.
# LE Cramping/ poor peripheral pulses: On review of symptoms,
patient complained of lower extremity cramping with exertion,
poor dorsal pedial pulses, and symptoms concerning for lower
extremity ischemia upon femoral artery vascular access. ABI
showed severe flow deficit of right lower extremity and
significant left tibial disease. This will need to followed as
an outpatient and referral to vascular surgery may be
appropriate.
#. s/p endotracheal intubation: Patient was emergently intubated
following post-arrest agitation for airway protection; requiring
minimal ventilatory support. Following resolution of
cardiogenic shock, patient was successfully extubated on [**3-26**].
Immediately following extubation, patient transientally
desaturated to mid 80s from mild pulmonary edema and mucus
plugging with possible VAP. Treated successfully with lasix and
broad-spectrum antibiotics. Respiratory status improved with
lasix and by [**3-27**] he was no longer requiring supplemental O2.
#. Elevated CK: Upon admission, patient had CK elevated to 2604
which trended up to 8716 during course of hospitalization.
Etiology was multifactorial from myocardial infarction, muscle
injury from cardiac resuscitation and early lower extremity
ischemia during intra-aortic balloon pump placement. Myocardial
ischemia was treated as above. CK trended down once balloon
pump was removed. Renal function was trended and there was no
evidence of myoglobinuria or renal injury associated with
elevated CK.
#. Fever: on [**3-25**], patient developed fever to 101.5.
Infectious evaluation with blood culture, urinalysis/ culture,
sputum culture and CXR was concerning for ventilator associated
PNA. Groin lines (IABP, a-line) also may have been source of
infection/ fever. Patient was started on broad spectrum
antibiotics with vancomycin and cefepime for HAP/ possible line
infection. Sputum culture was growing GNR and GPCs. Fever curve
and WBC count was trended.
#. Transaminitis: Likely shock liver in the setting of VF arrest
with cardiogenic shock. LFTs trended down thoughout his
hospitalization. Patient's underlying alcohol abuse may have
also contributed to elevated LFTs.
Medications on Admission:
unknown antihypertensive
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. cyanocobalamin (vitamin B-12) 100 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. famotidine 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO once a day.
Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*2*
10. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H
(every 8 hours).
Disp:*90 Tablet(s)* Refills:*2*
11. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain: apply to left buttock area as needed .
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*2*
13. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Disp:*11 Tablet(s)* Refills:*2*
14. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*90 Capsule(s)* Refills:*2*
15. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
16. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual 5 minutes apart as needed for chest pain: Take no
more than 2 tablets at a time and call Dr.[**Name (NI) 3733**] for any
chest pain. .
Disp:*25 tablets* Refills:*0*
17. Outpatient Lab Work
Please check Chem-7 on Friday [**3-31**] with results to Dr. [**Last Name (STitle) 3273**]
at [**Telephone/Fax (1) 75003**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Acute systolic congestive heart failure
ST Elevation myocardial infarction
Ventricular fibrillation arrest
coronary artery disease
hyperlipidemia
possible lib ischemia from balloon pump
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You had a heart attack and your heart developed a very dangerous
rhythm that required defibrillation. You needed a machine to
breathe and a machine to keep your heart pumping. You were
transferred here for an evaluation for your heart arteries but
we decided that this was not a good plan for you right now. You
had some extra fluid in your lungs and this was removed with
medications. You will need to take many new medicines every day
to keep your heart beating strong and to prevent the stents in
your heart artery from clotting off and causing another heart
attack or death. The two most improtant medicines are aspirin
and Plavix. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] of these medications or stop
taking them unless Dr.[**Name (NI) 3733**] specifically tells you not to.
You will see Dr. [**Last Name (STitle) 3273**] in 1 week and Dr.[**Name (NI) 3733**] in one
month. You should not drink alcohol at all until you are seen by
Dr.[**Doctor Last Name 3733**] and you are tolerating your medicines.
We made the following changes to your medicines:
1. Stop taking Pravastatin, take Atorvastatin instead to lower
your cholesterol
2. Start taking aspirin 325 mg and Plavix daily to prevent the
stent from clotting off and causing another heart attack
3. Start taking Metoprolol succinate to slow your heart beat and
help your heart pump better
4. STart taking Lisinopril to lower your blood pressure
5. Start taking Tylenol and a lidoderm patch to treat the pain
in your buttock. You can stop using these once the pain is gone
6. STart taking Benzonatate three times a day for your cough,
you can stop taking this once the cough is gone.
7. Start taking ciprofloxacin for your pneumonia for 5 more days
8. STart taking Vitamin B12, folate, thiamine and a multivitamin
to correct any nutritional deficiencies.
9. Take famotidine to protect your stomach from the aspirin and
Plavix
10. Start taking furosemide to prevent fluid from building up
again in your lungs.
11. Use nitroglycerin under your tongue if you have any chest
pain again. Sit down, take 1 tablet and wait 5 minutes, you can
take another tablet if the pain is still there. Call 911 if your
chest pain is not gone after 2 tablets. Call Dr.[**Doctor Last Name 3733**] if
you have any chest pain.
.
You will need to monitor yourself for fluid buildup in your legs
or lungs. Weight yourself every day before breakfast, call Dr. [**Name (NI) 11723**] if you notice that your weight increases more than 3
pounds in 1 day or 5 pounds in 3 days. Your weight at discharge
was 158 pounds. You will need to eat a low sodium diet.
Information regarding this was given to you.
You had some vascular flow studies to evaluate circulation in
your leg. This test is still pending today and will need to be
followed up by Dr.[**Name (NI) 3733**]
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] L.
Location: [**Hospital6 **]
Address: [**Hospital1 **], [**Hospital1 **],[**Numeric Identifier 12842**]
Phone: [**Telephone/Fax (1) 45347**]
When: Thursday, [**2102-4-6**]:15AM
Department: CARDIAC SERVICES
When: TUESDAY [**2102-5-2**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4511**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
ICD9 Codes: 486, 4271, 2875, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1453
} | Medical Text: Admission Date: [**2132-4-14**] Discharge Date: [**2132-4-23**]
Date of Birth: [**2093-11-27**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
38F spanish-speaking with acute onset abdominal pain.
Past Medical History:
PMH: HTN, Asthma
PSH: x 2 lap GYN procedures
Social History:
non drinker
non smoker
Family History:
n/c
Physical Exam:
a/o x 3
nad
grossly intact
supple
farom
cta
pos bs
rrr
palp distal pulses
Pertinent Results:
[**2132-4-23**] 06:35AM BLOOD
WBC-8.9 RBC-3.87* Hgb-10.9* Hct-32.0* MCV-83 MCH-28.3 MCHC-34.2
RDW-12.4 Plt Ct-363
[**2132-4-23**] 06:35AM BLOOD
Glucose-99 UreaN-11 Creat-0.7 Na-138 K-3.8 Cl-97 HCO3-28
AnGap-17
[**2132-4-21**] 06:45AM BLOOD
ALT-7 AST-9 AlkPhos-78 Amylase-52 TotBili-0.9
[**2132-4-23**] 06:35AM BLOOD
Calcium-9.0 Phos-3.5 Mg-2.3
[**2132-4-18**] 12:01 PM
CTA CHEST W&W/O C&RECONS, NON-; CTA ABD W&W/O C & RECONS
CT OF THE ABDOMEN:
Overall, there has been no significant interval change in
extension of dissection flap, which still originate at the level
of the subclavian artery origin. The ascending aorta remains
normal in size and measures approximately 2.6 cm in greatest
diameter.
The dissection flap and descending thoracic aorta is overall
unchanged in appearance. However, there appears to be slightly
better opacification of some areas of the false lumen, which may
be related to the rate of injection. The descending aorta
measures approximately 2.9 cm at the level of the left main
pulmonary artery, which is not significantly changed. The
pulmonary arteries are normal in caliber.
Note is made of prominent bilateral hilar lymph nodes. The
largest right hilar lymph node measures 1.7 x 2.4 cm. The
largest left hilar lymph node measures 1.5 x 1.1 cm. There is an
enlarged precarinal lymph node that measures 1.3 cm in AP
dimension x 1.3 cm in transverse dimension. No pathologically
enlarged axillary lymph nodes are identified.
There are small bilateral pleural effusions, left greater than
right with associated atelectasis. The left pleural effusion has
slightly increased in size. The left pleural effusion measures
up to 25 Hounsfield units in density and underlying hemorrhagic
component cannot be excluded.
Evaluation of the lung windows.
Two 6 mm nodules in the right upper and left lower lobes are
unchanged.
The liver is normal in size and contour. There is no
intrahepatic biliary dilatation. Incidental note is made of
accessory left hepatic artery. The spleen, pancreas, and adrenal
glands are unremarkable. The kidneys enhance symmetrically.
There is no hydronephrosis. There is a 2.6 cm cyst in the
interpolar region of the left kidney as well as additional
multiple hypodensities that are too small to be accurately
characterized.
There is mild aneurysmal dilatation of the suprarenal abdominal
aorta that is not significantly changed and measures
approximately 3.6 cm in maximum diameter. The celiac and
superior mesenteric arteries arise from the true lumen and are
patent. The right and left renal arteries arise just distal to
the end of the dissection flap and are patent. The common iliac,
external iliac and internal iliac arteries are patent.
CT OF THE PELVIS:
The uterus and adnexal regions are unremarkable. The urinary
bladder contains a Foley catheter and is collapsed. There is no
significant free pelvic fluid. Evaluation of the anterior
abdominal wall reveals a small hernia in the anterior abdominal
wall containing a part of the lumen of one of the small bowel
loops, consistent with a [**Doctor Last Name 6261**] hernia. There is no
associated bowel obstruction or pneumatosis. This is unchanged
since the prior study.
BONE WINDOWS: No suspicious lytic or sclerotic lesions are
identified. The Tarlov cyst is again noted in the sacrum.
IMPRESSION:
1. No significant interval change in extent of dissection flap,
which originates at the level of the proximal origin of the left
subclavian artery.
2. Slight interval increase in size of a small left pleural
effusion which measures up to 25 Hounsfield units in density. A
hemorrhagic component /rebleeding secondary to dissection cannot
be excluded. Diagnostic thoracentesis could be performed.
3. Hilar and mediastinal adenopathy of unclear etiology.
4. Two 6-mm pulmonary nodule. A followup in four to six months
with dedicated chest CT is recommended to assess for stability.
[**2132-4-19**] 2:36 PM
CHEST (PORTABLE AP)
Cardiac silhouette appears slightly larger compared to the
previous examination, but this difference could potentially be
due to the portable technique and lower lung volumes. Aorta
remains tortuous, and there is a new left pleural effusion
accompanied by adjacent left basilar atelectasis. Comparison to
the more recent CT torso of [**324-4-18**] confirms the presence
of a left effusion and adjacent atelectasis
Brief Hospital Course:
pt admitted
cta - type b dissection
admitted to CVICU
bedrest / pain control / BP control
BP meds adjusted
multipple CTA - stable
P BP under control
DC in stable condition
pt to have follow-up cta in one month
f/u with PCP
f/u with pulmonary for lung nodule arranged
Medications on Admission:
[**Last Name (un) 1724**]: Lisinopril 2.5 QD, ?inhaler
Discharge Medications:
1. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
2. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*2*
8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*80 Tablet(s)* Refills:*0*
9. 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*
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Type B dissection
HTN, Asthma
Discharge Condition:
Stable
Discharge Instructions:
What Are the Signs and Symptoms of an Aneurysm?
The signs and symptoms of an aneurysm depend on its type,
location, and whether it has ruptured or is interfering with
other structures in the body. Aneurysms can develop and grow for
years without causing any signs or symptoms. It is often not
until an aneurysm ruptures or grows large enough to press on
nearby parts of the body or block blood flow that it produces
any signs or symptoms.
Abdominal Aortic Aneurysm
Most abdominal aortic aneurysms (AAAs) develop slowly over years
and have no signs or symptoms until (or if) they rupture.
Sometimes, a doctor can feel a pulsating mass while examining a
patient's abdomen. When symptoms are present, they can include:
Deep penetrating pain in your back or the side of your abdomen
Steady gnawing pain in your abdomen that lasts for hours or days
at a time
Coldness, numbness, or tingling in your feet due to blocked
blood flow in your legs
If an AAA ruptures, symptoms can include sudden, severe pain in
your lower abdomen and back; nausea and vomiting; clammy, sweaty
skin; lightheadedness; and a rapid heart rate when standing up.
Internal bleeding from a ruptured AAA can send you into shock.
Shock is a life-threatening condition in which the organs of the
body do not get enough blood flow.
Thoracic Aortic Aneurysm
A thoracic (chest) aortic aneurysm may have no symptoms until
the aneurysm begins to leak or grow. Signs or symptoms may
include:
Pain in your jaw, neck, upper back (or other part of your back),
or chest
Coughing, hoarseness, or trouble breathing
Cerebral Aneurysm
If a cerebral (brain) aneurysm presses on nerves in your brain,
it can cause signs and symptoms. These can include:
A droopy eyelid
Double vision or other changes in vision
Pain above or behind the eye
A dilated pupil
Numbness or weakness on one side of the face or body
If a cerebral aneurysm ruptures, symptoms can include a sudden,
severe headache, nausea and vomiting, stiff neck, loss of
consciousness, and signs of a stroke. Signs of a stroke are
similar to those listed above for cerebral aneurysm, but they
usually come on suddenly and are more severe. Any of these
symptoms require immediate medical attention.
Peripheral Aneurysm
Signs and symptoms of peripheral aneurysm may include:
A pulsating lump that can be felt in your neck, arm, or leg
Leg or arm pain, or cramping with exercise
Painful sores on toes or fingers
Gangrene (tissue death) from severely blocked blood flow in your
limbs
An aneurysm in the popliteal artery (behind the knee) can
compress nerves and cause pain, weakness, and numbness in your
knee and leg.
Blood clots can form in peripheral aneurysms. If a clot breaks
loose and travels through the bloodstream, it can lodge in your
arm, leg, or brain and block the artery. An aneurysm in your
neck can block the artery to the brain and cause a stroke.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 3972**] [**Last Name (NamePattern4) 3973**], MD Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2132-5-13**] 1:40
Provider: [**Name Initial (NameIs) 10081**]/EXERCISE LAB Phone:[**Telephone/Fax (1) 1566**]
Date/Time:[**2132-5-21**] 1:45
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2132-5-28**] 11:45.
[**Hospital Ward Name 23**] building [**Location (un) **].
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2132-5-28**] 1:15. [**Last Name (un) 2577**] building [**Location (un) 442**]. [**Hospital Unit Name **].
You have been started on anti hypertensive medication. You
should call your PCP [**Name9 (PRE) **],[**Name9 (PRE) **] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 17826**]. Schedule
an appointment immediatly on discharge
You have an appointment wit Dr [**Last Name (STitle) **]. His office number is
([**Telephone/Fax (1) 29075**]. This is in the [**Hospital1 **] Building. [**Location (un) 453**] at
1000. [**5-8**].
Completed by:[**2132-4-23**]
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1454
} | Medical Text: Admission Date: [**2106-9-26**] Discharge Date: [**2106-9-30**]
Date of Birth: [**2023-8-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with drug eluting stent placement to the
third obtuse marginal coronary branch (OM3).
History of Present Illness:
The patient is an 83-year-old African American male with a known
history of hypertension, dyslipidemia and coronary artery
disease who is status-post BMS placement to OM3 in [**2095**]. He
presented to the emergency room after two episodes of substernal
chest pain. The first episode occured 1 day prior to admission.
At that time the patient states that he was sitting, preparing a
lesson plan, when he felt a sudden onset of [**8-25**] "sharp" chest
pain which radiated to his left shoulder and also involved his
left arm. The pain was "stabbing" and had no association with
dyspnea, nausea, vomiting, or diaphoresis. The patient taught a
class through the pain and his sub-sternal chest pain resolved
without medication. The following afternoon, the patient had an
almost identical episode of pain beginning at 1pm, although it
did not involve the left arm and it started while he was walking
and doing errands. He drove home and called for an ambulance
within one hour of the onset of his chest pain. As with his
episode from the prior afternoon, there was no nausea, shortness
of breath, vomiting, diaphoresis, lightheadedness or
palpitations associated with this second bout of chest pain.
.
Mr. [**Known lastname **] states that at his baseline his exercise tolerance is
limited only by his knee pain and longstanding osteoarthritis
"aches". He has never had any chest pain or shortness of breath
associated with exertion.
.
Upon arrival to [**Hospital1 18**] in the ED the patient reported [**3-25**] chest
pain and his EKG was notable for ST depressions in V1-V3.
Posterior EKG was done which showed ST elevations in posterior
V3-V6. STEMI protocol was initiated and MR. [**Known lastname **] was given a load
of 600mg Plavix, IV Heparin bolus, and started on Nitroglycerin
drip. 325mg ASA had already been given prior to arrival to the
hospital. The ST elevations resolved on repeat EKG with these
treatments and the patient's chest pain decreased to [**12-24**] and
was stable at that level leading up to his presentation to the
CCU.
.
Of note, the patient had an episode of chest pain in [**2095**] which
led to emergent cardiac catheterization with BMS placement to
OM3. He explains his chest pain in [**2095**] as being more severe and
intense. Unfortunately, subsequent to his MI in [**2095**] he endured
a frontal intraparenchymal hemorrhage immediately after the
hospitalization for this procedure which was attributed to a
combination of poorly controlled hypertension and several
anticoagulants, including ticlid, aspirin, and heparin. After
this CVA he had word finding difficulty, motor impairments, and
memory deficits but he states that all of these troubling
complications resolved over time and he has no lasting cognitive
impairments or focal motor/sensory neurologic handicaps at this
time.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations,
syncope or presyncope. He does have ankle edema which worsens
throughout the day and improves with leg elevation as well as
chronic intermittent knee aches secondary to a history of
osteoarthritis.
Past Medical History:
1. CARDIAC RISK FACTORS: + Dyslipidemia, + Hypertension,
+Age/Sex
2. CARDIAC HISTORY:
-PERCUTANEOUS CORONARY INTERVENTIONS:
[**2095**]: 90% stenosis in OM3 into which a BMS was placed
3. OTHER PAST MEDICAL HISTORY:
-Hyperlipidemia
-Glucose intolerance
-HTN
-Osteoarthritis
-Right inguinal hernia, status post repair in [**2068**]
-CVA: frontal intraparenchymal hemorrhage post-cath while on
Ticlid and aspirin
-Prostate cancer s/p local radiation
.
Social History:
Mr. [**Known lastname **] is married and lives with his wife in [**Location (un) 686**], MA. He
is a former
[**Hospital1 **] employee as a maintenance supervisor. He denies smoking
cigarettes. He reports drinking approximately [**12-16**] glasses of
wine per week and he denies using any other illicit drugs.
Family History:
No family history of early MI, otherwise his family history is
remarkable for diabetes mellitus type II in multiple family
members.
Physical Exam:
VS: T=98.1 BP=112/74 HR=64 RR=18 O2 sat= 99% on 2L Nasal Cannula
GENERAL: NAD. Oriented to person, place and time. Mood and
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesmas.
NECK: Supple, no thyromegaly, JVP of [**4-20**] cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No murmurs, rubs or gallops. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Respirations unlabored, no accessory muscle use. CTAB, no
crackles, no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
EXTREMITIES: Edema at ankles 2+ pitting symmetric, 1+ DP pedal
pulses, and 1+ PT pulses bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Right: Carotid 2+ , 2+ femoral, 2+ radial, 1 + DP
difficult to dopper
Left: Carotid 2+, 2+ femoral, 2+ radial, 1+ DP difficult to
doppler
Pertinent Results:
[**2106-9-26**] 11:48PM CK(CPK)-446*
[**2106-9-26**] 11:48PM CK-MB-63* MB INDX-14.1* cTropnT-0.20*
[**2106-9-26**] 03:45PM GLUCOSE-163* UREA N-14 CREAT-1.0 SODIUM-139
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-25 ANION GAP-13
[**2106-9-26**] 03:45PM CK(CPK)-177*
[**2106-9-26**] 03:45PM cTropnT-0.02*
[**2106-9-26**] 03:45PM CK-MB-7
[**2106-9-26**] 03:45PM WBC-4.8 RBC-4.72 HGB-13.8* HCT-40.2 MCV-85
MCH-29.2 MCHC-34.3 RDW-14.4
[**2106-9-26**] 03:45PM NEUTS-73.3* LYMPHS-18.5 MONOS-6.5 EOS-1.7
BASOS-0.1
[**2106-9-26**] 03:45PM PT-13.8* PTT-21.1* INR(PT)-1.2*
[**2106-9-26**] 03:45PM PLT COUNT-155
[**2106-9-27**] 08:04AM BLOOD CK(CPK)-1164*
[**2106-9-27**] 02:45PM BLOOD CK(CPK)-1026*
[**2106-9-30**] 05:55AM BLOOD Calcium-8.3* Phos-4.1 Mg-2.1
[**2106-9-27**] 02:45PM BLOOD %HbA1c-7.2*
[**2106-9-27**] 03:01AM BLOOD Triglyc-53 HDL-46 CHOL/HD-3.2 LDLcalc-88
[**2106-9-28**] 11:25PM BLOOD CRP-145.1*
[**2106-9-29**] 12:02PM URINE Blood-MOD Nitrite-NEG Protein-NEG
Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2106-9-28**] 11:08PM JOINT FLUID WBC-[**Numeric Identifier 7040**]* RBC-[**2097**]* Polys-85*
Lymphs-0 Monos-0 Macro-15
[**2106-9-28**] 11:08PM JOINT FLUID Crystal-FEW Shape-RHOMBOID
Locatio-INTRAC Birefri-POS Comment-c/w calcium
[**2106-9-30**] 05:55AM BLOOD WBC-11.8*# RBC-4.29* Hgb-12.7* Hct-35.7*
MCV-83 MCH-29.5 MCHC-35.5* RDW-14.0 Plt Ct-205
[**2106-9-30**] 05:55AM BLOOD Glucose-182* UreaN-29* Creat-1.0 Na-134
K-4.3 Cl-103 HCO3-22 AnGap-13
MICROBIOLOGY :
*URINE CULTURE (Final [**2106-9-30**]): NO GROWTH.
*FINAL REPORT [**2106-9-30**]* Blood Culture, Routine (Final [**2106-9-30**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET
ONLY.
SENSITIVITIES PERFORMED ON REQUEST. STAPHYLOCOCCUS, COAGULASE
NEGATIVE. SECOND MORPHOLOGY. ISOLATED FROM ONE SET ONLY.
Anaerobic Bottle Gram Stain (Final [**2106-9-28**]): GRAM POSITIVE
COCCI IN CLUSTERS. Aerobic Bottle Gram Stain (Final [**2106-9-28**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Additional Blood Cultures drawn [**2106-9-29**], [**2106-9-30**] have no
growth to date but final results pending.
[**2106-9-26**] EKG; rate 75, Sinus rhythm. Early precordial QRS
transition is non-specific. ST-T wave configuration suggest
posterolateral injury/ischemia.
.
[**2106-9-26**] EKG: Regular atrial rhythm with inverted p-waves in II,
III, aVF c/w ectopic atrial pacer and with 1mm ST elevation in
V5/V6 and TWI in III
.
[**2106-9-27**] CARDIAC CATH (left): Selective coronary angiography of
this right dominant system demonstrated 3 vessel coronary artery
disease. The LMCA was normal. The LAD had 50% stenosis
proximally, and diffuse irregularities
throughout. The LCX had a 30% proximal stensois. The OM2 had a
50%
proximal stenosis. OM3 had a 90% stenosis proximally within the
prior
stent, with normal flow. The RCA had a 30% proximal stenosis and
a 80%
stenosis distally. There was a 70% stenosis at the bifurcation
of the
PDA and PLV. The PDA was a small, diffusely diseased vessel.
Successful PTCA and placement of a 3.0x12mm Xience drug-eluting
stent
in the OM3 were performed. Final angiography showed normal
flow, no
apparent dissection, and no residual stenosis.
Successful PTCA using a 2.5x8mm Voyager balloon in the origin
OM2 was
performed. Final angiography showed normal flow, no apparent
dissection, and a 50% residual stenosis.
FINAL DIAGNOSIS:
1. Two vessel significant coronary artery disease.
2. Placement of a drug-eluting stent in the OM3.
.
[**2106-9-29**] CXR (PA and Lateral): Retrocardiac lung areas
are free of consolidations, no pneumonias. Aortic tortuosity,
but without signs suggestive of fluid overload. No pleural
effusions.
.
[**2106-9-28**] RIGHT KNEE X-RAY: Osteophytic changes in all three
compartments with considerable joint space narrowing in the
medial and patellofemoral joints. Prominent chondrocalcinosis.
Suboptimally visualized a moderate-sized effusion. Extensive
vascular calcifications. Similar findings were present on X-rays
done [**2104-12-15**] with equivocal progression. No acute fracture
or bone destruction.
.
[**2106-9-29**] 2D-ECHOCARDIOGRAM: The left atrium is mildly dilated.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Transmitral Doppler and tissue velocity imaging are consistent
with Grade I (mild) LV diastolic dysfunction. 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 mildly thickened. Trivial mitral regurgitation is
seen. The pulmonary artery systolic pressure could not be
determined. There is no pericardial effusion. Overall impression
: mild symmetric left ventricular hypertrophy with preserved
global and regional biventricular systolic function.
.
.
Brief Hospital Course:
In summary, the patient is an 83-year-old male with longstanding
history of hypertension, dyslipidemia and CAD (prior BMS
placement to
OM3 in [**2095**]) who developed recurrent chest pain for 2 days and
was found to
have posterior STEMI on arrival to the ED at [**Hospital1 18**] on [**2106-9-26**].
The [**Hospital 228**] hospital course was also marked by a Pseudogout
episode and a positive blood culture for coagulase negative
staphyococcus which was likely a contaminant as outlined below.
.
CAD / POSTERIOR STEMI: Mr. [**Known lastname 94783**] initial EKG was notable for ST
depressions in V1-V3. Posterior EKG was done which showed ST
elevations in posterior V3-V6. STEMI protocol was initiated and
the patient was given a load of 600mg Plavix, IV Heparin bolus,
and started on Nitroglycerin drip. He was also given 325mg ASA
and high dose Atorvastatin was started. ST-elevations soon
resolved on repeat EKG with medical therapy and the patient's
chest pain also abated. The etiology of his ST elevations
followed by complete resolution were thought to have been
related to a plaque rupture with spontaneous lysis of resultant
thrombus or coronary vasospasm resolved with nitroglycerin. He
was admitted to the CCU for further management and a left sided
cardiac catheterization was arranged soon after the patient was
admitted. He underwent successful placement of DES to OM3
coronary branch without any immediate complications. Of note,
the patient's CK level peaked on [**2106-9-27**] at 1164, with peak
Trops of 2.52, MB-I 14.5 and CK-MB 133. During his hospital stay
he was continued on daily ASA 325MG , Plavix 75 mg daily, a high
dose statin, IV heparin, Metoprolol and Captopril. Captopril was
eventually switched to PO Lisinopril prior to discharge and the
patient's beta-blocker was uptitrated to Metoprolol Succinate XL
150 mg daily at discharge. He was set up for a follow-up
Cardiology appointment with Dr. [**Last Name (STitle) **] on [**2106-11-3**].
.
PUMP FUNCTION: The patient had no prior ECHO results on file
prior to admission. On physical exam he demonstrated no crackles
or rales on lung exam and minimal lower extremity edema.
Post-catheterization ECHO (TTE) done [**2106-9-28**] showed LVEF of 55%
with mild diastolic dysfunction (Grade 1), trivial MR, no AS and
mild symmetrical LVH. Fortunately, Mr. [**Known lastname **] had no major akinesis
after this ACS/STEMI. He will continue to take his HTN and CAD
medications as outlined below and he will plan to follow-up in 4
weeks for a Cardiology visit with Dr. [**Last Name (STitle) **].
.
RHYTHM: EKG on hospital day 1 revealed some evidence of ectopic
atrial pacer beats exhibited by inverted p-wave in II, III, aVF
with shorter PR. This was felt to be related to his acute
presentation and was not felt to be clinically relevant given
that repeat telemetry and EKGs throughout his hospital course
showed NSR with no evidence of any prominent arrhythmias.
.
RIGHT KNEE PAIN - One day after stent placement Mr. [**Known lastname **]
developed swollen, warm, tender right knee which was notably
effused. A joint aspiration/tap was performed by the orthopedic
service and Mr. [**Known lastname **] was found to have joint fluid calcium
pyrophosphate crystals with rhomboid shape that were positively
bifringent and consistent with Pseudogout. The orthopedic team
also performed a local injection with Bupivicaine and Cortisone
for pain control. The fluid tap itself was very therapeutic in
that it also readily relieved the effusion. Physical therapy was
also called to help Mr. [**Known lastname **] [**Last Name (Titles) **] and recuperate with
exercises. He was pain free and ambulating without difficulty at
the time of discharge. The patient will have secondary benefit
from daily ASA, and additional Tylenol can be used for recurrent
pain as needed. The patient was asked to follow-up with Dr. [**First Name (STitle) 4304**]
[**Name (STitle) 284**] in the orthopedics department who he already sees for
his osteoarthritis management if he had a return of his knee
pain or effusion in the coming weeks. Of note, the joint fluid
gram stain was negative for any microorganisms and the total
WBCs were 26,000 which indicated an inflammatory process but not
quite high enough to suspect septic joint. The patient's right
knee x-ray showed no new changes, just his baseline
known osteophytic changes and joint space narrowing with
chondrocalcinosis that was equivalent to his [**12/2104**] x-ray.
.
BACTEREMIA: The patient had blood cultures drawn on admission
on [**2106-9-27**] which revealed [**1-18**] positive samples/cultures with
gram positive cocci which were later identified as coagulase
negative staphylococcus species. In the interim the patient was
treated with IV Vancomycin for 3 days due to concern for a
possible MRSA infection. However, after cultures revealed
coagulase negative species on [**2106-9-29**] it was felt that the
culture results may have been tainted by a normal skin
contaminant. With the exception of a fever of 101 on hospital
day 2, the patient had no ongoing fevers, chills, headaches,
cough, URI symptoms and he had a clear CXR. Moreover, he had
negative urine cultures, negative knee fluid cultures and no
noted leukocytosis. Mr. [**Known lastname 94783**] antibiotics were stopped prior to
discharge. At time of discharge the plan was to follow-up all
pending cultures from [**Date range (3) 94784**] which have shown no
growth to date. Patient advised to call PCP as soon as possible
if he has any recurrent fevers, chills, rigors or develops upper
respiratory symptoms such as cough or productive sputum or has
dysuria.
.
STROKE HISTORY : The [**Hospital 228**] medical history is significant
for a neurologic event/hemorrhagic CVA which occured in the
setting of anticoagulation and hypertension in [**2095**]. Thus,
Integrillin was never initiated as part of his MI management and
the CCU team aggressively controlled the patient's hypertension
with a SBP goal < 140 and during his stay he underwent daily
full neurological checks. He had no evidence of any focal
neurological deficits.
.
HTN - Amlodipine was held and eventually discontinued as the
patient had good BP control with SBP ranges in the 120s on
uptitrated doses of beta-blockers and ace-inhibitors during his
stay. The patient was given Captopril which was increased
gradually and switched to 40mg PO Lisinopril along with 150mg
Metoprolol XL at time of discharge. The patient was asked to
continue these 2 medications for his hypertension management.
.
GLUCOSE INTOLERANCE: The patient has no known diagnosis of DM
but he has a prominent family history of DM-2. He had several
high blood sugar levels during his hospital stay. He was started
on a sliding scale insulin drip soon after his admission for
better control in the CCU setting. He had fasting glucose levels
in the 140-180 range and he was asked to follow-up with his PCP,
[**Last Name (NamePattern4) **].[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4390**] (appointment set up for [**2106-10-15**]) for
additional diabetic screening and to discuss the need for
additional control with medications on an ongoing basis. During
this admission Mr. [**Known lastname 94783**] Hgb A1c collected was suboptimal with
level of 7.2.
.
PROPHYLAXIS/CODE STATUS : The patient was initially given IV
anticoagulation in the ACS setting which served as dual DVT PPx
and he was switched to subcutaneous Heparin later in his
hospital course to prevent DVTs. The patient was given a bowel
regimen of Senna and Colace to maintain regularity. The patient
was maintained as a full code status for the entirety of his
hospital stay.
.
Mr. [**Known lastname **] was asked to please return to the emergency room or call
his new
cardiologist or PCP as soon as possible if he had any worsening
shortness of breath, chest pain, dizziness or lightheadedness
after discharge.
Medications on Admission:
AMLODIPINE 10mg daily
ASPIRIN 325 MG daily
ATENOLOL 100mg daily
SIMVASTATIN 10 mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Take every day for 1 year.
Disp:*30 Tablet(s)* Refills:*11*
4. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily).
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain: Take for right knee pain.
7. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual every 5 minutes x3, then call 911 as needed for chest
pain.
Disp:*30 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
ST Elevation Myocardial Infarction
Right Knee Pseudogout
Hypertension
Compensated Systolic Heart Failure
Hyperglycemia, A1C 7.2
Discharge Condition:
Stable,
A1C 7.2
BUN 29
Creat 1.0
Hct: 35
Discharge Instructions:
You had a heart attack and a cardiac catheterization. A Drug
eluting stent was placed in your coronary artery (OM3 branch) .
You will need to take Plavix for one year. Do not stop taking
this medicine unless Dr. [**Last Name (STitle) **] tells you otherwise. Your
heart function is mostly preserved after this heart attack.
Physical therapy has seen you and told you how much exercise to
do. You should go to cardiac rehabilitation after Dr. [**Last Name (STitle) **]
tells you it is OK. Your blood sugars were somewhat high during
this hospital stay. You should discuss this with your primary
care doctor. You had a bacteria that grew out of one set of
blood cultures. Subsequent blood cultures were negative and it
is likely this bacteria was a contaminant from the top of the
bottle. Please call Dr. [**Last Name (STitle) 4390**] if you develop any fevers,
chills, shakes, lightheadedness, chest pain, nausea, trouble
breathing or any other concerning symptoms.
.
New medicines:
Your simvastatin was increased to 80 mg
Plavix: to prevent the stent from clotting off
Lisinopril: to control your blood pressure
Your aspirin was increased to 325mg
Metoprolol XL: to control your heart rate and prevent another
heart attack.
Stop taking Atenolol and Amlodipine
Followup Instructions:
Primary Care:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4390**], MD Phone: [**Telephone/Fax (1) 3070**] Date/time: [**10-15**]
at 11:30am
Cardiology:
[**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone: [**Telephone/Fax (1) 62**] Date/Time: Wednesday
[**11-3**] at 1pm.
Completed by:[**2106-10-2**]
ICD9 Codes: 5990, 7907, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1455
} | Medical Text: Admission Date: [**2130-4-4**] Discharge Date: [**2130-4-10**]
Date of Birth: [**2060-9-14**] Sex: F
Service: CT Surgery
HISTORY OF PRESENT ILLNESS: This 69-year-old woman presented
with a known history of coronary disease and a myocardial
infarction in [**12-28**]. At another hospital, she had an exercise
tolerance test which was abnormal. She was admitted in [**2-25**]
and catheterized at an outside hospital which showed an
ejection fraction of 51% and three vessel disease. Please
refer to the catheterization report.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Mitral regurgitation.
3. Non-insulin dependent diabetes mellitus.
4. Hypertension.
5. Hyperlipidemia.
6. Peripheral vascular disease with known occlusion of left
iliac, 90% right iliac occlusion, and severe infrarenal
disease.
PAST SURGICAL HISTORY: Includes a femoral-femoral bypass and
a right common iliac stent. Past surgical history includes
uterine surgery and the fem-fem bypass.
ALLERGIES: She had no known allergies.
MEDICATIONS ON ADMISSION: Atenolol, Imdur, Lipitor, Zoloft,
hydrochlorothiazide, Cozaar, and Zestril.
PREOPERATIVE LABORATORIES: Showed a white count of 9.6,
hematocrit of 33, platelet count 242,000. Sodium 138, K 3.9,
chloride 101, CO2 24, BUN 13, creatinine 1.1, and a blood
sugar of 97.
The patient was on Plavix, preoperatively. Her last dose was
on [**3-29**]. She was Portugese speaking.
Chest x-ray showed no acute cardiopulmonary disease.
HO[**Last Name (STitle) **] COURSE: The patient was taken to the Operating Room
on [**4-4**] and had a coronary artery bypass grafting times two by
Dr. [**Last Name (Prefixes) **] with LIMA to the LAD and a vein graft to the
PDA. She was transferred to Cardiothoracic ICU stable on a
propofol drip and a nitroglycerin drip.
On postoperative day one, her Neo-Synephrine drip was weaned
off and she was extubated. She was hemodynamically stable,
in sinus rhythm in the 60's, with a blood pressure of 120/65.
Her hematocrit, postoperatively, was 24 with a BUN of 19,
creatinine of 0.8, blood sugar of 142, K of 5.0, PT of 13.3,
PTT of 40.8, and INR of 1.2. Her lungs were clear
bilaterally. Her abdomen was soft. Her extremities were
within normal limits. Her sternum was intact. She had no
neuro issues. She started her Lasix diuresis, as well as
Lopressor and aspirin. Pulmonary toilet was begun, and she
was transferred out to the floor.
She was seen by Case Management and worked up by Physical
Therapy to begin her ambulation.
On postoperative day two, her exam was benign. She was
hemodynamically stable with a blood pressure of 142/62,
saturating 94% on four liters. She had bibasilar rales. Her
abdominal exam was normal. Her wounds were clean, dry, and
intact. Her chest tubes were discontinued, as was her Foley
catheter. She continued to ambulate and was screened for a
rehabilitation bed.
On postoperative day three, her temporary pacing wires were
also discontinued. Her lungs were clear and her heart was
regular in rate and rhythm, was in sinus rhythm at 70 with a
good blood pressure. Incisions were clean, dry, intact. She
continued to ambulate with Physical Therapy as she was being
screened.
On postoperative day four, the patient did complain of some
right upper quadrant tenderness and was seen by Surgery. The
patient's white count was 17. The patient had a negative
ultrasound for cholecystitis. She remained NPO with IV
fluids, and they recommended abdominal CT. The CT scan
showed pericholecystic fat. The General Surgery team
continued to follow the patient. She remained NPO on Flagyl.
She did have some tenderness and some guarding with no
rebound. The question was whether or not she had acute
cholecystitis developing. General Surgery continued to
follow. She did continue to ambulate and Lasix diuresis was
held, and she continued to get her IV Lopressor. Her
hematocrit remained stable in the 30's and her liver function
tests were normal. Another CT scan showed a left lower lobe
infiltrate with bilateral pleural effusions and an apparent
rib fracture.
On postoperative day five, the patient was reevaluated again
by General Surgery team. Negative laboratories showed that
it was most likely cholecystitis. Her diet was advanced.
She had decreased pain and continued to ambulate.
On exam, her lungs were clear and wounds were clean, dry, and
intact. Her abdomen was soft with some slight right upper
quadrant tenderness, but no rebound or guarding. She had no
edema in her extremities. Her hematocrit was stable. Chest
x-ray did show a question of a left lower lobe pneumonia.
Her diet was advanced. She continued on levofloxacin for her
pulmonary process and continued to rehabilitate on the floor
with Physical Therapy.
On[**4-10**] the patient was discharged to home in stable
condition with instructions to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
in one week, the primary care physician, [**Name10 (NameIs) **] to follow-up
with Dr. [**Last Name (Prefixes) **] in six weeks.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass grafting times two.
2. Hypertension.
3. Non-insulin dependent diabetes mellitus.
4. Congestive heart failure.
5. Hypercholesterolemia.
6. Severe peripheral vascular disease as documented with
prior fem-fem bypass and iliac stenting.
DISCHARGE MEDICATIONS:
1. Lipitor, 40 mg PO q d.
2. Zoloft, 25 mg PO q d.
3. Enteric coated aspirin, 325 mg PO q d.
4. Lopressor, 75 mg PO b.i.d..
5. Lasix, 20 mg PO q d times one week.
6. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**], 20 mEq PO q d times one week.
7. Plavix, 75 mg PO q d.
8. Protonix, 40 mg PO q d.
9. Tylenol, 650 mg PO q 4 hours p.r.n..
10. Percocet, one to two tabs PO p.r.n. q 4-6 hours for pain.
11. Levaquin, times seven days antibiotic therapy.
On the day of discharge, the patient's blood pressure was
159/73 with a heart rate of 85, saturating 94% on room air.
Sternum was stable. Wounds were clean, dry, and intact.
Heart was regular rate and rhythm. Lungs were clear to
auscultation bilaterally. The extremities were warm with
some ecchymosis on the right thigh which was soft. White
count was 11,000, BUN of 18, creatinine of 1.2. The
abdominal pain and the white count had both improved and the
patient remained on antibiotic therapy for the left lung
infiltrate.
Again, the patient was discharged to home in stable condition
on [**2130-4-10**].
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D.
Dictated By:[**Last Name (NamePattern1) 37991**]
MEDQUIST36
D: [**2130-9-20**] 15:35
T: [**2130-9-26**] 07:51
JOB#: [**Job Number 40391**]
ICD9 Codes: 486, 4019, 2720, 412 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1456
} | Medical Text: Admission Date: [**2163-6-7**] Discharge Date: [**2163-6-11**]
Date of Birth: [**2084-12-8**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 5188**]
Chief Complaint:
Abdominal wall hematoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 1683**] is a 78 year old woman on coumadin for Afib currently
on a lovenox bridge for upcoming surgery now w/expanding
hematoma of her right abdominal wall. Patient took last dose of
coumadin on Saturday and took lovenox [**Hospital1 **] Sunday and her first
dose on [**Hospital1 766**] (80mg and 70mg respectively). Noted a small
hematoma at injection site [**Hospital1 766**]. Saw her PCP today who
referred her for ED eval as the hematoma was expanding. No
bleeding from skin. No diffuse abdominal pain, just discomfort
over hematoma sites. No palpitations, no
SOB, no dizziness.
Past Medical History:
Past Medical History: Lymphoma '[**55**], Afib, "ministrokes" on MRI
Past Surgical History: ?partial nephrectomy '80s for
nephrolithiasis
Social History:
Unknown
Family History:
Unknown
Physical Exam:
Vitals: Tm 99.3, Tc 98.5, HR 73, BP 118/81, RR 16, SaO2 97%RA
General: in no acute distress, alert and oriented x 3
Cardiac: regular rate and rhythm
Lungs: Clear to auscultation bilaterally
Abdomen: soft, non-tender, hematoma present on left lower
abdomen
Pertinent Results:
[**2163-6-7**] CT abd/pelvis R rectus sheath hematoma, rupture into
subcutaneous tissue
[**2163-6-7**] 11:16PM HCT-27.1*# HGB-11.2* calcHCT-34
[**2163-6-7**] 01:00PM GLUCOSE-113* UREA N-24* CREAT-1.5* SODIUM-141
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-28 ANION GAP-12
[**2163-6-7**] 01:00PM PT-17.1* PTT-25.8 INR(PT)-1.5*
Brief Hospital Course:
Ms. [**Known lastname 1683**] was managed conservatively and had her
anti-coagulation held throughout her hospitalization. She
received 2 units of PRBCs in the emergency department due to a
low hematocrit caused by the massive extravasation of blood into
the wall of abdomen. Her hematocrit rose appropriately and
stabilized. Her pain was well managed. She had an episode of
orthostatic hypotension that resolved with fluid and a unit of
PRBC. Her abdominal wall hematoma remained stable and began to
resorb during her admission. The patient's hematologist and PCP
felt that it would be ideal to continue holding anti-coagulation
until after the breast lumpectomy scheduled for [**7-1**]. The
patient agreed with this decision, and she was instructed to
contact her cardiologist to confirm the decision making.
Medications on Admission:
Digoxin .125 qday, lsinopril 5 qya, metoprolol XL 50mg qday,
zocor 40mg qday, tricor 48mg qday, levothyroxine 175mcg qday,
coumadin 2.5mg qM-F/1.5 qSa/[**Doctor First Name **]
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Tricor 48 mg Tablet Sig: One (1) Tablet PO once a day.
6. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal wall hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the surgery service for your abdominal wall
hematoma, which developed while you were on Lovenox. We would
like you to call your cardiologist on [**Doctor First Name 766**] [**2163-6-13**] to confirm
holding your anticoagulation until after you procedure scheduled
on [**2163-7-1**].
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:
You will receive a call from Dr.[**Name (NI) 6045**] secretary next
week regarding a follow-up appointment.
Please contact your cardiologist on [**Name (NI) 766**].
[**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]
ICD9 Codes: 4254, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1457
} | Medical Text: Admission Date: [**2174-8-13**] Discharge Date: [**2174-8-26**]
Date of Birth: [**2100-4-30**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1881**]
Chief Complaint:
shortness of breath and productive cough
Major Surgical or Invasive Procedure:
Rigid bronchoscopy [**2174-8-18**]
Flex Bronchoscopy [**2174-8-19**]
History of Present Illness:
74F h/o anca positive vasculitis (Wegeners) with pulmonary and
renal involvement, complicated by tracheobronchial disease who
p/w fever. Patient visited pulm/rheum as outpatient on [**8-11**], and
was believed to have evidence of worsening tracheobronchial
disease vs infection. Written for levaquin but never obtained
rx. CT as outpatient on [**8-12**] showed pronounced opacities at the
lung bases bilaterally and stable appearance of wall thickening
of the distal trachea and right and left main stem bronchi.
Family reports increase in coughing with production of yellowish
sputum. She denies stridor, shortness of breath, or chest pain.
Has chronic DOE at baseline. The patient also reports loss of
appetite. She denies abdominal pain, nausea, vomiting, or
diarrhea. Currently taking prednisone 20 mg daily (decreased
about 3 weeks ago) and has noticed that her chronic cough and
fatigue has gradually worsened on the lower dose.
.
In the ED, initial vs were: temp 101.8 110 110/53 20 92% RA.
EKG: sinus tach 106, LAD, QTC 450, old Q waves inferiorly.
HCAP coverage started with vanco/zosyn. Review CT chest from
[**8-12**] - pronounced nodules at the lung bases bilaterally likely
resolving wegener's (markedly improved since [**5-/2174**]), patchy
densities of bases b/l remain (also improved since [**5-/2174**]),
distal trachea and r/l mainstem bronchi demonstrate wall
thickening (similar [**3-/2174**]), R middle bronchus narrow. Given 2L
NS. Exam notable for coarse breath sounds, A&Ox3, baseline short
term memory loss and thrush. Blood cultures sent prior to abx
initiation. Chest xray obtained. Access is 20g in L arm. Labs
notable for WBC 29.2, bands 30, plts 507 and lactate 1.7. Most
recent vitals: 98.5 103 114/56 20 94%2L. Admitted to medicine w
concern for treatment failure of pna vs vasculitis flare.
.
On the floor, patient desatted to 86% after returning from a
walk to the bathroom. She quickly recovered and was asymptomatic
for the entire episode.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
- Wegener's granulomatosis: Followed by Dr. [**Last Name (STitle) **]; recent
history detailed in progress note by Dr. [**First Name (STitle) **] [**2174-3-24**], recently
complicated by tracheobronchial disease in particular bilateral
bronchial stenosis status post balloon dilation with
intralesional steroid therapy by [**Month/Day/Year **] pulmonology
- Hypothyroidism
- Osteoporosis
- History of breast cancer: in [**2151**], s/p surgery and chemo
- minimal short term memory
Social History:
Lives with her son [**Name (NI) 122**]. Quit smoking ~50 years ago. Former
social drinker, no alcohol in 2 years.
Family History:
-Brother with [**Name (NI) 98796**] Disease
-Mother passed from sudden cardiac arrest s/p "hand procedure"
at age 75
-Father passed at 89 from "old age" with Parkinson's Disease
-Hypertension in several family members
-[**Name (NI) **] history of cancer, autoimmune diseases
Physical Exam:
ON ADMISSION:
Vitals: 101.0 104 108/50 22 91% tent/hum w/50% O2
General: Alert, oriented (poor short term memory), no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, slight supraclavicular LAD
Lungs: course upper airway breath sounds and on bottom with mild
end exp wheezes and diffuse rhonchi
CV: Regular rate and rhythm, normal S1 + S2, high pitched
holosystolic murmur heard best at the left sternal border
Abdomen: soft, non-distended,non-tender, thin, bowel sounds (+),
no rebound tenderness or guarding, no HSM
Ext: No lower extremity edema
Neuro: motor function and sensation grossly normal
.
ON DISCHARGE:
General: Alert, oriented (poor short term memory), no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: soft crackles at L base; mildly decreased breath sounds
at L base relative to R
CV: Regular rate and rhythm, normal S1 + S2
Abdomen: soft, non-distended,non-tender, thin, bowel sounds (+),
no rebound tenderness or guarding, no HSM
Ext: 2+ pitting edema to mid-shins bilat
Neuro: motor function and sensation grossly normal
Pertinent Results:
LABS ON ADMISSION:
[**2174-8-13**] 03:15PM BLOOD WBC-29.2*# RBC-4.05* Hgb-13.3 Hct-40.7
MCV-101*# MCH-32.9* MCHC-32.7 RDW-14.6 Plt Ct-507*
[**2174-8-13**] 03:15PM BLOOD Neuts-59 Bands-30* Lymphs-3* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-1*
[**2174-8-13**] 03:15PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+
Pencil-OCCASIONAL Tear Dr[**Last Name (STitle) 833**] [**Name (STitle) 16591**]1+
[**2174-8-13**] 03:15PM BLOOD PT-12.6 PTT-22.6 INR(PT)-1.1
[**2174-8-13**] 03:15PM BLOOD Glucose-112* UreaN-22* Creat-0.8 Na-140
K-3.8 Cl-101 HCO3-23 AnGap-20
[**2174-8-14**] 09:15AM BLOOD Calcium-8.1* Phos-2.9 Mg-1.8
.
Discharge Labs:
[**2174-8-26**] 05:32AM BLOOD WBC-6.3 RBC-3.15* Hgb-10.1* Hct-30.7*
MCV-98 MCH-32.3* MCHC-33.1 RDW-14.9 Plt Ct-494*
[**2174-8-26**] 05:32AM BLOOD Glucose-69* UreaN-9 Creat-0.6 Na-144
K-3.5 Cl-101 HCO3-35* AnGap-12
[**2174-8-26**] 05:32AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.7
.
LABS OF INTEREST:
[**2174-8-14**] 09:15AM BLOOD B-GLUCAN-Negative
[**2174-8-14**] 09:15AM BLOOD ASPERGILLUS GALACTOMANNAN
ANTIGEN-Negative
[**2174-8-17**] 09:33AM BLOOD ANCA-NEGATIVE
[**2174-8-18**] 11:00PM BLOOD Type-ART Temp-36.7 PEEP-5 pO2-85 pCO2-55*
pH-7.36 calTCO2-32* Base XS-3 Vent-CONTROLLED
[**2174-8-18**] 10:48PM BLOOD CK-MB-2 cTropnT-<0.01
[**2174-8-19**] 05:56AM BLOOD-ART pO2-91 pCO2-38 pH-7.48* calTCO2-29
Base XS-4
[**2174-8-20**] 04:37AM BLOOD ALT-9 AST-27 LD(LDH)-296* AlkPhos-59
TotBili-0.2
[**2174-8-20**] 12:57PM BLOOD B-GLUCAN-Negative
[**2174-8-20**] 12:57PM BLOOD ASPERGILLUS ANTIBODY-Negative
[**2174-8-23**] 06:03PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM
.
Microbiology:
[**2174-8-13**] 3:15 pm BLOOD CULTURE
**FINAL REPORT [**2174-8-19**]**
Blood Culture, Routine (Final [**2174-8-19**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final [**2174-8-14**]):
GRAM NEGATIVE ROD(S).
Reported to and read back by [**Doctor First Name **] LOCK #[**Numeric Identifier **] [**2174-8-14**]
0805.
.
[**2174-8-15**] 10:28 am SPUTUM Source: Induced.
GRAM STAIN (Final [**2174-8-15**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2174-8-18**]):
SPARSE GROWTH Commensal Respiratory Flora.
YEAST. SPARSE GROWTH.
HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE.
MODERATE GROWTH.
Beta-lactamse negative: presumptively sensitive to
ampicillin.
Confirmation should be requested in cases of treatment
failure in
life-threatening infections..
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
[**2174-8-16**]): NEGATIVE for Pneumocystis jirovecii
(carinii)..
.
[**2174-8-18**] 6:55 pm BRONCHIAL WASHINGS Site: ENDOTRACHEAL
**FINAL REPORT [**2174-8-20**]**
GRAM STAIN (Final [**2174-8-18**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2174-8-20**]): NO GROWTH, <1000
CFU/ml.
.
[**2174-8-21**] 12:11 pm SPUTUM Source: Expectorated.
**FINAL REPORT [**2174-8-23**]**
GRAM STAIN (Final [**2174-8-21**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Final [**2174-8-23**]):
MODERATE GROWTH Commensal Respiratory Flora.
.
STUDIES OF NOTE:
.
CT Torso ([**2174-8-12**]) - IMPRESSION:
1. Small irregular densities throughout the lungs bilaterally,
likely resolving changes from known Wegener's vasculitis. More
pronounced opacities at the lung bases bilaterally, also likely
related to prior episode of vasculitis and these too have
improved since the outside hospital study of [**2174-5-26**].
2. Stable appearance of wall thickening of the distal trachea
and right and left main stem bronchi when compared to the [**Month (only) 958**]
[**Hospital1 18**] chest CT study of [**2174-3-25**]. The right middle lobe
bronchus remains markedly narrowed with resulting right middle
lobe collapse.
3. Multiple small sclerotic foci scattered throughout the entire
visualized skeleton. The lesions throughout the ribs, scapula,
and thoracic spine are stable in appearance since the [**2174-3-25**] chest CT. However, there are no recent CT studies for
comparison of the abdomen and pelvis. These lesions were not
present on the CT torso of [**2173-4-16**].
.
LUE US ([**2174-8-15**]) - IMPRESSION: No evidence of DVT.
.
[**2174-8-17**] CXR: Left lower lobe PNA w/ small loculated L pleural
effusion.
.
[**2174-8-18**] ECHO: The left atrium is mildly [**Month/Day/Year 6878**]. No atrial
septal defect is seen by 2D or color Doppler. 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 diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
masses or vegetations are seen on the aortic valve. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Trivial mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
IMPRESSION: No transthoracic echocardiographic evidence of
valvular vegetation or abscess. Mild pulmonary artery systolic
hypertension. Compared with the prior study (images reviewed) of
[**2174-7-15**], a large left pleural effusion is now seen. The
absence of valvular vegetations on transthoracic echocardiogram
does not preclude the presence of endocarditis. If clinical
suspicion for endocarditis is high, a transesophageal
echocardiogram may be considered.
.
[**2174-8-24**] LEFT UPPER EXTREMITY VENOUS ULTRASOUND: The Grayscale,
color, and pulse Doppler son[**Name (NI) 867**] of the left internal
jugular, axillary, subclavian, brachial, basilic and cephalic
veins were obtained. Normal flow, compressibility, augmentation,
and waveforms are demonstrated and no
intraluminal thrombus is identified. A PICC is in place via the
left basilic vein.
IMPRESSION: No deep venous thrombosis in left upper extremity.
.
CXR ([**2174-8-24**]) - IMPRESSION:
1. Complete resolution of pulmonary edema.
2. Right middle lobe collapse.
3. Left lower lobe pneumonia.
Brief Hospital Course:
This is the brief hospital course for a 74 year-old female with
a past medical history significant for Wegener's granulomatosis
with pulmonary, tracheobronchial, and renal involvement who
presented with worsening fever and productive cough. The
[**Hospital 228**] medical issues dealt with during this hospital stay
are detailed below.
# Wegener's (lung) / pneumonia: The patient was found to have a
left lower lobe pneumonia and a pleural effusion on chest x-ray
[**8-17**], [**2174**]. Prior imaging on admission was negative for this
finding. Clinically, the patient began to develop upper airway
sounds the following day prompting an evaluation by
[**Year (4 digits) **] pulmonary for possible bronchoscopy. In the
meantime, the patient was continued on her admission course of
Prednisone 20 mg daily for treatment of her Wegener's. She was
also on Vancomycin/Zosyn, which was transitioned to
Vancomyin/Meropenem for treatment of E. coli bacteremia which
was likely caused by a pneumonia as urine cultures were negative
for bacteria and sputum cultures were negative for PCP.
[**Name10 (NameIs) 11063**] pulmonology took the patient for rigid
bronchoscopy [**2174-8-18**] with intratracheal decadron injection and
ballooning of the L main stem, with 100-200 cc of bleeding which
resolved. She desated to 80%s when extubated and had to be
reintubated, which was complicated by left lung collapse as well
as transient hypotension (SBP to 70s) after a propofol bolus.
Her SBPs corrected with NEO to 100-130s and she was admitted to
the ICU for monitoring, intubated and on pressors. Her code
status had been DNR on admission and was reversed for the
procedure. On [**2174-8-19**], she had flexible bronchoscopy showing
plaques suggestive of worsening Wegener's and had opening of
left upper lobe and debridement. Pressors were weaned and CXR
showed improvement of L lung. Sputum culture from [**2174-8-18**] grew
Haemophilus influenzae and on [**2174-8-20**], she was switched to
Ampicillin-Sulbactam 3 g IV q6hr. She was extubated on [**2174-8-20**]
and on follow-up CXR had increased left lower lobe opacity,
consistent with for new/worsening PNA vs. blood vs. effusion.
Vancomycin was added because repeat sputum culture grew GPCs in
clusters. Her respiratory status gradually improved, and she was
moved to the floor on [**2174-8-22**]. Vancomycin was stopped on [**2174-8-25**],
as it was felt that the GPCs in her sputum were normal
respiratory flora. She completed a 14 day course of antibiotics
by [**2174-8-26**] and her pulmonary exam gradually cleared with less
rhonchi and better air movement. She had symptomatic improvement
with albuterol nebulizers. On discharge, she was oxygenating
well on 1 L NC and had a non-productive cough. At discharge, she
remained on 20 mg prednisone daily. She will f/u with rheum and
pulmonary as an outpatient. Her flovent was held, given her
recent lung infection. She should discuss whether to restart
this at her pulmonary f/u appointment.
.
# Ecoli bacteremia: As above, a blood culture from [**2174-8-13**] grew
out pan-sensitive E. coli. The patient was changed from IV
Vancomycin and IV Zosyn to IV Vancomycin and IV Meropenem
because on past episodes such as this, the patient grew out
species of E. coli which were resistent to Zosyn. A decision was
made to switch to Meropenem as the patient developed x-ray
changes significant for a new pleural effusion while on the
Zosyn containing regimen. Subsequent blood cultures were
negative. Ultimately, as above, she was transitioned to unasyn
and completed a total 14 day [**Last Name (un) 10128**] of antibiotics.
.
# Hypotension: As above, was hypotensive during rigid
bronchoscopy [**2174-8-18**] after propofol bolus and was briefly
supported with pressors while in the intensive care unit. She
had a brief episode of hypotension on [**2174-8-20**] which responded to
500 cc NS bolus.
.
# Aspiration risk: She had a video swallow on [**2174-8-22**] that showed
aspiration of thin liquids and she was changed to a nectar diet.
Of note, she had had recent speech/swallow evaluation on [**2174-5-30**]
showing silent aspiration of thin liquids.
.
# Hypothyroidism: She has known hypothyroid (TSH 0.7 on [**7-2**])
and was maintained on home levothyroxine while in house.
.
.
TRANSITIONAL ISSUES:
- PICC line in place at time of discharge, as pt still receiving
last few doses of IV unasyn. PICC should be discontinued after
IV antibiotics are complete.
- Flovent on hold at time of discharge, as pt with recent
pulmonary infection. Can likely be restarted at pulm follow-up
appointment.
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs(s)
inhaled twice a day - No Substitution
ALENDRONATE - 70 mg Tablet - 1 Tablet(s) by mouth weekly
ATOVAQUONE [MEPRON] - 750 mg/5 mL Suspension - 10 ml by mouth
daily
CITALOPRAM - 20 mg Tablet - One Tablet(s) by mouth daily
DIAZEPAM - 5 mg Tablet - 1 Tablet by mouth [**Last Name (un) **] 12 hours as
needed
FLUTICASONE [FLOVENT DISKUS] - 250 mcg Disk with Device - 2
puffs
inh twice a day - No Substitution
FUROSEMIDE - 40 mg Tablet - [**1-23**] Tablet(s) by mouth once a day
LEVOFLOXACIN [LEVAQUIN] - 500 mg Tablet - 1 Tablet(s) by mouth
daily
LEVOTHYROXINE [SYNTHROID] - 150 mcg Tablet - 1 Tablet(s) by
mouth
once a day
NYSTATIN - 100,000 unit/mL Suspension - 10 ml by mouth swish and
swallow 3 times a day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth at night
PREDNISONE - (Dose adjustment - no new Rx) - 20 mg Tablet - 1
Tablet(s) by mouth in the morning , half a tablet at night;
[**First Name9 (NamePattern2) 98798**] [**2083-7-16**] mg daily. - No Substitution
SIMVASTATIN - 20 mg Tablet - 1 Tablet by mouth DAILY (Daily)
.
Medications - OTC
B COMPLEX VITAMINS [VITAMIN B COMPLEX] - (Prescribed by Other
Provider) - Dosage uncertain
CALCIUM CARBONATE [TUMS E-X] - (Prescribed by Other Provider) -
Dosage uncertain
CHOLECALCIFEROL (VITAMIN D3) [DELTA D3] - (OTC) - 400 unit
Tablet - 2 Tablet(s) by mouth daily
DEXTROMETHORPHAN HBR [COUGH SUPPRESSANT] - 15 mg/5 mL Syrup -
[**1-23**]
tsp by mouth up to every four hours as needed for cough
OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - (Prescribed by Other
Provider) - Dosage uncertain
VIT C-VIT E-LUTEIN-MINERALS [OCUVITE LUTEIN] - (Prescribed by
Other Provider) - Capsule - 1 (One) Capsule(s) by mouth once a
day
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day (2) **]: One (1) Inhalation Q4H (every 4 hours) as
needed for sob, wheezing.
2. heparin (porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1)
Injection TID (3 times a day).
3. atovaquone 750 mg/5 mL Suspension [**Month/Day (2) **]: Ten (10) mL PO DAILY
(Daily).
4. prednisone 20 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
5. nystatin 100,000 unit/mL Suspension [**Month/Day (2) **]: Ten (10) ML PO TID
(3 times a day) as needed for thrush.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) [**Month/Day (2) **]: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. furosemide 40 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO QAM (once a
day (in the morning)).
8. alendronate 70 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a week.
9. levothyroxine 150 mcg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a
day.
10. citalopram 20 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day.
11. simvastatin 20 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day.
12. ampicillin-sulbactam 3 gram Recon Soln [**Month/Day (2) **]: Three (3) grams
Injection Q6H (every 6 hours): For 1 more day, to complete a 14
day course of antibiotics, ending on [**2174-8-27**].
13. 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.
14. B complex vitamins Oral
15. calcium carbonate Oral
16. cholecalciferol (vitamin D3) 400 unit Tablet [**Date Range **]: Two (2)
Tablet PO once a day.
17. omega-3 fatty acids-vitamin E Oral
18. vit C-vit E-lutein-minerals Capsule [**Date Range **]: One (1) Capsule
PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 14468**] Nursing & Rehabilitation Center - [**Location (un) 1456**]
Discharge Diagnosis:
Primary: Pneumonia
Secondary: Wegeners granulomatosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. [**Known lastname 98795**], it was a pleasure to take care of you during your
hospital stay here. You were admitted for worsening shortness of
breath and cough. You were found to have infections in your
lungs and blood. Because of the infection, and your underlying
lung disease (from Wegeners), you required treatment in the
intensive care unit including intubation. During your admission,
you also underwent bronchoscopy (insertion of a camera into your
lungs to get a better look at your lungs). Your breathing has
improved and the infection has been treated with a two-week
course of antibiotics.
CHANGES IN MEDICATIONS:
- You are being given heparin injections to prevent blood clots
when you are spending a lot of time in bed. When you are moving
around at your rehabilitation facility, this can be stopped.
- You will continue the IV antibiotics that we started
(AMPICILLIN-SULBACTAM) for one more day, to complete a total 14
day course of antibiotics, ending on [**2174-8-27**].
- We STOPPED your flovent while you are recovering from a
pulmonary infection. You should discuss with your lung doctors
when [**Name5 (PTitle) **] should restart this medication.
- We STOPPED your valium. You should discuss with your doctor
when you should restart this medication.
You are being discharged to a rehabilitation facility. You have
follow-up appointments with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] on
[**2174-9-15**], a CT scan on [**2174-9-19**], and flexible bronchoscopy on
[**2174-9-21**] the [**Hospital3 **] (details are below).
Followup Instructions:
Department: MEDICAL SPECIALTIES
When: THURSDAY [**2174-9-15**] at 3:00 PM
With: DR. [**Last 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
Department: RHEUMATOLOGY
When: MONDAY [**2174-9-19**] at 9:30 AM
With: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
*The office is going to call you at the rehab facility if they
get any cancellations for sooner appointments.
Date/Time:[**2174-9-22**] 2:40
Department: PULMONARY FUNCTION LAB
When: THURSDAY [**2174-9-15**] at 2:40 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**] MD, [**MD Number(3) 1883**]
ICD9 Codes: 5180, 5119, 2449 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1458
} | Medical Text: Admission Date: [**2131-11-22**] Discharge Date: [**2131-11-29**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
L. carotid stenosis
Major Surgical or Invasive Procedure:
Left carotid endarterectomy
History of Present Illness:
This is an 85 y/o M with a history of bilateral carotid stenosis
and a history of prior stroke. The patient has a R. hand TIA and
critical L. carotid stenosis.
Past Medical History:
70-80% R carotid stenosis
R MCA stroke '[**10**] w residual slight L sided weakness
excision of neck mass
gout
HTN
Type 2 DM
gastritis
Social History:
lives with wife and son, retired salesman, no current or past
tobacco use, no EtOH
Family History:
no family hx of stroke, CAD, cancer, DM, or other neurologic
disease
Physical Exam:
T=97.6 P=68 BP=167/58 RR=16 100%RA
HEENT: no icterus, MMM
CHEST: CTA B/L
HEART: S1, S2, RRR
ABD: soft, NT, ND, +BS
EXT: no edema
Neuro: baseline dysarthria, diff. enunciating words, strength
R>L
Pertinent Results:
[**2131-11-21**] 08:55AM GLUCOSE-130* UREA N-30* SODIUM-143
POTASSIUM-4.6
[**2131-11-21**] 08:55AM PT-12.6 PTT-31.9 INR(PT)-1.1
[**2131-11-21**] 08:45AM WBC-8.7 RBC-3.88* HGB-11.7* HCT-33.2* MCV-86
MCH-30.2 MCHC-35.2* RDW-14.7
[**2131-11-21**] 08:45AM PLT COUNT-224
[**11-22**] MRI Brain:
1. Late subacute right parafalcine subdural hematoma with
maximal thickness of [**5-9**] mm.
2. No acute infarcts.
3. Moderate small vessel ischemic changes and an old infarct of
the right medulla.
4. 1.3 x 0.9 cm calcified meningioma versus degenerative pseudo
mass posterior to the body of C2. This can be further evaluated
by CT of the cervical spine.
[**11-22**] MRA Brain: Short segment narrowing of the V4 segment of
the left vertebral artery.
Brief Hospital Course:
The patient was admitted to the Vascular surgery A team on
[**2131-11-22**] for a left carotid endarterectomy with a Dacron patch.
There were no surgical complications and the patient was
hemodynamically stable in the PACU. During the post-operative
course in the PACU, the patient develped a 3cm hematoma at the
incision site. There was no blood drainage, gentle pressure was
applied for 10 minutes, and a pressure dressing was applied to
the wound. The patient was transferred to the VICU. During the
evening of POD0, the patient developed worsening dysarthria.
Neurology was consulted and a stat MRI Head with stroke protocol
was ordered. In addition, neurology recommended that the HOB
remain flat and to maintain a goal SBP 120-130 to maximize
cerebral perfusion pressure. MRI and MRA of the brain showed a
R frontal parafalcine stroke (no acute changes). On POD1, the
patient's speech was improved and he remained hemodynamically
stable. The patient's POD1 HCT=25.0. The patient received 2u
PRBCs.
[**Date range (3) 70697**] patient remained in hospital for continued
observation and physical thearphy.Patient was assesed by PT and
will require rehab prior to discharge home.Rehab screening in
progress. family agreeable to plans.
[**2131-11-29**] d/c to rehab. stable
Medications on Admission:
ecotrin 81'
metoprolol 25"
folic acid 1'
plavix 75 (held)
simvastatin 20'
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
5. Ciprofloxacin 500 mg Tablet Sig: 1.5 Tablets PO Q48H (every
48 hours) for 2 weeks.
6. Dipyridamole-Aspirin 200-25 mg Cap, Multiphasic Release 12 HR
Sig: One (1) Cap PO DAILY (Daily).
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
8. Insulin Regular Human 100 unit/mL Solution Sig: as directed
Injection four times a day.
Discharge Disposition:
Extended Care
Facility:
Maples Nursing & Retirement Center - [**Location (un) 6151**]
Discharge Diagnosis:
L. carotid stenosis
history of right middle cerebral artery stroke [**2110**] residual
rt. sided weakness
history of hyperlipdemia
history of presumed pneumonia by cxr on admission-Cipro
Dm2 uncontrolled
chronic anemia-transfused
chronic renal insuffiency 2.0
old subdural hematoma by CT [**11-7**]
perioperative dysarthria,improving
Discharge Condition:
Good
Followup Instructions:
Please call Dr.[**Name (NI) 1392**] office at ([**Telephone/Fax (1) 4852**] to schedule
a follow-up appointment
Completed by:[**2131-11-29**]
ICD9 Codes: 486, 5859, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1459
} | Medical Text: Admission Date: [**2114-5-17**] Discharge Date: [**2114-6-1**]
Date of Birth: [**2045-11-21**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
intracranial hemorrhage
Major Surgical or Invasive Procedure:
[**2114-5-17**]
1. Left-sided frontal craniotomy for resection.
2. Evacuation of hematoma.
3. Partial frontal lobotomy.
[**2114-5-23**]
1. Tracheostomy.
2. Percutaneous endoscopic gastrostomy (PEG).
History of Present Illness:
Ms. [**Known lastname 67988**] is a 68 yo woman with a PMH of a left CEA 3 days
prior to admission, on aspirin 81mg daily who was transferred
from an OSH after being found down by her husband in the
bathroom with urinary and fecal incontinence. She was taken to
an OSH, where she had a witnessed seizure and was intubated.
Noncontrast head CT demonstrated a large left frontal
intracranial hemorrhage. Her INR was less than one and her
platelets were 248. She loaded with dilantin and given Vit K and
4 units of FFP prior to being transferred to [**Hospital1 18**] for further
management.
Per OSH operative note from [**2114-5-15**], patient underwent L CEA
with EEG monitoring, arteriotomy of ulcerated plaque with bovine
pericardial patch for an asymptomatic critical left ICA stenosis
(>80%) in setting of right ICA occlusion. Prior work-up over
past 6 months included initial US showing right occlusion and
left >80%. Then CT angiogram in [**9-23**] with R occlusion and
critical L stenosis with ulcerated web-like plaque at origin of
L ICA.
Past Medical History:
s/p left CEA ([**2114-5-15**])
NIDDM
Parkinson's disease
Social History:
married, living with husband
Family History:
noncontributory
Physical Exam:
Physical Exam on Admission
O: T: AF BP: 157/63 HR: 67 SR 100% on ET
Gen: intubated in c-collar, obese
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: intubated, off sedation she does not follow
commands or open eyes.
Cranial Nerves:
I: Not tested
II: R Pupil is irregular and appears surgical, L is circular
2.5-2mm
III, IV, VI: + corneals, no dolls
V, VII: Face appears symmetric, however ET in place distorts
anatomy
VIII, IX, X, [**Doctor First Name 81**], XII: + gag
Motor: moves the L arm and both legs to nox stim
Sensation: as above, but does not localize
Reflexes: B T Br Pa Ac
Right 2 0 0 0 0
Left 2 0 0 0 0
Toes mute bilaterally
Coordination: NA
Pertinent Results:
Studies:
CT HEAD W/O CONTRAST [**2114-5-17**] 7:33 PM
1. Large area of intraparenchymal hemorrhage in the right
frontal lobe, with intraventricular extension. Extensive left
greater than right frontal subarachnoid hemorrhage.
2. Marked mass effect locally in the left frontal lobe, and
marked rightward subfalcine herniation of greater than 1 cm. No
defninite uncal or transtentorial herniation. Slight enlargement
of the occipital [**Doctor Last Name 534**] of the right lateral ventricle may suggest
early ventricular entrapment.
.
CT C-SPINE W/O CONTRAST [**2114-5-17**] 7:34 PM
1. No fracture or malalignment. Mild multilevel degenerative
change as described above.
.
CT HEAD W/O CONTRAST [**2114-5-18**] 3:17 AM
There has been an interval left frontal craniostomy with almost
complete evacuation of intraparenchymal hemorrhage in the left
frontal lobe. Residual subarachnoid and intraparenchymal blood
is seen, and again a small amount of blood is seen layering in
the right occipital [**Doctor Last Name 534**] of the lateral ventricle. There are
expected postoperative changes with non-tension pneumocephalus.
There is a decreased effacement of the right lateral ventricle.
Apart from the postoperative changes, no other bony
abnormalities are seen, and the mastoid air cells and visualized
portions of the paranasal sinuses are clear.
.
MR HEAD W & W/O CONTRAST [**2114-5-19**] 10:03 PM
Left frontal resection cavity filled with fluid as well as
residual blood seen extending into the corpus callosum.
Extensive subarachnoid hemorrhage and intraventricular blood is
again seen. No underlying enhancing lesions are identified.
.
CT HEAD W/O CONTRAST [**2114-5-19**] 7:57 AM
Since yesterday, there is no significant interval change except
for accumulation of low-density fluid in the left frontal
pneumocephalus. There is no evidence of significant acute
re-hemorrhage. The amount and distribution of acute blood
products in the bifrontal extra-axial space, right frontal
subarachnoid space and layering in the right lateral ventricle
are stable. There is stable mass effect on the left lateral
ventricle and mild rightward subfalcine herniation of
approximately 5 mm. There is no evidence of transtentorial
herniation. Visualized paranasal sinuses and mastoid air cells
remain well aerated.
.
EEG [**2114-5-19**]
Markedly abnormal portable EEG due to the markedly suppressed
background consisting of low voltage fast activity with admixed
theta frequencies. The first finding suggests a marked
encephalopathy suggesting dysfunction of bilateral subcortical
and deep midline structures. Medications, metabolic
disturbances, and infection are among the common causes of
encephalopathy but there are others. The hemispheric asymmetry
with loss of faster frequencies over the left side suggests an
ongoing structural or destructive process affecting the left
hemisphere versus material interposed between the cortex and
skull on that side (e.g. hemorrhage). There were no epileptiform
features and no electrographic seizure activity was noted. The
low voltage fast background likely reflects medication effects
from concomitant propofol administration.
.
CT HEAD W/O CONTRAST [**2114-5-22**] 11:27 AM
No significant change in the bifrontal intraparenchymal,
subdural and subarachnoid hemorrhage with no significant change
in the mild subfalcine herniation to the right. No change in the
small amount of intraventricular hemorrhage in the right lateral
ventricle.
.
BILAT LOWER EXT VEINS [**2114-5-28**] 3:51 PM
No evidence of DVT in both lower extremities.
.
CXR ([**5-27**]): Right subclavian catheter has been removed with no
pneumothorax. Tracheostomy tube remains in standard position.
Lungs are clear, except for focal linear areas of atelectasis in
the left mid and retrocardiac areas.
.
CXR ([**5-31**]): Lungs volumes are low, and the heart size is top
normal. A tracheostomy tube is in standard position. There is no
evidence of effusion, consolidation, or pulmonary edema.
IMPRESSION: No acute cardiopulmonary process.
.
Labs on admission: [**2114-5-17**]
- GLUCOSE-289* UREA N-16 CREAT-1.1 SODIUM-138 POTASSIUM-4.0
CHLORIDE-95* TOTAL CO2-25 ANION GAP-22* GLUCOSE-262*
- WBC-11.9* RBC-3.97* HGB-10.6* HCT-32.6* MCV-82 MCH-26.8*
MCHC-32.6 RDW-15.7* PLT SMR-NORMAL PLT COUNT-279 (NEUTS-89.7*
BANDS-0 LYMPHS-7.9* MONOS-2.2 EOS-0.1 BASOS-0.1 HYPOCHROM-NORMAL
ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-1+
POLYCHROM-NORMAL)
- PT-11.7 PTT-20.9* INR(PT)-1.0
- ABG on vent: PO2-281* PCO2-27* PH-7.58* TOTAL CO2-26 BASE XS-5
- freeCa-0.99*
- Cardiac enzymes: CK(CPK)-234*, CK-MB-5 cTropnT-<0.01
- PHENYTOIN-15.9
- ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG
tricyclic-NEG
- URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG
amphetmn-NEG mthdone-NEG
.
Urine:
COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009 BLOOD-MOD NITRITE-NEG
PROTEIN-30 GLUCOSE-1000 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG
PH-6.5 LEUK-NEG
RBC-[**6-26**]* WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2
.
Pertinent results:
HCT: range 20.9 - 32.6; on discharge - 29.2
WBC: [**5-29**] - 13.5 --> [**6-1**] - 10.3
Sodium max: 152 ([**5-29**])
.
Microbiology:
Blood cultures: ALL NO GROWTH TO DATE
.
MRSA screen: POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS
.
- Urine cx: [**5-26**] - Yeast, gram positive bacteria; [**5-28**] - Yeast
*** Stool [**5-31**] - C.dif POSITIVE
- Sputum: [**5-22**] - heavy growth gram neg. rods - two morphologies
*** [**5-26**] & [**5-28**] - coag positive staph aureus, sensitivities -->
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S
Brief Hospital Course:
# Intracranial hemorrhage:
Ms. [**Known lastname 67988**] was transferred to the [**Hospital1 18**] from and OSH. Repeat
head CT here demonstrated significant left intraparenchymal
hemorrhage, L > R frontal subarachnoid hemorrhage, and marked
mass effect with rightward subfalcine herniation. She was
evaluated by the neurology and neurosurgery teams, and the
decision was made to take the patient to operating room for
emergent craniotomy for evacuation of her left intracranial
hemorrhage. Postoperative CT demonstrated normal postoperative
changes without any new intracranial hemorrhage. Postoperatively
the patient was transferred to the trauma SICU and was
maintained on dilantin for seizure prophylaxis and
dexamethasone. Tube feeds were started for nutritional support.
The stroke service was consulted and followed the patient
postoperatively. The patient was slowly weaned off of
dexamethasone. On [**2114-5-23**] the patient went to the operating room
for PEG and tracheostomy with the general surgery service. The
patient was transitioned from dilantin (last dose 5/9) to
Keppra. She should follow-up in Dr.[**Name (NI) 9034**] office for
follow-up CT scan and evaluation in 8 weeks. Throughout her
hospitalization, she remained comatose without significant
change, responding to pain on the left side and with occasional
spontaneous eye blinks and lip smacking, but no gross motor
movements or wakefulness.
.
# Fever:
The patient was intubated upon admission to the outside
hospital. She began developing fevers on [**5-19**] without a clear
source. She started to develop a leukocytosis with WBC up to 13
on [**5-29**]. As she had increased sputum production that she cleared
from her trach, a sputum cx was sent. Initial sputum cx was
polymicrobial, but subsequent sputum cx on [**5-26**] and [**5-28**] both
grew coag. positive staph aureus that was resistent to
oxalacillin. On [**5-28**] she was started on Vancomycin for presumed
ventilator associated pneumonia, with plan for a 10 day course.
Chest X-ray, however, remained clear, without evidence of
infiltrate. With this treatment, her WBC count returned to
[**Location 213**]. Despite this, she continued to have low grade fevers
intermittently. It was felt that a likely etiology for this was
due to her large intracranial hemorrhage.
.
# C. diff colitis:
The patient had a few loose stools, and stool cultures sent. An
initial stool culture was negative for C.diff, however on [**5-31**] a
subsequent specimen returned positive for C.diff. On [**5-31**] she
was started on metronidazole with plan of a 10 day course.
.
# Hypertension:
The patient intermittently had systolic BPs ranging up to 170s,
with one [**Location (un) 1131**] over 200. This was controlled by increasing her
captopril dose as needed to 37.5mg tid and metoprolol 50mg po
tid. With this, her SBP ranged in the 140s-150s. She will
benefit from continued close blood pressure monitoring and
uptitration of these medications.
.
# Diabetes mellitus Type II:
The patient experienced elevated blood glucoses in the 300s
intially. The [**Last Name (un) **] diabetes team was asked to see the patient
and gradually uptitrated her medications, including q8hr NPH
with a sliding scale of Regular insulin.
.
# Hypernatremia:
The patient's sodium level was found to trend up, with a maximum
of 152 on [**5-29**], which was felt to be due to volume depletion.
She was started on free water flushes through her PEG tube with
good improvement in her plasma sodium. She should continue on
these to maintain a normal sodium level.
.
# Parkinson's disease:
Her Parkinson's medications were held upon admission
.
# Nutrition:
The nutrition team followed the patient and continued to make
recommendations. She was started on tubefeeds, which she
tolerated well.
.
# Prophylaxis: Famotidine and heparin SC
.
# Code: FULL. Confirmed with her husband
Medications on Admission:
-Lasix 40 mg QD
-Atenolol 100mg PO QD
-Premarin 0.125mg PO QD
-aspirin 81mg PO QD
-Glyburide
-Actos
-Metformin
-Sinemet
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day) as needed for constipation.
4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-17**]
Drops Ophthalmic PRN (as needed).
5. Ferrous Sulfate 300 mg/5 mL Liquid Sig: Five (5) mL PO DAILY
(Daily).
6. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
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. Levetiracetam 100 mg/mL Solution Sig: 1000 (1000) mg PO Q AM
().
10. Levetiracetam 100 mg/mL Solution Sig: Five Hundred (500) mg
PO Q PM ().
11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours): hold for sbp<100, hr<60.
12. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Thirty
Five (35) units Subcutaneous every eight (8) hours.
14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days: last dose 5/25.
15. Captopril 12.5 mg Tablet Sig: Three (3) Tablet PO Q 8H
(Every 8 Hours): hold for sbp<100.
16. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
17. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q 12H (Every 12 Hours) for 10 days: last dose
[**6-10**].
Disp:*10 day supply* Refills:*0*
18. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1)
injection Subcutaneous four times a day: per insulin sliding
scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Primary:
Left frontal intracranial hemorrhage
Left greater than right frontal subarachnoid hemorrhage
Secondary:
Possible ventilator associated pneumonia.
C. dif colitis
Hypertension
Hypernatremia
Diabetes mellitus type II
Parkinson's disease
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital after suffering from a large
stroke to the left side of your brain. You had a lot of bleeding
in this region causing swelling inside your head, requiring
brain surgery. You then needed a breathing tube in your neck
(called a tracheostomy) and a PEG tube so that you could receive
tubefeeds to maintain your nutrition.
.
You will be going to an acute rehabilitation facility upon
discharge for further managment of your medical condition.
Followup Instructions:
Please arrange follow-up with Dr. [**Last Name (STitle) **] (neurosurgery) - call
[**Telephone/Fax (1) 1669**] to arrange CT Head and appointment.
.
Please arrange follow-up with patient's PCP as appropriate.
ICD9 Codes: 486, 2760, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1460
} | Medical Text: Admission Date: [**2108-5-10**] Discharge Date: [**2108-5-28**]
Date of Birth: [**2056-3-15**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Fatigue and hyponatremia
Major Surgical or Invasive Procedure:
Diagnostic and therapeutic paracentesis ([**2108-5-11**])
PICC ([**2108-5-17**])
EGD with feeding tube placement ([**2108-5-18**])
History of Present Illness:
Mr. [**Known firstname **] [**Last Name (NamePattern1) 7183**] is a 52 year-old gentleman with MVP and MR,
EtOH cirrhosis MELD of 18, CPS of 12 (C) not on the transplant
list (not sober for >3 months), HFE mutation (heterocygus) who
comes with fatigue and hyponatreima. He was in his prior state
of health until [**Month (only) 404**] of this year when he started noticing
URI symptoms. He went fo see a new primary care physician, [**Last Name (NamePattern4) **].
[**Last Name (STitle) 17528**] (Atrius) after nos seeing a doctor since [**2093**]. He
was diagnosed with influenzae, but was also found to have
abnormal LFTs (AST 124, ALT 99, AP 115, TB 2.5, creat 0.63). He
had edema and ascities. It was thought that he had alcohol
hepatitis given that he had history of drinking >10 beers daily
for ~30 years. He was started on furosemide 20 mg daily and
spironolactone 50 md daily. He lost 12 pounds and his abdomen
and legs significantly improved.
.
He had extensive work up including: Abdominal US in early [**Month (only) **]
of this year demonstrated nodular liver, splenomegaly, ascities
and forward flow in portal vein. He was refered to a Dr. [**First Name11 (Name Pattern1) **]
[**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 10113**] (GI) who thought he had Grade I encephalopathy given
his daytime sleepiness and difficulty falling asleep at night.
He reveiewed the labs and recommended starting lactulose. His
labs were significant for: WBC 9.6 with slight increase in PMNs,
but no blasts. PLTs 80, HCT 38, Creatinine of 0.6 on [**2108-4-16**].
AST 102, ALT 81, AP 124, TB 5.2, Direct bili of 1.8, albumin of
2.6, on [**2108-5-8**]. , AFP of 3.64, [**Doctor First Name **] positive (unkown titer),
[**Last Name (un) 15412**] weakly positive, AMA negative, iron 45, TIBC 186, ferritin
860, PT 1.9, ceruloplasmin 49, A1-antitrypsin 283, HAVAb
negative, HBVSAb positive, HCVab negative. Guaiac negative.
.
During the last days his fatigue has been worse. He is requiring
to take naps during the day. He also developped a [**Hospital1 **]-temporal
headache without any other neurologic symptoms and went to see
his PCP. [**Name10 (NameIs) **] had been feeling very dry and was very thirsty. He
had increased his fluid intake having close to 4 L of free water
per day. He had lab work that showed a sodium of 124 5 days ago.
He was immediately called and told to stop his diuretics and
have high-salt diet. His apetite was very poor and therefore he
did not eat much. His renal function was stable and his LFTs
were pretty much unchanged from 1 week prior. His symptoms did
not improve and therefore he was sent here for further work up.
.
Of note, he reports feeling cold, but not chills, rigors. He has
no cough, dysuria, but has been very constipated and has not
moved his bowels in [**4-14**] days, despite the lactulose. He has also
noted a lot of difficulty concentrating at work, needing >15 min
for some calculations that take him [**2-12**] at baseline. He reports
day-night cycle pattern inversion.
.
In our ED his initial VS were: 99.4 116 139/76 20 99%. He was
found to be cachectic, no asterexis. There was no neuro exam
done (other than asterexis), no documentation of his
concentration or formal delirium assesment. His labs were
significant for: WBC 7.7, HCT 31.8, PLT 75, ALT 92, AST 121, AP
108, TB 4.2, Alb 2.6, Lip 146, negative serum tox, PT: 18.9 PTT:
47.2 INR: 1.7, Lactate 1.5, Na 118, K 4.2, Cl 90, CO2 20, BUN
14, Cr 0.9, glu 111. He had no imaging done such as chest x-ray,
no UA or UC and no diagnostic tap. VS prior to transfere: 99,9
86 108/58 16 99%ra. He is admitted for hyponatremia. The liver
fellow was paged and recommended fluid restriction and 500cc of
5% albumin.
Past Medical History:
PAST MEDICAL HISTORY:
* Cirrhosis: with ascities, thought [**3-14**] EtOH, no prior episodes
of encephalopahty, never hospitalized. HFE positive
(heterozygous) with ferritin of ~800, Hep serologies negative,
normal cerulopasmin, A-antitrypsin, etc. AMA weakly positive.
Never scoped, no prior episodes of SBP.
* Mitral valve regurgitation
* MVP
* Venous insufficiency with varicose veins
* HFE mutation (H3D1 copy mutated; C282Y, S65C normal)
* Splenomegaly (portal HTN)
* Thrombocytopenia (most likely [**3-14**] cirrhosis)
* Abnormal LFTs ([**3-14**] cirrhosis)
Social History:
He works for the [**Location (un) 86**] police officer performing accident
investigation. He is married with 3 children. He quit smoking in
[**2091**]. He quit drinking in [**Month (only) 404**] and has history of heavy
drinking, having 10 beers/day for many years and even more at
parties. He denies any illicit drug use.
Family History:
Son had Hodgkin's lymphoma. Father had MI in his 70s. No family
history of premature CAD, stroke, SCD.
Physical Exam:
GENERAL - well-appearing man in NAD, comfortable, appropriate,
jaundiced (skin, mouth, conjuntiva)
HEENT - NC/AT, PERRLA, EOMI, sclerae mildly icteric, MMM, OP
clear, mildly enlarge parotid glands
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
CHEST - no gynecomastia
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses, mild splenomegaly, no
rebound/guarding, spiders present, patient has positive fluid
wave, but not tense abdomen
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), no asterexis
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3 (including hosp, floor, exact date,
season), CNs II-XII grossly intact, muscle strength 5/5
throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait; good
concentration, could do months backwards, could not do serial
sevens.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2108-5-10**] 07:05PM BLOOD WBC-7.7 RBC-3.03* Hgb-11.9* Hct-31.8*
MCV-105* MCH-39.1* MCHC-37.2* RDW-16.5* Plt Ct-75*
[**2108-5-28**] 06:00AM BLOOD WBC-4.3 RBC-2.62* Hgb-9.9* Hct-27.8*
MCV-106* MCH-37.8* MCHC-35.6* RDW-20.4* Plt Ct-70*
[**2108-5-10**] 07:05PM BLOOD Neuts-84.2* Lymphs-7.7* Monos-7.3 Eos-0.4
Baso-0.4
[**2108-5-19**] 06:44AM BLOOD Neuts-71.9* Lymphs-18.8 Monos-6.1 Eos-2.7
Baso-0.4
[**2108-5-10**] 09:56PM BLOOD PT-18.9* PTT-47.2* INR(PT)-1.7*
[**2108-5-28**] 06:00AM BLOOD PT-18.0* PTT-49.7* INR(PT)-1.6*
[**2108-5-19**] 06:44AM BLOOD ESR-30*
[**2108-5-24**] 05:46AM BLOOD ESR-43*
[**2108-5-10**] 07:05PM BLOOD Glucose-111* UreaN-14 Creat-0.9 Na-118*
K-4.2 Cl-90* HCO3-20* AnGap-12
[**2108-5-28**] 06:00AM BLOOD Glucose-104* UreaN-22* Creat-0.8 Na-132*
K-3.9 Cl-102 HCO3-22 AnGap-12
[**2108-5-10**] 07:05PM BLOOD ALT-92* AST-121* AlkPhos-108 TotBili-4.2*
[**2108-5-28**] 06:00AM BLOOD ALT-41* AST-60* LD(LDH)-347* AlkPhos-81
TotBili-1.6*
[**2108-5-14**] 05:15AM BLOOD CK-MB-2 cTropnT-<0.01
[**2108-5-14**] 05:15PM BLOOD CK-MB-17* MB Indx-12.0* cTropnT-0.12*
[**2108-5-14**] 11:15PM BLOOD CK-MB-18* cTropnT-0.27*
[**2108-5-15**] 04:13AM BLOOD CK-MB-14* MB Indx-11.0* cTropnT-0.29*
[**2108-5-11**] 04:40AM BLOOD VitB12-1743* Folate-10.1
[**2108-5-19**] 06:44AM BLOOD %HbA1c-5.3 eAG-105
[**2108-5-11**] 04:40AM BLOOD Osmolal-262*
[**2108-5-11**] 04:40AM BLOOD TSH-1.3
[**2108-5-10**] 07:14PM BLOOD Lactate-1.5
Brief Hospital Course:
Mr. [**Known lastname 7173**] was a 52 year-old male with MVP and MR, EtOH
cirrhosis (admit MELD of 18) not on the transplant list (not
sober for >3 months) who presents with fatigue and hyponatremia
found to have spontaneous bacterial peritonitis and native valve
endocarditis with high-grade S. viridans bacteremia. Hospital
course complicated by embolic phenomena from endocarditis with
asymptomatic inferior STEMI from vegetation in RCA terrority,
kidney/splenic infarcts in addition to non-convulsive seizures
from encephalopathy, melena from portal gastropathy.
#. Cirrhosis with Grade I encephalopathy and spontaneous
bacterial peritonitis:
Patient has alcoholic cirrhosis with MELD of 18 and Child-[**Doctor Last Name 14477**]
score of 12 (Class C). He had not seen a doctor since [**2093**] and
reported to a PCP in [**Name9 (PRE) 404**] for influenza and found to have
incidentally elevated liver function tests. He has been sober
since [**Month (only) 404**] and seems to have good social support although it
is uncertain if he had drank in the past few months given his
AST/ALT ratio. Outpatient GI work-up has included heterozygous
for HFE (H3D1) with ferritin of 830. He has a borderline [**Doctor First Name **] and
negative antibodies otherwise. AFP is normal. US not suggestive
of PVT. On admission, his transaminases appeared at baseline;
however, he total biliruin and INR were elevated. He also
displayed grade I encephalopathy with inversion of day-night
cycle and difficulty concentrating as well as fatigue. He was
placed on lactulose and rifaximin with clearing of
encephalopathy. Etiology of decompensated liver disease is
infection as below. EGD was performed for feeding tube placement
showing 3 cords of grade II varices. Diagnostic and therapuetic
paracentesis was performed revealing neutrocytic ascites from
portal hypertension (WBC 825, PMNs 313, SAAG > 1.1, low protein)
with a 5-day course of SBP received in addition to albumin on
day # 1 and # 3. He will need to start SBP prophylaxis
(ciprofloxacin 250 mg PO qD) after finishing his below
antibiotic course. He was discharged on spironolactone 50 mg PO
qD, nadolol, lactulose, and rifaximin.
.
# Native valve endocarditis with high-grade S. viridans
bacteremia:
Patient met Duke criteria based on ECHO, sustained bacteremia,
predisposition with MVP, fever, and embolic phenomena with
STEMI, conjunctival hemorrhages, and splenic and renal infarcts.
He was initially started on ceftriaxone for SBP, flagyl, and
vancomycin given high-grade gram positive bacteremia. He
completed a 5-day course of ceftriaxone for SBP. He antibiotics
were narrowed to ceftriaxone ([**2108-5-11**] - [**2108-5-23**]) with
vancomycin and cefepime briefly re-started ([**2108-5-23**] - [**2108-5-25**])
in setting of fever from embolic phenomena. Etiology of
recurrent fever likely embolism and infarction. No evidence of
nosocomial or other concurrent infections such as PICC line
infection. Initial ECHO on [**2108-5-14**] suggestive of likely mitral
valve vegetation/endocarditis. Repeat ECHO in setting of fever
on [**2108-5-24**] showed similar findings and was read perhaps
myxomatous mitral valve leafts with bileafet prolapse, which has
become partially flail. TEE was not pursued given risk with
varices. Initial ESR/CRP was 30 and 10.4 on [**2108-5-19**] with repeat
on [**5-24**] 43 and 12.7, respectively. Patient had multiple embolic
phenomena including inferior STEMI and renal/spleen infarcts
from emboli. Cardiac surgery evaluated, but given advanced liver
disease, the risk of operation were too high to be considered a
surgical candidate for AVR.
The plan will be to continue ceftriaxone for 4 week course with
ID follow-up before end date intended to be [**2108-6-9**] for 4 week
total course. ESR/CRP in addition to safety labs will be drawn
and if continued to be elevated, the course will need to be
extended to 6 weeks or longer. He will also follow-up with
atrius cardiology in [**5-16**] weeks with repeat ECHO. Of note, serial
ECG were obtained with non-specific changes and PR interval
remained within normal limits with very mild intraventricular
conduction delay.
Of note, if he is re-admitted with fevers, his PICC line should
be discontinued. He should be re-started on cefepime and
vancomycin with imaging to look for abscess given embolic
phenomena. Medications such as meropenem and flagyl should be
avoided given prior seizures. If he would continue to spike,
cefepime should be broadened to zosyn or tigecycline.
# Melena secondary to portal gastropathy:
Patient has had dark stool likely from portal gastropathy in
setting of feeding tube placement resulting in transient
transfusion-depedent anemia. Stools returned to [**Location 213**] color
after initiation of 5-day course of octreotide ([**5-21**] - [**5-25**])
with Hct stable at discharge.
He was continued on vitamin K 5 mg PO daily for coagulopathy and
pantoprazole 40 mg PO q 12.
# Inferior STEMI:
Patient had ECG on [**2108-5-14**] suggesting inferior STEMI likely
from embolic phenomenon with repeat ECG showing resolved
changes. Patient was asymptomatic during event, which likely was
very transient with no subsequent wall motion abnormalities
noted on repeat ECHO. Troponin peaked at 0.29 and CK-MB at 18,
which trended down. Atrius cardiology was consulted, and the
patient was deemed to not be a candidate for anti-coagulation
secondary to coagulopathy of liver disease and thrombocytopenia.
He was initially placed on metoprolol and transitioned to a
non-selective beta blocker (nadolol) after varices were noted on
EGD. His Hgb was kept above 10. As above, serial ECG remained
similar to prior.
He will follow-up with cardiology as above.
# Non-convulsive seizure
Code stroke called on [**2108-5-15**] after patient averbal, clenching
teeth, and had left facial twitching and altered mental status.
CT head with no acute intracranial pathology. Neurology
impression was non-convulsive seizure in setting of
encephalopathy. There was no evidence to suggest alcohol
withdrawal. He was placed on a brief course of keppra with
lactulose dosing enforced. He subsequently had no seizures after
keppra was tapered off.
# Nutrition
Physical exam notable for sarcopenia and wasting. A feeding tube
was placed and the patient was trasiently receiving feeding
formula in addition to oral feeds. On the day of discharge, he
was eating well and no longer required tube feeds. He was
strongly advised to continue to consume a 2800 calorie diet.
.
# Transitions of care
- Safety and inflammatory marker labs will be faxed to Dr. [**First Name (STitle) 1075**]
([**Hospital1 18**] Infectious Diseases) at [**Telephone/Fax (1) 2258**]. If inflammatory
markers continue to elevate, antibiotic course should be
extended to 6 weeks
- continue ceftriaxone until [**2108-6-9**] with ID follow-up before
course ends
- Follow-up with cardiology with repeat ECHO
- Patient needs prophylaxis with ampicillin 2 grams by mouth
30-60 minutes before dental procedures. Before any
interventions, the need for antibiotic prophylaxis must be
reviewed.
- Patient needs nutrition follow-up
- Patient may benefit from Alcoholic Anonymous referral to
maintain abstinence
-outpatient vaccination for Hepatitis A and B
- consideration for transplant evaluation if maintains alcohol
abstinence
Medications on Admission:
Lasix 20 mg Daily (stopped 5 days ago)
Spironolactone 50 mg Daily (stopped 5 days ago)
Lactulose titrate to [**3-15**] bowel movements per day
Discharge Medications:
1. Outpatient Lab Work
[**2108-5-31**]: Chem 10, Liver function tests (AST, ALT, Tbili, LDH,
ALP), CBC with differential, ESR/CRP
[**2108-6-5**]: Chem 10, Liver function tests (AST, ALT, Tbili, LDH,
ALP), CBC with differential, ESR/CRP
Fax results to Dr. [**First Name (STitle) 1075**] ([**Hospital1 18**] Infectious Disease) [**Telephone/Fax (1) 1419**]
2. ampicillin 500 mg Capsule Sig: Four (4) Capsule PO before
dental procedures: Take 30-60 min before procedure for any
dental procedure in future.
Disp:*4 Capsule(s)* Refills:*2*
3. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a
day: Start this antibiotic on the morning following completion
of your ceftriaxone course.
Disp:*30 Tablet(s)* Refills:*2*
4. Carnation Instant Breakfast
Four times daily
5. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day).
Disp:*3600 ML(s)* Refills:*2*
6. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. 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*
10. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. ceftriaxone 2 gram Recon Soln Sig: One (1) Intravenous once
a day for 11 days: Date of completion [**2108-6-8**] unless otherwise
directed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] [**Telephone/Fax (1) 11486**] (has appointment
[**2108-6-8**]).
Disp:*11 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Health Services
Discharge Diagnosis:
Primary diagnosis: spontaneous bacterial peritonitis, native
valve endocarditis with embolic phenomena, Streptococcus
viridans bacteremia, ST-elevation myocardial infarction,
non-convulsive seizure, melena secondary to portal gastropathy,
alcoholic cirrhosis, esophageal varices
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for fatigue and low sodium in your blood. You
were found to have an infection in your belly (spontaneous
bacterial peritonitis) in addition to an infection of your heart
valve called endocarditis. You will be treated with an
antibiotic to clear your infection. It is important to follow-up
with Dr. [**First Name (STitle) 1075**] before your antibiotic course ends to determine if
you need a longer course of antibiotics.
You also had a small heart attack from your heart infection and
will need to follow-up with a cardiologist as below. You were
also noted to have dark stools, which is from bleeding in your
stomach. If you notice additional episodes of dark stools,
fevers, or other symptoms concerning to you, please call your
primary care doctor immediately or report to the nearest
emergency room.
You must STOP drinking alcohol completely. Drinking any more
alcohol will result in further damage to your liver and increase
your chance of death and other medical problems. [**Name (NI) **] line is
that you ABSOLUTELY CANNOT DRINK ALCOHOL ANYMORE.
Nutrition is very important to survival. Liver disease and
infection make your body need much more calories than the normal
person. It is important maintain a calorie count at home - your
goal is around 2800 calories per day, which can be achieved by
eating regular food along with supplements such as at least four
Carnation Instant Breakfast supplements a day. If you are not
able to maintain your nutrition, please call the liver center
for further evaluation.
The following changes have been made to your home medications:
1. START TAKING ceftriaxone 2 g IV daily
2. START TAKING lactulose 30 mg by mouth four times daily for a
clear mind. You may adjust the dose so that you are having [**4-13**]
bowel movements daily. You need to take AT LEAST one to two
doses of lactulose a day. Although having diarrhea is
unpleasant, the lactulose will prevent confusion from toxins in
your body that your liver is not clearing.
3. START TAKING nadolol 20 mg by mouth daily. This medication is
to minimize the risk of bleeding from enlarged veins in your
esophagus.
4. START TAKING pantoprazole 40 mg by mouth twice daily. This
medication is to prevent further bleeding from inflammation in
your stomach caused by your liver disease.
5. START TAKING rifaximin 550 mg by mouth twice daily. This
medication is also to prevent confusion.
6. START TAKING folic acid 1 mg by mouth daily. This is a
nutritional supplement.
7. START TAKING thiamine 100 mg by mouth daily. This is a
nutritional supplement.
8. WHEN CEFTRIAXONE COURSE IS COMPLETE, START TAKING
ciprfloxacin 250 mg by mouth daily. This medication will prevent
another infection in your belly.
9. TAKE AS NEEDED ampicillin 30-60 minutes before any dental
procedure. *** Please talk to your primary care doctor before
any dental or other surgical procedures. You will need to take
ampicillin 2 grams by mouth 30-60 minute before any dental
procedure. You will likely need antibiotics before any other
procedures as well. If you do not take antibiotics as prescribed
for your heart valve condition, your valve may become infected
again resulting in severe morbidity and death.***
10. STOP TAKING furosemide unless/until directed to resume by
your physician.
Please take your medications as prescribed. Please follow up
with your physicians as recommended below.
Followup Instructions:
1. PRIMARY CARE
Name: [**Last Name (LF) 17528**],[**First Name3 (LF) 17529**]
Location: [**Location (un) 2274**]-[**University/College **]
Address: [**Hospital1 3470**], [**University/College **],[**Numeric Identifier 23943**]
Phone: [**Telephone/Fax (1) 17530**]
Fax: [**Telephone/Fax (1) 6808**]
- Please call to schedule an appointment with your primary care
doctor to discuss this admission. You should review your
medications with your doctor and plan for any necessary
referrals to cardiology, infectious disease, and hepatology
(liver clinic) as below.
2. INFECTIOUS DISEASE
Department: INFECTIOUS DISEASE
When: FRIDAY [**2108-6-8**] at 10:30 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST
Best Parking: [**Hospital Ward Name **] Garage
3. CARDIOLOGY
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], [**First Name3 (LF) **]
Phone: [**Telephone/Fax (1) 2258**]
- Please set up an appointment for 4-6 weeks. You will require a
follow up echocardiogram at this visit.
4. LIVER
Description: Liver Center
Department: Medicine
Location: W/LMOB-8E
Organization: [**Hospital1 18**]
Phone: ([**Telephone/Fax (1) 1582**]
- Please call to schedule follow up with a hepatologist for [**3-15**]
weeks or as available. You may ask to see Dr. [**Last Name (STitle) 497**] who saw you
in the hospital; if he has no availability Dr. [**Last Name (STitle) **], Dr. [**First Name (STitle) 679**]
or Dr. [**Last Name (STitle) **] would also be appropriate.
ICD9 Codes: 7907, 2761, 4271, 2762, 4240 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1461
} | Medical Text: Admission Date: [**2166-1-2**] Discharge Date: [**2166-1-19**]
Date of Birth: [**2088-12-7**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
ICD placement, dyspnea
Major Surgical or Invasive Procedure:
ICD implantation
History of Present Illness:
This is a 77 year old gentleman with a history of known coronary
artery disease, s/p stent to the left circumflex in [**2144**] and
CABG in [**2160**] with a LIMA to the LAD, SVG to diagonal, sequential
SVG to the ramus/OM, SVG to the PDA. He also has a history of
hypertension, hyperlipidemia, diabetes, systolic and diastolic
CHF (EF 35-40%) and atrial fibrillation on coumadin, and
presented for placement of ICD for primary prevention of sudden
cardiac death. Patient noted several weeks of worsening dyspnea
on exertion, in that previously he was able to walk around the
mall without getting symptomatic, but lately cannot ascend a
flight of stairs without having to stop to catch his breath. He
also had not been sleeping well and is occasionally waking with
dyspnea. He admitted to two-pillow orthopnea, which is not new.
There had also been worsening lower extremity edema over the
last few weeks. He had gone a week or two without taking many
of his medications, including Plavix, Lasix, and metoprolol, due
to him not sending away for his supply of pills.
.
Patient went for ICD placement on the day of admission, and
patient appeared fluid overloaded on presentation. He received
80 mg IV Lasix x 1 after ICD placement, and was transferred to
the floor. He was on 3 liters of O2 upon presenting to the
cardiology floor.
.
On review of systems, he denied any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, black stools or
red stools. He denied recent fevers, chills or rigors. He
denied exertional buttock or calf pain. All of the other review
of systems are negative.
.
Cardiac review of systems was notable for absence of chest pain,
palpitations, syncope or presyncope.
.
At the time of arrival to the floor, patient complained of
dyspnea mostly when he dozes off and falls asleep. He reported
no chest pain, palpitations, or syncope.
.
Past Medical History:
Cardiac Risk Factors: +Diabetes +Dyslipidemia +Hypertension
.
Cardiac History: CAD s/p PTCA to LCx and CABG in [**2161-10-8**] -
CABGx5 (LIMA->LAD, Vein->Diagonal, Vein->Ramus sequentialed to
Obtuse marginal, Vein->Posterior descending artery)
.
Other Past History:
Hypertension
Hyperlipidemia
Aortic stenosis
Diabetes mellitus type 2
Hx of pleural effusions, s/p left thoracentesis
Chronic renal insufficiency
Atrial fibrillation s/p treatment with Amiodarone and
cardioversion in [**2164**]
Colon Cancer s/p resection in [**2157**]
Probable GERD
Tonsillectomy
Social History:
He is a widower with six adult children. He lives with his
daughter and grandson. [**Name (NI) **] is retired. Prior to retiring he
worked as a design draftsman. He quit smoking over 20 years
ago, reports social alcohol use and denies illicit drug use.
Family History:
Father reportedly died of a myocardial infarction at the age of
39.
Physical Exam:
On admission:
VS: T= 96.9 BP= 137/100 HR= 104 RR= 18 O2 sat= 97%3L O2 BS=
191
GENERAL: WDWN obese male in NAD. Oriented x 3. Mood, affect
appropriate. Pleasant and cooperative
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva are
pink, MM slightly dry, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK: Supple with JVP of 6 cm above the clavicle.
CARDIAC: Tachycardic, regular rhythm, normal S1, S2. No m/r/g
audible. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, moderate kyphosis.
Respirations are unlabored, no accessory muscle use. CTAB,
bibasilar rales, no wheezes or rhonchi audible.
ABDOMEN: Soft NT, obese and distended, + shifting dullness.
Mild pitting edema present. No HSM.
EXTREMITIES: 3+ pitting edema up to above the knee, warm and
well-perfused.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
On discharge:
VS: Tm/Tc 98.7/97.8 BP 119/72 (111-139/67-86) P 88 (82-94) R
18 Sat 96%RA BS 166-196
I/O: 1715/1800
Wt: 87.9-->79.8 kg
GENERAL: WDWN obese male in NAD. Oriented x 3. Mood, affect
appropriate. Pleasant and cooperative.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva are
pink, MM slightly dry, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP elevated to 4 cm above clavicle.
CARDIAC: Irregularly irregular, normal S1, S2. II/VI SEM
indicative of TR, III/VI blowing holosystolic murmur at apex
indicative of MR.
CHEST: no swelling of ICD placement site, no erythema, no pain
to palpation around site.
LUNGS: No chest wall deformities, moderate kyphosis.
Respirations are unlabored, no accessory muscle use. CTAB, no
rales present, no wheezes or rhonchi audible.
ABDOMEN: Soft NT, obese, less distended than previous. No HSM.
EXTREMITIES: WWP, no c/c/e present.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS
--------------
[**2166-1-2**] 07:15AM BLOOD WBC-8.9 RBC-4.97 Hgb-11.6* Hct-37.8*
MCV-76* MCH-23.3* MCHC-30.7* RDW-20.3* Plt Ct-373
[**2166-1-2**] 07:15AM BLOOD Neuts-84.1* Lymphs-8.3* Monos-5.1 Eos-1.3
Baso-1.1
[**2166-1-2**] 07:15AM BLOOD PT-21.3* INR(PT)-2.0*
[**2166-1-2**] 07:15AM BLOOD Glucose-164* UreaN-34* Creat-2.0* Na-143
K-4.4 Cl-103 HCO3-27 AnGap-17
[**2166-1-3**] 07:10AM BLOOD Calcium-8.8 Phos-4.4 Mg-2.4
DISCHARGE LABS
--------------
[**2166-1-19**] 07:31AM BLOOD WBC-8.4 RBC-3.47* Hgb-8.8* Hct-26.7*
MCV-77* MCH-25.4* MCHC-32.9 RDW-19.7* Plt Ct-237
[**2166-1-19**] 07:31AM BLOOD PT-18.2* PTT-78.9* INR(PT)-1.6*
[**2166-1-19**] 07:31AM BLOOD Glucose-132* UreaN-72* Creat-3.2* Na-140
K-4.6 Cl-103 HCO3-27 AnGap-15
[**2166-1-19**] 07:31AM BLOOD Calcium-9.5 Phos-4.0 Mg-2.1
MICROBIOLOGY
------------
[**2166-1-3**] 07:14PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009
[**2166-1-3**] 07:14PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2166-1-3**] 01:03PM URINE Hours-RANDOM UreaN-389 Creat-54 Na-53
K-50 Cl-59
[**2166-1-17**] 10:51AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
IMAGING
-------
ECG on admission:
Artifact is present. Probable sinus tachycardia, although
baseline abnormality precludes definitive assessment of the
rhythm. Left axis deviation. Non-specific intraventricular
conduction delay. There is a late transition with Q waves in the
anterior leads consistent with prior myocardial infarction.
Non-specific ST-T wave changes. Compared to the previous tracing
of [**2165-4-10**] the rhythm has probably changed.
CXR on admission:
Current study demonstrates mild degree of pulmonary edema,
significantly
improved when compared to the [**Month (only) 547**] radiograph. The pacemaker
defibrillator
was newly inserted with its lead terminating in the expected
location of the right ventricle. There is no evidence of
pneumothorax. There are still
present bibasilar areas of atelectasis and right basal
interstitial changes
that potentially might represent interstitial lung disease
underlying
pulmonary congestion. If clinically warranted, further
evaluation of the
patient with HRCT at some point may be reasonable for precise
characterization of the lung findings to differentiate between
the interstitial lung disease and superimposed part of pulmonary
edema.
TTE [**2166-1-7**]:
The left atrium is dilated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is severely depressed (LVEF= 25 %)
secondary to severe hypokinesis of the inferior free wall,
interventricular septum and anterior free wall, extensive apical
akinesis with focal dyskinesis. [Intrinsic left ventricular
systolic function is likely more depressed given the severity of
valvular regurgitation, and relatively preserved function of the
basal posterior and lateral walls.] A large apical thrombus is
seen in the left ventricle. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). There
is no ventricular septal defect. The right ventricular free wall
thickness is normal. The right ventricular cavity is dilated
with depressed free wall contractility. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] There are focal
calcifications in the aortic arch. There are three aortic valve
leaflets. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (valve area 1.2-1.9cm2). The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Moderate to severe (3+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. Severe
[4+] 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 main pulmonary artery is
dilated. The branch pulmonary arteries are dilated. The
pulmonary artery is not well visualized. There is no pericardial
effusion.
Compared with the findings of the prior study (images reviewed)
of [**2165-4-1**], there has been a major further reduction of
left ventricular ejection fraction as well as significant
increase in the mitral and tricuspid regurgitation. A large
apical thrombus is now present in the left ventricle. The right
ventricle is now dilated and hypocontractile.
.
Renal ultrasound [**2166-1-12**]:
IMPRESSION: Normal renal son[**Name (NI) **]
.
Cardiac catheterization [**2166-1-14**]:
COMMENTS:
1. Coronary angiography in this right dominant system
demonstrated three
vessel disease. The LMCA had no angiographically apparent
disease. The
LAD was occluded in its mid-portion. The LCx was occluded at
OM1. The
RCA was not engaged as it was known to be occluded.
2. Resting hemodynamics revealed normal right sided filling
pressures
with RVEDP 8mmHg and a normal pulmonary capillary wedge pressure
of
13mmHg. There was mild pulmonary arterial systolic hypertension
with
PASP 35mmHg. The cardiac index was preserved at 3 L/min/m2. The
systemic
and pulmonary vascular resistances were normal at 973
dynes-sec/cm5 and
80 dynes-sec/cm5 respectively. The systemic arterial blood
pressure was
normal with SBP 100mmHg and DBP 61mmHg.
3. Arterial conduit angiography revealed the LIMA-LAD, SVG-OM,
SVG-Diag,
and SVG-PDA to be patent.
4. Supravalvular aortography revealed no significant aortic
regurgitation.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent bypass grafts.
3. Normal filling pressures.
.
TTE [**2166-1-15**]:
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. There is mild to moderate regional left ventricular
systolic dysfunction with severe hypokinesis of the distal third
of the left ventricle, mid to distal inferior wall, and true
apex. large thrombus is seen in the left ventricle. The right
ventricular cavity is mildly dilated with normal free wall
contractility. The aortic root is mildly dilated at the sinus
level. The aortic valve leaflets (3) are mildly thickened. There
is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is moderate pulmonary artery systolic hypertension. Significant
pulmonic regurgitation is seen. The end-diastolic pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2166-1-7**],
left ventricular systolic function has improved. The severity of
mitral and tricuspid regurgitation is reduced.
Brief Hospital Course:
77 year-old man with ischemic cardiomyopathy and an LVEF of 30%
referred for ICD implantation, presenting with weeks of
worsening dyspnea on exertion secondary to medication
noncompliance.
.
[**Hospital1 **] COURSE
-------------
# Systolic congestive heart failure, acute on chronic: patient
presented with symptoms of worsening dyspnea on exertion and at
rest, and peripheral and pulmonary edema, in the setting of
medication noncompliance. Initially, patient received boluses
of IV furosemide, but urine output was not optimal, so he was
switched to an IV furosemide drip. Urine output was still not
optimal and metolazone was added. His home dose of
spironolactone and lisinopril were initially continued, but then
the medication was discontinued due to worsening renal function.
He was continued on his home dose of metoprolol.
Echocardiography was initially performed, showing an ejection
fraction of 25% and worsening mitral and tricuspid
regurgitation. Patient was started on milrinone drip, and
initially required pressor support but was quickly weaned. He
was able to maintain good urine output, achieving net -1.5 - 2.0
L fluid balance per day. He was restarted on home spironalactone
25 mg qd, kept on milrinone gtt, and transferred back to [**Hospital1 1516**]
service. Diuresis was continued upon coming back to the
cardiology service, but was stopped when he was found to be
euvolemic and his creatinine started to rise. Prior to
catheterization on [**2166-1-14**], all diuresis was discontinued,
patient was given intravenous hydration, but milrinone was
continued. Fluid restriction and a low sodium diet were
employed and strict ins and outs and daily weights were
recorded. Diuresis was resumed with torsemide after returning
from catheterization, and milrinone was discontinued. His
creatinine continued to rise, so torsemide was discontinued upon
discharge and more IV fluid was given, to which his creatinine
downtrended. He is being discharged without further diuresis at
this time. He will likely need torsemide dosing in the future
as an outpatient.n Echocardiography was performed again after
diuresis, and showed improvement in ejection fraction and
valvular function. He is scheduled to follow up with Dr. [**First Name (STitle) 437**],
his new heart failure doctor on the day after discharge, who
will determine when to resume diuresis. He is being discharged
on metoprolol for therapy. His lisinopril and spironolactone
are currently being held due to elevated creatinine level.
.
# Status post ICD placement: patient initially presented for the
placement of an ICD, for primary prevention due to low ejection
fraction. He underwent the procedure without complication. He
is scheduled for follow-up at the device clinic for
post-procedure evaluation.
.
# Left ventricular thrombus: patient was noted on echocardiogram
to have a left ventricular thrombus present. He was started on
a heparin drip and also started on coumadin. At the time of his
discharge, his INR was 1.6. He will continue coumadin therapy
and see Dr. [**First Name (STitle) 437**] on the day after discharge for further
management of anticoagulation.
.
# Acute kidney injury on chronic kidney disease: baseline
creatinine approximately 1.7, in the setting of likely diabetic
nephropathy. On admission, patient creatinine was 2.0 compared
to baseline of 1.7, which peaked at 3.5 after initiation of
milrinone drip. Urine lytes showed FeUrea 37.5%, which was not
consistent with prerenal etiology. Etiology was likely from the
milrinone drip and fluid overload. It was subsequently
exacerbated by likely overdiuresis and dye load during
catheterization. Creatinine should continue to be monitored as
outpatient. Patient's medications were renally dosed and
nephrotoxins were avoided. Due to patient's creatinine levels,
his home doses of lisinopril and spironolactone were
discontinued. They may be added back in the future if his
creatinine returns towards baseline. Patient should have his
creatinine checked three times per week at rehab to evaluate
status of kidney function. His discharge creatinine was 3.2.
.
# Microcytic anemia, acute on chronic: patient's hematocrit
slowly trended down during his hospital stay. He was provided
with one unit blood transfusion on the day before discharge.
Patient has had a colonoscopy within the last two years that was
reported to be free of polyps or cancer, reported by the
patient, but this is not in our records system. He was noted to
be guaiac positive while admitted and on heparin IV. Patient
should have his CBC checked three times per week at rehab to
evaluate status of anemia. His discharge hematocrit level was
26.
.
INACTIVE ISSUES
---------------
# Coronary artery disease: s/p CABG, patient reported no chest
pain during his hospitalization. He was continued on his home
dose of clopidogrel as well as low-dose aspirin. He was also
continued on his home dose of metoprolol. Since patient is on
amiodarone, his rosuvastatin dose was decreased to 10 mg daily.
He was continued on his home dose of Plavix. He is being
discharged on metoprolol for therapy. His lisinopril is
currently being held due to elevated creatinine level.
Catheterization was performed during his stay and showed no new
lesions in the coronary arteries. Patient will follow up with
both his general cardiologist and heart failure specialist upon
discharge.
.
# Atrial fibrillation/flutter: patient is on coumadin and
amiodarone, as well as metoprolol for rate control, all of which
were given during his hospitalization. His coumadin was held
prior to admission for ICD placement, and then later for
catheterization. It was restarted after the procedures and INR
trended up until the time of discharge. He was monitored on
telemetry during this admission. He stayed in normal sinus
rhythm during his hospital stay. He is being discharged on his
home dose of warfarin, metoprolol and amiodarone. Patient
should have his INR checked two times per week at rehab to
evaluate status of therapeutic coumadin dosing.
.
# Hypertension: patient remained normotensive on his home
medications. His metoprolol succinate was continued, and he
will continue taking this as an outpatient. His Imdur was
discontinued since he was normotensive during his stay. His
lisinopril and spironolactone was held when his potassium and
creatinine level rose above 2.5.
.
# Hyperlipidemia: patient's statin dose was decreased to
rosuvastatin 10 mg daily due to being on amiodarone, and he will
continue this dosage upon discharge.
.
# Diabetes mellitus type 2: patient has a history of diabetic
retionopathy with likely nephropathy as well. Patient's
glyburide was held and sliding scale insulin was begun. Blood
sugar levels were well controlled throughout this
hospitalization. Patient is being discharged on glipizide for
further diabetic management instead of glyburide due to his
renal function.
.
# GERD: patient was continued on his home dose pantoprazole
during hospitalization.
.
TRANSITION OF CARE
----------------
# Code status: patient is confirmed full code.
.
# Follow-up: patient will follow up with his general
cardiologist and a heart failure specialist. He needs follow-up
of his INR levels due to being subtherapeutic on coumadin upon
discharge. He also needs follow-up of his kidney function and
anemia, since both were active issues upon discharge. He may
need a colonoscopy due to noted guaiac positive stools. His
INR, CBC and Chem7 should be checked at rehab as described
above.
Medications on Admission:
Furosemide 80 mg PO BID
Imdur 60 mg PO daily
Warfarin 3 mg PO daily
Plavix 75 mg PO daily
Lisinopril 20 mg PO daily
Metoprolol succinate 200 mg PO daily
Amiodarone 200 mg PO daily
Spironolactone 25 mg PO BID
Rosuvastatin 20 mg PO daily
Allopurinol 200 mg PO daily
Ventolin aerosol 2 puffs IH qid PRN
Protonix 40 mg PO daily
Spiriva 18 mcg IH daily
Glyburide 5 mg PO BID
Coenzyme Q10 200 mg PO daily
Multivitamin PO daily
Fish oil - dose uncertain
Discharge Medications:
1. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual Q5MIN () as needed for chest pain.
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheeze.
4. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. metoprolol succinate 200 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
10. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
11. glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
12. coenzyme Q10 200 mg Capsule Sig: One (1) Capsule PO once a
day. Capsule(s)
13. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
14. Fish Oil Oral
15. rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
16. Outpatient Lab Work
Please perform INR check twice per week starting on [**2165-1-21**] and
17. Outpatient Lab Work
Please perform Chem7 and CBC three times a week and fax results
to MD on call
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
Primary diagnosis:
Systolic congestive heart failure, acute on chronic
Acute on chronic renal insufficiency
Left ventricular thrombus
Microcytic anemia, acute on chronic
Secondary diagnosis:
Coronary artery disease
Atrial fibrillation
Hypertension
Hyperlipidemia
Diabetes mellitus type 2
Gastroesophageal reflux disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 68637**],
It was a pleasure taking care of you at the [**Hospital1 18**]. You came for
placement of a defibrillator (ICD), but were found to have
increased fluid and decompensation of your heart failure.
Further tests showed that you had worsening heart function on
echocardiogram, and you were given medications to help take this
fluid off. Your kidneys were also found to not be working
optimally. A cardiac catheterization showed no problems with
the blood vessels of your heart. Your kidneys are still not
working like they used to, and this will need follow-up. It is
important that you continue to take your medications and follow
up with the appointments listed below, one of which is with Dr.
[**First Name (STitle) 437**] on the day after your discharge, Monday [**1-20**]. Weigh
more than 3 lbs.
The following changes have been made to your medications:
We STOPPED your furosemide, lisinopril and spironolactone
We STOPPED your glyburide, which is given for diabetes, and
ADDED glipizide, which is better for this condition given your
kidney function.
We DECREASED your rosuvastatin dose due to your kidney function
We STOPPED your isosorbide mononitrate (Imdur), since your blood
pressure appears to be controlled.
We DECREASED your dose of allopurinol, to adjust for your kidney
function
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2166-1-20**] at 9:00 AM
With: DR. [**Known firstname **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **],[**First Name3 (LF) **] W.
Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 4475**]
Appt: Please call Dr [**Last Name (STitle) 68638**] office to book a follow up appt
from your hospital stay in the next two weeks.
ICD9 Codes: 5845, 4280, 2724, 4241, 5859, 4168 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1462
} | Medical Text: Admission Date: [**2125-8-16**] Discharge Date: [**2125-9-8**]
Date of Birth: [**2073-11-30**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 51 year-old
male with end stage liver disease secondary to hepatitis C
cirrhosis and end stage renal disease secondary to membranous
proliferative glomerulonephritis who presented for
simultaneous liver and kidney transplant. The patient has
had some reported episodes of hepatic encephalopathy although
none directly prior to admission. The patient was also on
hemodialysis three times a week. The patient denies fevers
or chills, nausea, vomiting, chest pain, shortness of breath.
PAST MEDICAL HISTORY:
1. End stage liver disease secondary to hepatitis C.
2. End stage renal disease secondary to membranous
proliferative glomerulonephritis.
3. Hepatitis C cirrhosis.
4. Hypertension.
5. Esophageal varices, although no bleeds.
6. Gastroesophageal reflux disease.
7. Peripheral neuropathy.
8. History of VRE.
PAST SURGICAL HISTORY: Significant for right arm AV graft,
cholecystectomy.
MEDICATIONS ON ADMISSION:
1. Mycelex.
2. Tums.
3. Metoprolol 100 b.i.d.
4. Prevacid 30 b.i.d.
5. Amitriptyline 30 q.h.s.
6. Epogen.
7. Coumadin 4 q.h.s.
8. Celexa 10 q day.
9. Norvasc 10 q day.
10. Lactulose 30 prn.
11. Milk of Magnesia 30 prn.
SOCIAL HISTORY: Significant for alcohol use, intravenous
drug use, and 13 pack year history of smoking.
PHYSICAL EXAMINATION: The patient was in no acute distress.
Alert and oriented times three. Neck was supple. No JVD.
Regular rate and rhythm. No murmur. Clear to auscultation
bilaterally. Abdomen was soft, nontender, nondistended.
Positive bowel sounds. Extremities no lower extremity edema.
HOSPITAL COURSE: The patient was taken to the Operating Room
on [**2125-8-16**]. Attending surgeon Dr. [**Last Name (STitle) **], assistant Dr.
[**First Name (STitle) **] and Dr. [**Last Name (STitle) **]. For complete account please see
operative reported dated [**2125-8-16**] for both orthotopic liver
transplant and cadaveric kidney transplant. Postoperatively,
the patient was admitted to the Intensive Care Unit per
protocol. Intensive Care Unit course was unremarkable. The
patient was transferred to the floor on postoperative day
number eight. Delay in transfer was only due to bed
availability issues. Upon transfer to the floor the patient
had a creatinine of 2.2, ALT 105, AST 32, alkaline
phosphatase 104 and total bilirubin 2.3. On postoperative
day number ten the patient's immunosuppression regimen went
as follows, Cyclosporin 100 mg b.i.d., Prednisone 20 mg q
day, CellCept [**Pager number **] mg b.i.d. Cyclosporin levels were being
adjusted daily per level. On postoperative day number 11 the
patient's JP output picked up to 180 cc and JP output
creatinine was noted to be 15.5. The patient was examined by
CT to evaluate for possible leak. CT scan was normal.
Ultrasound, however, approximately 7 by 2 by 2 cm fluid
collection superomedial to the transplanted kidney.
Treatment at that time was decided to be leave the JP drain
in until output was minimal as well as the Foley.
Contributing to this treatment plan was the fact that the
patient suffers from benign prostatic hypertrophy.
On postoperative day number 13 the patient began to get
increasingly agitated and began to have mental status
changes. A sitter was written for in order to watch the
patient. Psychiatric consult was also obtained recommending
Haldol to treat the patient's agitation. By postoperative
day number 15 the patient became increasing agitated,
actively hallucinating and frankly delirious and psychotic.
The patient requiring 4 point leather restraints at times.
Haldol seemed to have no effect. Later on postoperative day
fifteen the patient began to have respiratory difficulties
and the patient was transferred to the Intensive Care Unit
and was intubated and sedated. The patient remained
intubated in the Intensive Care Unit for a day and a half at
which time CT scan revealed a right lower lobe consolidation.
The patient received bronchoscopy to reopen atelectally
collapsed right lower lobe. Cultures from that consolidation
had been negative to date. The patient was placed on Zosyn
for a ten day course for empiric treatment of pneumonia. The
patient was then taken off Cyclosporin for a presumptive
Cyclosporin induced psychosis and delirium. After extubation
the patient quickly returned to baseline mental status. He
remembered vividly his episodes of confusion. The patient
was started on Prograf and got to a therapeutic level of 10.
On postoperative day number 20 the patient was found to have
on ultrasound duplex of the central veins a nonocclusive
thrombus on the right IJ. On [**2125-9-5**] the patient went back
to the Operating Room for ligation of right arm AV fistula
prior to which the patient had marked right upper extremity
edema. Postoperative day number 21 from the liver kidney
transplant the patient returned to the floor doing well. The
patient's staples were removed and Steri-Strips were applied.
Postoperative day number 22 status post kidney liver
transplant and on Zosyn day eight for right lower lobe
pneumonia the patient remained afebrile, vital signs were
stable. JP drain was discontinued for minimal output.
Creatinine was 1.1, AST 20, ALT 27, alkaline phosphatase 82,
total bilirubin 0.7. The patient's mental status was at
baseline. The patient was therapeutic on Prograf 2 mg b.i.d.
dose being adjusted daily for levels. Also postoperative day
number 22 hepatitis C viral load continued to be negative.
The patient's wound was clean, dry and intact and preliminary
read of an ultrasound of the transplanted kidney revealed no
detectable fluid collection. The patient's Foley still in
place. The Foley is to remain in place for one to two weeks.
The patient at this time was deemed well enough and go be
discharged to a rehabilitation center and then to home
thereafter with close follow up with the transplant center.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To [**Hospital3 **].
DISCHARGE DIAGNOSES:
1. Status post cadaveric renal transplant.
2. Status post orthotopic liver transplant.
3. Hepatitis C cirrhosis.
4. End stage renal disease secondary to membranous
proliferative glomerulonephritis.
5. Hypertension.
6. Right lower lobe pneumonia.
DISCHARGE MEDICATIONS:
1. Tacrolimus 2 mg po b.i.d.
2. Percocet one to two tabs po q 4 to 6 hours prn.
3. Protonix 40 mg po q day.
4. Diflucan 200 mg po q day.
5. Multivitamins once a day.
6. Valcyte 450 mg po q day.
7. Metoprolol 100 mg po b.i.d.
8. Ipratropium bromide MDI q 4 to 6 hours prn.
9. Albuterol q 6 hours prn.
10. Prednisone 15 mg po q day.
11. Doxazosin 2 mg po q.h.s.
12. Amlodipine 5 mg po q day.
13. CellCept [**Pager number **] mg po b.i.d.
14. Bactrim single strength one tab po q day.
FOLLOW UP: The patient is to follow up with Dr. [**Last Name (STitle) **] on
[**2125-9-12**] at 9:50, with Dr. [**Last Name (STitle) 497**] on [**2125-9-19**] at 9:40 a.m. Both
appointments at the Transplant Center.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**Name (STitle) 106550**]
MEDQUIST36
D: [**2125-9-7**] 11:33
T: [**2125-9-7**] 11:57
JOB#: [**Job Number 106551**]
ICD9 Codes: 486, 5180 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1463
} | Medical Text: Admission Date: [**2159-4-8**] Discharge Date: [**2159-4-10**]
Service: NEUROLOGY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5831**]
Chief Complaint:
Decreased responsiveness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a [**Age over 90 **]-year-old right-handed woman with history of
HTN, CAD s/p MI, and CHF who has had progressive cognitive and
physical decline over the past 5-6 months now transferred for
further evaluation of her mental status. Her mental status had
started worsening in [**2158-11-1**] when she was admitted to [**Hospital1 **]
[**Location (un) 620**] with group B Strep bacteremia possibly related to lung
infection. Prior to this, she had been living alone
independently in her apartment. She was discharged to a nursing
home in [**2158-12-2**]. She was transferred to a [**Hospital1 1501**] on [**2159-1-2**],
for worsening mental status, confusion, agitation, and
screaming.
She was admitted to [**Hospital1 **] [**Location (un) 620**] in [**2159-1-2**] for further
evaluation of agitation and mental status changes. During that
admission, she was found to have an Enterococcus positive UTI.
Then, she was admitted to [**Hospital 1191**] Hospital for further management
of her mental status changes which was attributed to increasing
anxiety. She was prescribed trazadone. She had further decline
in her mental status which was thought to be secondary to
psychosis so she was started on twice daily risperidone and
required a 1:1 sitter. While at [**Doctor First Name 1191**], she developed a right
facial droop and was unresponsive. She was also noted to have
generalized muscular hypertonicity. She was transferred to [**Hospital6 38673**] on [**2159-4-7**] to rule out stroke. She was started
on
ASA PR. Head CT did not show large territorial infarct or
intracranial hemorrhage. In the ED at [**Hospital3 **], she received
a
dose of vancomycin and levoquin. This was not continued as she
was afebrile and did not have a leukocytosis. Cardiac enzymes
were negative times three. She was consulted by neurology who
considered that she may be in a drug-induced state from the
risperidone. However, it was felt that nonconvulsive status
epilepticus should also be ruled out. Therefore, she was
transferred to [**Hospital1 18**] for bedside EEG monitoring to rule out
seizure.
ROS: per HPI. No recent fever. She is noted to have
progressively worsening decline, both in mental status, in p.o.
intake, and also, to have depressive symptoms.
Past Medical History:
COPD
h/o Ventricular tachycardia, after long discussion w/family
decision was made not to place ICD in [**11-6**]
History of breast cancer
History of urinary tract infections, Streptococcus bacteremia,
hypothyroidism, congestive heart failure, macular degeneration,
cataracts, osteoarthritis, gastroesophageal reflux disease,
COPD,
coronary artery disease status post MI and status post stenting,
hyponatremia which is chronic, chronic back pain, hypertension,
peripheral edema, and aortic, regurgitation with last
echocardiogram showing an EF of 55%.
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Vitals: T: 100.2 P: 88 R: 10 BP: 129/49 SaO2: 96% RA
General: She was sleeping and difficult to arouse.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally. Both hands appear arthritic.
Skin: no rashes noted.
Neurologic:
-Mental Status: She was sleeping and difficult to arouse
initially. She did not speak. She followed commands to smile,
stick out her tongue, and to grasp.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. +blink to threat
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Not wearing her hearing aids and so the examiner must yell
loudly for her to hear bilaterally
IX, X: Did not cooperate with checking palate elevation.
[**Doctor First Name 81**]: Did not participate in this part of the exam.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, increased tone in all extremities. Did not
participate in testing for pronator drift. No adventitious
movements, such as tremor, noted. Moves all extremities in
response to light touch.
-Sensory: Moves all extremities to light touch. Opened eyes to
sternal rub.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 1 1 1 1 1
R 1 1 1 1 1
Toes mute
-Coordination: unable to test
-Gait: unable to test
Pertinent Results:
CBC: 9.6> 9.7/ 29.7 < 352
Chemistry: 135 100 24 93
4.4 23 1.2
Ca 9.4 Mg 2.1 P 3.3
ALT 50; AST 54
UTox negative
UA pH 5.5, sp gr 1.015; tr protein, 40 ketone, hazy, otherwise
negative
Brief Hospital Course:
Confusion
Ms. [**Known lastname 4223**] was transferred to [**Hospital1 18**] for diminished
responsiveness. She had recently been given risperidone which
was held on admission. On the morning after admission she was
alert and interactive with the team. She is very hard of hearing
which can contribute to confusion, but the most likely etiology
to her delerium was medication-induced. We suggested Seroquel 25
mg PRN as a substitiute if she becomes agitated. We spoke to her
daughter who requested that she not be hospitalized in the
future. She states that she has made her facilty aware of this
do not hospitalize order. There was no evidence of seizure on
exam and she was moving extremities well.
Medications on Admission:
ACETAMINOPHEN SUPPOSITORY 650 MG Every 6 Hours
Rectal
ALBUTEROL 0.042% NEB [**Male First Name (un) **] 1 NEB Every 4 Hours
Nebulizer
NEBULIZER (Accuneb 0.042% 1.25 MG/3 Ml)
ALBUTEROL INHALER 0 GM Every 6 Hours
PRN Inhalation
ALBUTEROL/IPRATROPIUM 1 NEB Every 6 Hours
(Duoneb 2.5 MG-0.5 MG Nebulizer)
ASPIRIN SUPPOSITORY 300 MG Every Day
Rectal
BISACODYL SUPPOSITORY 10 MG Every Day
Rectal
BISACODYL SUPPOSITORY 10 MG Daily as
needed
Rectal
LEVOTHYROXINE VIAL 25 MCG Every Day
Intravenous
(note home dose of PO levothyroxine is 50 mcg PO daily)
SODIUM BIPHOSPHATE/SODIUM 133 ML Daily as
needed
Per rectum
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a
day.
5. Seroquel 25 mg Tablet Sig: One (1) Tablet PO QHS: PRN as
needed for Agitation.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] - [**Location (un) 620**]
Discharge Diagnosis:
Delerium
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital after being transferred from
an outside hospital for concern of possible seizures. You had
recently been started on Trazadone and Risperdal. These
medications were held and on the following morning you were
speaking clearly and said that you felt good. On examination you
were very hard of hearing and mildly disoriented. In addition
you had some subtle weakness on your right side. You had a
normal CT from the outside hospital and there was no idication
for EEG. You had no issues related to agitation or confusion.
We would recommend the following.
1. No risperidone in the future
2. No trazadone in the future
3. If agitated, please use small dose of Seroquel (25 mg prn
agitation)
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **] [**1-5**] weeks.
Completed by:[**2159-4-10**]
ICD9 Codes: 4280, 4019, 412, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1464
} | Medical Text: Admission Date: [**2136-1-27**] Discharge Date: [**2136-2-3**]
Date of Birth: [**2084-8-30**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Morphine
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Unresponsive
Major Surgical or Invasive Procedure:
Intubation
A Line [**1-27**]
Lumbar Puncture ([**1-27**], [**1-30**])
History of Present Illness:
51 yo Male with a history of HIV CD4 152 VL 1340, h/o bacterial
meningitis x2, and history of cerebral toxoplasmosis in [**2131**],
[**2132**], currently on treatment, and seizures, who presented to the
ED by EMS unresponsive. EMS initially thought this was an
oxycontin overdose. Upon giving Narcan, his respiratory rate
went up from 4 to 40. He was reportedly alert but combative.
In the ED, initial vs were: T 101.9 P 137 BP 110/P R 30 O2 sat
73% on RA. Upon arrival to the ED, patient was febrile to T 102,
altered, combative and hypoxic to the low 70s on RA. He was
urgently intubated. On intubation, airways were notably full of
purulent secretions.
Patient was given 3L IV NS. Atropine, fentanyl, versed in the
setting of intubation. He was given Vanc, Ctx, Levofloxacin. He
received methylprednisolone 125mg x2. He was not given
Ampicillin b/c of allergy to PCN. Head CT showed 13 x 7 mm
hypodensity in the left medial cerebellar hemisphere with
surrounding edema. Thus, LP was not attempted. Neurosurgery was
consulted, but had not evaluated the patient prior to transfer
to the MICU. Acyclovir was ordered but not administered prior to
transfer. Tamiflu was also ordered. Vitals prior to transfer:
HR 92 BP 106/60 RR 22 100% T 101.9.
On the floor, patient is intubated and sedated.
Per his partner, the patient went to see his primary care doctor
5 days prior to admission. He complained of coughing and
shortness of breath. He was not found to have a fever at that
time.
One day prior to admission, the patient went with his
significant other to see his therapist. He also saw his
psychiatrist and was sleepy at that time. When he got home
around 4pm, his significant other [**Name (NI) 28167**] him very sleepy, so she
let him sleep for several hours. He ate dinner afterwards. When
she fed him his drink she noticed that he spilt his drink on the
floor. She gave him another drink, and again he spilt it on the
floor. She noticed that he had poor movement of his R side.
After leaving the room for a few minutes, she found him on the
ground. She helped him to get up. He slept well overnight. On
the morning of admission, he slept much longer than usual. When
his partner tried to wake him up around 11am, he didn't respond.
She called EMS thereafter.
Review of systems:
(+) Per HPI
(-) Unable to complete
Past Medical History:
PMH
1. HIV/AIDS (CD4 [**8-16**] = 4; [**10-19**] = 360)
-dx [**2125**]
-restarted HAART therapy, [**6-/2131**]
-Ring-enhancing lesion on [**2132-1-2**] CT L thalamocapsular region;
treated as Toxoplamosis in [**1-18**]; residual R-sided weakness and
sensory loss
-most recent CD4 = 360 VL = 405 [**2134-10-15**]
2. Neprholithiasis s/p lithotripsy and L ureteral stent
placement
-dx [**3-/2128**]
-L ureteroscopy, stone ablation; double J ureteral stent [**3-/2128**]
-L lithotripsy [**4-/2128**]
-bilateral laser lithotripsy w/ stents [**8-/2134**] (removed [**9-5**])
3. Major Depression s/p multiple suicide attempts
4. MVA age 23
5. Witnessed seizure in the setting of otitis media ([**8-/2131**]
[**Hospital1 18**] admission) - EEG negative for epileptiform changes
([**2131-8-17**])
6. Chronic otitis media (> 30 yrs)
7. Pruitis Nodularis
8. Dementia
Social History:
Tobacco: [**1-14**] ppd 30 years; Denies ETOH, IVDU. Lives with HIV +
wife and 22 [**Name2 (NI) **] son, originally from [**Name (NI) 5976**]. Highest education 4th
grade. Quit job as HIV counselor for Cambrisge Cares 1 week ago
due to current symptoms. No pet exposure.
Family History:
Left [**Country 5976**] at age 14. Unknown family history. Father may have
died from cancer.
Physical Exam:
Vitals: T:98.6 BP:96/56 P:103 R: 18 O2: 93%
General: Intubated and sedated
HEENT: Sclera anicteric, MMM. Pinpoint pupils.
Neck: Supple, no meningismus. JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally on anterior exam, no
wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: Foley present
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Does not respond to deep nailbed pressure or sternal rub.
Pertinent Results:
Labs on Admission:
[**2136-1-27**] 12:56PM WBC-8.6 RBC-5.21 HGB-15.5 HCT-47.1 MCV-90
MCH-29.8 MCHC-33.0 RDW-13.8
[**2136-1-27**] 12:56PM PT-13.5* PTT-26.3 INR(PT)-1.2*
[**2136-1-27**] 12:56PM FIBRINOGE-540*
[**2136-1-27**] 12:56PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2136-1-27**] 12:56PM ALT(SGPT)-9 AST(SGOT)-17 LD(LDH)-142 ALK
PHOS-93 TOT BILI-1.5
[**2136-1-27**] 12:56PM LIPASE-13
[**2136-1-27**] 12:56PM GLUCOSE-121* UREA N-10 CREAT-1.1 SODIUM-143
POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-20* ANION GAP-19
[**2136-1-27**] 02:00PM GLUCOSE-115* LACTATE-2.2* NA+-147 K+-4.0
CL--105 TCO2-25
Labs on Discharge:
[**2136-2-3**] 05:50AM BLOOD WBC-4.8 RBC-4.36* Hgb-12.8* Hct-37.5*
MCV-86 MCH-29.2 MCHC-34.0 RDW-14.1 Plt Ct-206
[**2136-2-3**] 05:50AM BLOOD Glucose-88 UreaN-15 Creat-0.7 Na-139
K-3.5 Cl-109* HCO3-17* AnGap-17
Other Pertinent Labs:
Absolute CD4: 40
ASPERGILLUS GALACTOMANNAN ANTIGEN: negative
HTLV I AND II: negative
LEVETIRACETAM (KEPPRA): 19.5
Microbiology:
[**2136-1-31**]: C Diff Negative
[**2136-1-30**]: CSF Gram stain: No PMNs, No microorganisms. Fluid
culture: no growth. [**Month/Day/Year **] culture (prelim): No growth. Acid
Fast culture (prelim): No growth (may take 3-8 weeks to grow).
Viral culture(prelim): No growth.
[**2136-1-30**] CSF Cryptococcal Antigen not detected
[**2136-1-30**] Sputum gram stain: [**11-5**] PMNs and <10 epithelial
cells/100X field. No microorganisms seen. Culture: Yeast,
sparse growth, of two colonial morphologies. Legionella culture
(prelim): none isolated. [**Month/Year (2) **] culture (prelim): Yeast of two
colonial morphologies.
CMV: DNA not detected, IgG Ab negative, IgM Ab negative
HIV-1 Viral Load/Ultrasensitive (Final [**2136-1-30**]): 8,930
copies/ml.
Direct Influenza A Ag Negative, Influenza B Ag Negative
Aspirate from vesicle/[**Last Name (un) **] on dorsum of left foot: Gram stain:
No PMNs, No microorganisms. No growth from wound culture.
Viral culture (prelim): None isolated so far. VZV(prelim): No
virus isolated.
[**2136-1-27**] BAL Gram stain 2+ PMNS, 2+ GPC in pairs, culture grew
streptococcus pneumoniae >100,000 organisms/ml presumptively
penicillin sensitive by oxacillin screen. Legionella not
isolated. Immunoflourescent negative for PCP. [**Name10 (NameIs) **] culture
(prelim): Yeast. AFB smear negative. AFB culture (prelim): No
growth.
Urine culture: No growth
Blood culture: No growth
Studies:
CT Head:
1. Hypodense lesion within the medial left cerebellar
hemisphere,
nonspecific, but may indicate an area of infection, chronic
infarct, or small mass with surrounding edema. MRI is
recommended for further evaluation. 2. No intracranial
hemorrhage. 3. Coarse calcifications within the left thalamus,
extending into the mid brain, likely due to sequela of prior
toxoplasmosis infection. 4. Extensive sinus opacification,
likely related to intubation. 5. Opacification of the left
mastoid air cells may suggest ongoing inflammation.
MRI Head:
Partially limited examination related to motion artifacts. The
pattern of
enhancement in the previously described lesion at the left mid
brain appears less conspicuous with no abnormal enhancement.
Persistent areas with high- signal intensity on T2 and FLAIR on
the left cerebellar hemisphere and left mid brain, no diffusion
abnormalities are detected or new lesions. Maxillary mucosal
thickening is noted, more significant on the left.
CT Head: 1. No intracranial hemorrhage. Unchanged size and
appearance of the ventricles. 2. Subtle hypodensity in the left
cerebellar hemisphere (2:9), more conspicuous in comparison to
[**1-27**], may be positional and/or due to partial volume
averaging. However, infarct cannot be excluded, although there
is no corresponding finding on the MRI from [**2136-1-28**].
Brief Hospital Course:
51 year old male with HIV on HAART, history of bacterial
meningitis, toxoplasmosis, seizure disorder, who presented with
progressive decline in mental status, ataxia, then found
unresponsive and hypopneic.
#. Altered Mental Status. He originally presented with AMS and
was intubated for airway protection. There was significant
concern for infection in this immunosuppressed patient with HIV
and history of multiple opportunistic infections. He had two
lumbar punctures and was followed by the ID and neurology teams.
Ultimately it was felt that his AMS was most likey due to
medication effect, as he was on multiple sedating medications
and his dose of Baclofen was recently increased. 24 hour EEG
did not reveal seizues, and LP results did not show evidence of
infection. Culture results are still pending at the time of
discharge. Given his previous toxoplasmosis in his brain, he
may have decreased reserve and a small insult may alter his
mental status significantly. At the time of discharge, he was
fully oriented and communicative. He retained right-sided
weakness but was ambulating with a walker.
#. Hypoxemic Respiratory Failure. He was intubated in the
emergency room due to hypoxic respiratory failure, thought to be
due to an aspiration event in the setting of AMS. He also may
have had decreased respiratory drive due to his possible
medication effect that caused his AMS. His O2 sat was 73% in
the ED and CXR was not consistent with PCP. [**Name10 (NameIs) **] was intubated in
the ED and successfully extubated on [**2136-1-31**]. Bronchoscopy
showed particulate matter in RLL (likely aspiration). Legionella
negative. PCP [**Name Initial (PRE) 5963**]. Now extubated and doing well. The BAL
culture showed strep. pneumoniae and he was treated with a 7 day
course of ceftriaxone and Flagyl and a 5 day course of
azithromycin.
#. HIV. ON this admission, his CD4+ was 40 and viral load 8,930.
His low CD4 was likely due to present illness. Continued
outpatient HAART regimen: Kaletra, Truvada, Atazanavir.
#. Hx of Seizure. Continued Keppra. He had a 24 hour EEG that
did not show evidence of seizures
#. Bradycardia. Patient had one episode of bradycardia to 40s;
otherwise hemodynamically stable during MICU course. Etiology
unclear and episode resolved.
Medications on Admission:
HIV: Atazanavir, truvada, kaletra
Toxo: leukovorin, pyrimethamine, sulfadiazine
- history of non adherence: pyrimethamine was missed for ~6
months,
but currently adherent
ALBUTEROL SULFATE 2 puffs inh qid
ATAZANAVIR - 300 mg po daily
BACLOFEN - 10 mg po tid
CITALOPRAM [CELEXA] - 40 mg po daily
DEXTROAMPHETAMINE - 5 mg at 8am and 1pm
EMTRICITABINE-TENOFOVIR [TRUVADA] - 200 mg-300 mg po daily
FAMOTIDINE - 20 mg po bid
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - i puff ih twice a day
LEUCOVORIN CALCIUM - 25 mg po daily
LEVETIRACETAM [KEPPRA] - 1,000 mg po bid
LOPINAVIR-RITONAVIR [KALETRA] - 50 mg-200 mg Tablet - 2
Tablet(s)
by mouth 2x/d
LORAZEPAM - 1 mg po qhs
MIRTAZAPINE - 45 mg po qhs PRN insomnia
OLANZAPINE [ZYPREXA] - 20 mg po qhs
OXYCODONE - 30 mg po q3h PRN right-sided body pain through
[**2136-2-22**]
PREGABALIN [LYRICA] - 300 mg po bid
PYRIMETHAMINE - 75 mg po daily
QUETIAPINE [SEROQUEL] - 300 mg po qhs
QUETIAPINE [SEROQUEL] - 100 mg po q6h prn agitation
SULFADIAZINE - 1500 mg po qid
TRAZODONE - 100 mg Tablet - [**1-14**] Tablet(s) po qhs
ZOLPIDEM [AMBIEN] - 10 mg po qhs
FOOD SUPPLEMENT, LACTOSE-FREE [BOOST] - Liquid - 1 can by mouth
6x/day
Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
2. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
3. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
puff inhaled Inhalation twice a day.
7. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
8. Kaletra 200-50 mg Tablet Sig: Two (2) Tablet PO twice a day.
9. Pyrimethamine 25 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. Sulfadiazine 500 mg Tablet Sig: Three (3) Tablet PO Q6H
(every 6 hours).
11. Boost Liquid Sig: One (1) Supplement PO six times a day.
12. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO three
times weekly (M,W,F).
Disp:*12 Tablet(s)* Refills:*2*
13. Leucovorin Calcium 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis:
Altered mental status
Secondary Diagnosis:
HIV
History of toxoplasmosis
History of seizures
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Level of Consciousness: Arousable, some pscychomotor slowing
Mental Status: Clear and coherent, alert and oriented x 3
Discharge Instructions:
You were admitted to the hospital with altered mental status and
unresponsiveness. You had a number of procedures and diagnostic
studies to determine what caused this episode. You had two
lumbar punctures which showed that you did not have bacterial
meningitis. You also had an MRI which showed no new lesions in
your brain. You had an EEG that did not show that you are
having seizures. Your mental status slowly cleared during your
hospitalization.
One possible cause of this event is taking too much baclofen or
other sedating medications. Your dose of baclofen was changed
prior to hospitalization and this could have contributed to your
altered mental status.
CHANGES to your medications:
Stopped baclofen, dextroamphetamine, ativan, trazodone,
mirtazapine, Zyprexa, oxycodone, Lyrica, and Seroquel
** You may need to restart some of these medications for pain or
your mood in the future. You should discuss with this with your
primary care doctor, and together you should decide which one to
restart
Followup Instructions:
You have the following appointments scheduled:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (Infectious Disease)
Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2136-2-3**] 10:00am
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7212**], MD (Primary Care)
Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2136-2-20**] 11:10am
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20751**], M.D. (Cognitive Neurology)
Phone:[**Telephone/Fax (1) 1682**]
Date/Time:[**2136-3-1**] 10:00am
ICD9 Codes: 5070, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1465
} | Medical Text: Admission Date: [**2106-10-5**] Discharge Date: [**2106-10-13**]
Date of Birth: [**2027-10-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
Aortic valve replacement (21mm [**Doctor Last Name **] pericardial)/MAZE/Left
atrial ligation [**2106-10-7**]
TEE [**2106-10-6**]
History of Present Illness:
78 year old white female has known aortic stenosis and
paroxsymal atrial fibrillation with worsening dyspnea on
exertion. Her most recent echo and cath have shown severe aortic
stenosis with no coronary artery disease. She was referred for
aortic valve surgery.
Past Medical History:
Severe Aortic Stenosis
Paroxysmal Atrial Fibrillation
Hypertension
Hyperlipidemia
Diabetes Mellitus-diet controlled
Spinal surgery
Uterine polypectomy
Bladder Cancer removed
Cataract surgery
Tonisellectomy
Social History:
Lives with her husband
[**Name (NI) **]: Caucasian
Tobacco: Denies
ETOH: Denies
Family History:
noncontributory
Physical Exam:
Pulse: 61 Resp: 16 O2 sat: 96% RA
B/P Right: 134/66 Left: 122/63
Height: 5'1" Weight: 200lbs
General: well-developed, well-nourished female in no acute
distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur 2/6 SEM
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] Edema Varicosities:
None [X]
Neuro: Grossly intact
Pulses:
Femoral Right/Left: 2+
DP Right/Left: 1+
PT [**Name (NI) 167**]/Left: 1+
Radial Right/Left: 2+
Carotid Bruit Right/Left: none
Pertinent Results:
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2106-10-12**] 9:09 AM
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 84651**]
Reason: (R) apical PTX
[**Hospital 93**] MEDICAL CONDITION:
78 year old woman s/p AVr/MAZE
REASON FOR THIS EXAMINATION:
(R) apical PTX
Final Report
INDICATION: 78-year-old woman, status post AVR/maze with right
pneumothorax,
for followup.
COMPARISON: [**2106-10-9**]; [**2106-10-7**].
PORTABLE UPRIGHT CHEST RADIOGRAPH: Again seen is a small left
apical
pneumothorax. Sternal wires are intact. AVR is noted.
Cardiomegaly and
mediastinal contours unchanged. Low lung volumes limit
assessment. There is
no pulmonary edema. Persistent retrocardiac opacification
suggests
atelectasis/left lower lobe collapse. Haziness at the left base
suggests
persistent small left pleural effusion.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 5206**] [**Name (STitle) **]
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
Approved: TUE [**2106-10-12**] 11:11 AM
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 84652**] (Complete)
Done [**2106-10-7**] at 11:02:18 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2027-10-28**]
Age (years): 78 F Hgt (in): 61
BP (mm Hg): 134/78 Wgt (lb): 200
HR (bpm): 56 BSA (m2): 1.89 m2
Indication: Intraoperative TEE for AVR, MAZE and left atrial
ligation. Aortic valve disease. Atrial fibrillation. Chest pain.
Left ventricular function. Mitral valve disease. Preoperative
assessment. Right ventricular function.
ICD-9 Codes: 427.31, 786.05, 799.02, 440.0, 424.1, 424.0, 424.2
Test Information
Date/Time: [**2106-10-7**] at 11:02 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1510**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2009AW1-: Machine: aw5
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Ascending: 2.8 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *3.8 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *59 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 29 mm Hg
Aortic Valve - Valve Area: *0.9 cm2 >= 3.0 cm2
Mitral Valve - E Wave: 0.6 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A ratio: 1.00
Findings
LEFT ATRIUM: No mass/thrombus in the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s)
LAA ejection velocity.
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: Mild symmetric LVH. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Simple atheroma in ascending aorta.
Simple atheroma in aortic arch. Simple atheroma in descending
aorta.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Severe AS (area 0.8-1.0cm2). Mild to moderate ([**12-11**]+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild (1+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
Prebypass
No mass/thrombus is seen in the left atrium or left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy.
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 are
severely thickened/deformed. There is severe aortic valve
stenosis (valve area 0.8-1.0cm2). Mild to moderate ([**12-11**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is no
pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the
results on [**2106-10-7**] at 830am.
Post bypass
Patient is AV paced and receiving an infusion of phenylephrine.
Biventricular systolic function is unchanged. Bioprosthetic
valve seen in the aortic position. The valve appears well seated
and the leaflets move well. There is no aortic insufficiency.
The mean gradient across the valve is 10 mm Hg. Mild mitral
regurgitation persists. The left atrial appendage has been
ligated. Aorta is intact post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2106-10-7**] 15:06
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2106-10-13**] 07:45AM 8.2 3.22* 9.5* 28.2* 88 29.4 33.6 14.3
252#
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2106-10-13**] 07:45AM 19.1* 1.7*
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2106-10-13**] 07:45AM 123* 18 0.8 138 4.2 102 24 16
Brief Hospital Course:
She was admitted prior to surgery for Heparin bridge and
pre-operative work-up on [**10-5**]. On [**10-6**] she had a TEE to rule
out for clot and evaluate aortic stenosis. She was cleared for
surgery and brought to the operating room on [**10-7**] where she
underwent an Aortic valve replacement and MAZE procedure with
left atrial appendage ligation. Please see operative report for
surgical details. She received vancomycin for perioperative
antibiotics. Following surgery she was transferred from the
CVICU for hemodynamic monitoring. Within 24 hours she was
weaned from sedation, awoke neurologically intact and extubated.
On post-op day one she was doing well and transferred to the
telemetry floor for further care. Chest tubes and Epicardial
pacing wires were removed on post-op day two and chest x-ray
after removal showed small right apical pneumothorax. Coumadin
was resumed for her history of Paroxysmal atrial fibrillation.
On post-op day three she required blood transfusion since she
had a hematocrit of 23.5. She otherwise appeared to be
recovering well and worked with physical therapy for strength
and mobility. On post-op day six she was discharged to rehab
facility with the appropriate medications and follow-up
appointments.
Medications on Admission:
Lipitor 10mg qd, Citalopram 40mg qd, Clonazepam 0.5mg prn qd,
Cardizem CD 180mg qd, Cardura 4mg qd, Monopril 20mg [**Hospital1 **], Lasix
40mg qd, Isosorbide mononitrate 30mg qd, Lopressor 100mg [**Hospital1 **],
Nitrol 0.4mg SL prn, Coumadin as directed, aspirin 81mg qd,
Vitamin D3 1,000 units qd, MVI qd, Fish oil [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours). Tablet(s)
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours).
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: goal
INR 2.5.
10. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day). Tablet(s)
11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO ONCE (Once).
14. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
15. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses.
16. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day
for 7 days: Give 3 tabs at 10 PM on [**10-13**], then 400 mg [**Hospital1 **] for 7
days. After 7 days, give 400 mg PO daily for 7 days, then
decrease to 200 mg PO daily.
Discharge Disposition:
Extended Care
Facility:
[**Doctor Last Name **]Nursing Home
Discharge Diagnosis:
aortic stenosis s/p aortic valve replacement
Atrial Fibrillation s/p MAZE and ligation of left atrial
appendage
Hypertension
Hyperlipidemia
Diabetes type 2
Depression
s/p resection of bladder cancer
s/p tonsillectomy
s/p uterine polypectomy
s/p spinal surgery
s/p cataract surgery
Discharge Condition:
Alert and oriented x3
Ambulating short distance with assistance
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming
Monitor wounds for infection and report any redness, warmth,
swelling, tenderness or drainage
Please take temperature each evening and Report any fever 100.5
or greater
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Please call to schedule appointments
Surgeon Dr [**Last Name (STitle) 914**] in 2 weeks [**Telephone/Fax (1) 170**]
Cardiologist Dr [**Last Name (STitle) 39975**] in 4 weeks [**Telephone/Fax (1) 66607**]
Primary care Dr [**Last Name (STitle) **] in 6 weeks [**Telephone/Fax (1) 74598**]
Completed by:[**2106-10-13**]
ICD9 Codes: 4241, 2859, 311, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1466
} | Medical Text: Admission Date: [**2132-2-10**] Discharge Date: [**2132-2-20**]
Date of Birth: [**2076-4-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Intermittent chest pain and shortness of breath
Major Surgical or Invasive Procedure:
[**2132-2-14**]
Coronary artery bypass grafting x3 to left internal mammary
artery to left anterior descending artery, bypass from the
ascending aorta to the obtuse marginal branch of the circumflex
artery using reverse
autologous saphenous vein graft and bypass from ascending aorta
to the diagonal artery branch of left anterior descending artery
using reverse autologous saphenous vein graft
History of Present Illness:
55 year old [**Country **] Rican male who emigrated to US in
[**2099**]-primarily spanish speaking but understands and speaks
english relatively well. He is transferred to [**Hospital1 18**] today from
[**Hospital6 **] after a positive stress test in the
setting of increasing episodes of chest pain over the last month
with minimal activity. The patient has a family history
significant for premature coronary artery disease. The cath was
done with Plavix at LGH. The cath showed that the patient has
left main coronary artery disease. The patient
was subsequently transferred to [**Hospital3 **] Medical Center.
Since the patient had Plavix, a decision was made to postpone
the procedure until the Plavix is washed out.
Past Medical History:
hypertension, asthma, GERD
CVA in [**2131-3-20**] - ? residual
Social History:
Race: [**Country **] Rican
Last Dental Exam: edentulous
Lives with: sister
Contact: Phone #
Occupation:disabled (previous forklift driver)
Cigarettes: Smoked no [] yes [x-1 pk every three days since age
11- quite 1 year ago]
Hx:
Other Tobacco use: marijuana -occas. onset age 17 heavy use
until
1 year ago now occasional
ETOH: < 1 drink/week [x] [**3-25**] drinks/week [] >8 drinks/week []
Illicit drug use: marijuana, cocaine-heroine inhaled. Denies
IVDA. Stopped illicit drug use one year ago after CVA.
Family History:
Family History:Premature coronary artery disease
Father MI < 55 [] died of cancer age 60 Mother < 65 [x-MI]
Physical Exam:
Physical Exam-Admission
Pulse:58 Resp: 18 O2 sat: 100%
B/P Right:146/93 Left:
Height: 5' 11" Weight: 69.2 kg
General: NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x]
Extremities: Warm [x], well-perfused [x] Edema -none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: cath site- small hematoma Left:+2
DP Right: +2 Left:+2
PT [**Name (NI) 167**]: +2 Left:+2
Radial Right: +2 Left:+2
Carotid Bruit Right: Left:
Pertinent Results:
Labs-Admission:
[**2132-2-10**] 05:28PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2132-2-10**] 05:28PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2132-2-10**] 07:50PM PT-11.1 PTT-31.2 INR(PT)-1.0
[**2132-2-10**] 07:50PM PLT COUNT-142*
[**2132-2-10**] 07:50PM WBC-7.1 RBC-4.43* HGB-14.2 HCT-41.5 MCV-94
MCH-32.0 MCHC-34.1 RDW-12.3
[**2132-2-10**] 07:50PM HCV Ab-POSITIVE*
[**2132-2-10**] 07:50PM HBsAg-NEGATIVE HBs Ab-NEGATIVE HBc
Ab-NEGATIVE
[**2132-2-10**] 07:50PM %HbA1c-5.5 eAG-111
[**2132-2-10**] 07:50PM ALBUMIN-4.5 MAGNESIUM-2.2
[**2132-2-10**] 07:50PM LIPASE-34
[**2132-2-10**] 07:50PM ALT(SGPT)-28 AST(SGOT)-26 ALK PHOS-74
AMYLASE-126* TOT BILI-0.6
[**2132-2-10**] 07:50PM GLUCOSE-92 UREA N-19 CREAT-1.0 SODIUM-138
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-23 ANION GAP-17
[**2132-2-10**] 11:41PM CK-MB-1 cTropnT-<0.01
[**2132-2-10**] 11:41PM CK(CPK)-102
Labs-Discharge:
[**2132-2-20**] 04:20AM BLOOD WBC-7.6 RBC-3.08* Hgb-10.0* Hct-29.2*
MCV-95 MCH-32.4* MCHC-34.1 RDW-12.6 Plt Ct-292
[**2132-2-20**] 04:20AM BLOOD Plt Ct-292
[**2132-2-20**] 04:20AM BLOOD Glucose-102* UreaN-17 Creat-0.8 Na-135
K-4.3 Cl-98 HCO3-27 AnGap-14
[**2132-2-20**] 04:20AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.2
[**2132-2-14**] TTE
LEFT ATRIUM: No spontaneous echo contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum.
LEFT VENTRICLE: Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Trivial
MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS:
Conclusions:
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is in SR, on no inotropes.
Preserved biventricular systolic fxn.
Aorta intact. Trace MR, no AI.
Radiology Report CT CHEST W/O CONTRAST Study Date of [**2132-2-19**]
12:42 PM
REASON FOR THIS EXAMINATION: eval RUL nodule, eval for source of
infection
Wet Read: JKSd [**First Name8 (NamePattern2) **] [**2132-2-19**] 5:10 PM
Final Report
FINDINGS: A 5-mm nodule at the right lung apex (4:37)
corresponds with the
nodule seen on the prior chest x-rays. An additional 3-mm
pulmonary nodule in the right middle lobe is also present
(4:84). There is paraseptal emphysema, predominantly in the
upper lobes bilaterally, with prominent apical bullae.
There are small bilateral pleural effusions with adjacent
atelectasis. There is no evidence of pulmonary infection. Linear
atelectasis is noted within the lingula. The airways are clear.
Patient is status post CABG. There are small retrosternal fluid
collections, many of which contain small air-fluid levels. Other
than expected mild stranding within the subcutaneous fat, the
chest wall subcutaneous fat remains preserved. There is no
presternal fluid collection.
This examination is not tailored for subdiaphragmatic
evaluation. A small
calcified granuloma is noted within the right lobe of the liver.
Otherwise, the non-contrast appearance of the upper abdomen is
within normal limits.
BONE WINDOWS: Patient is status post recent sternotomy. There is
no evidence of dehiscence or sternal wire fractures. There is no
erosion of the bone. There are no osseous lesions concerning
for metastatic disease.
IMPRESSION:
1. 5-mm right apical and 3-mm right middle lobe pulmonary
nodules. Six-month followup chest CT is recommended.
2. Moderate paraseptal emphysema with prominent apical bullae.
3. No evidence of pneumonia. Small bilateral pleural effusions
with adjacent atelectasis.
4. Multiple small retrosternal fluid collections, some with
air-fluid levels, not unexpected in this recently post-surgical
patient. No sternal dehiscence or evidence of sternal wire
fracture. No presternal fluid collection.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2132-2-18**] 2:03
PM
Final Report
The right IJ line has been removed.
The lungs are hyperinflated, suggesting background COPD, with
prominent
bullous change in the upper lobes bilaterally.
There are multiple sternal wires, similar in configuration to
[**2132-2-17**]. No
obvious break in the sternal wires is identified. Mediastinal
clips
consistent with CABG are present. he cardiomediastinal
silhouette is stable compared with one day earlier, with
mild-to-moderate cardiomegaly and an unfolded aorta.
Slight patchy opacity at the left base is overall unchanged.
Left pleural
effusion is smaller. Doubt CHF.
Again seen is the nodular opacity at the right lung apex,
IMPRESSION:
1. COPD and cardiomegaly.
2. Patchy opacity left base, essentially unchanged.
3. Small nodule at right lung apex again seen. Please see
recommendation for CT, described on prior CXR report.
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2-14**] where the patient underwent coronary
artery bypass grafing x3 please see operative report for
details. In summary he had: Coronary artery bypass grafting x3
to left internal mammary artery to left anterior descending
artery, bypass from the ascending aorta to the obtuse marginal
branch of the circumflex artery using reverse
autologous saphenous vein graft and bypass from ascending aorta
to the diagonal artery branch of left anterior descending artery
using reverse autologous saphenous vein graft. His bypass time
was 76 minutes with a crossclamp time of 62 minutes.
The patient tolerated the procedure well and post-operatively
was transferred to the CVICU in stable condition for recovery
and monitoring. POD 1 found the patient extubated, alert and
oriented and breathing comfortably. The patient was
neurologically intact and hemodynamically stable, phenylephrine
was sucessfully weaned off. Beta blocker was initiated and the
patient was gently diuresed toward the preoperative weight. The
patient was transferred to the telemetry floor on POD #1 for
further recovery. Chest tubes and pacing wires were
discontinued per cardiac surgery protocol. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. The remainder of his hospital course was
uneventful, by the time of discharge on POD6*the patient was
ambulating freely, the wound had small amount od bloody drainage
from mid incision, and pain was controlled with oral analgesics.
The patient was discharged home with visiting nurses in good
condition with appropriate follow up instructions.
Medications on Admission:
Lisinopril 10 daily, atenolol 25 daily, HCTZ 25 daily, ASA 325
daily, omeprazole 20 daily, spiriva,
Discharge Medications:
1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*30 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. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Keflex 500 mg Capsule Sig: One (1) Capsule PO three times a
day for 10 days.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary artery disease with worsening angina
Secondary Diagnosis:
hypertension
asthma
GERD
CVA [**2131-3-20**] - ? residual
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. Trace Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
WOUND CARE CLINIC Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2132-2-26**] 10:30
Surgeon: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2132-3-25**] 1:00
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 42394**] on [**2132-3-26**] @ 11:30AM
Please call to schedule appointments with:
Primary Care Dr. [**Last Name (STitle) **] in [**5-22**] weeks [**0-0-**]
***Chest CT w/pulmonary nodules-recommend f/u CT in 6 months***
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2132-2-20**]
ICD9 Codes: 4111, 4019, 2859, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1467
} | Medical Text: Admission Date: [**2183-11-5**] [**Month/Day/Year **] Date: [**2183-11-26**]
Date of Birth: [**2123-10-28**] Sex: M
Service: MEDICINE
Allergies:
Benzodiazepines
Attending:[**First Name3 (LF) 10488**]
Chief Complaint:
Found unresponsive
Major Surgical or Invasive Procedure:
Right internal jugular vein central venous catheter placement
-[**2183-11-5**]
Intubated prior to admission
History of Present Illness:
The patient is a 60yo M with history of CHF, COPD, DM who was
brought to an outside hospital after bieng found down and was
transferred here for management of shock and respiratory
failure.
.
He was found unresponsive at home by his wife. She reported that
he had increasing lethargy over the several weeks prior and
seemed normal his morning but wa unresponsive around 3pm. At
that time blood glucose was 41. He was given 1 amp D50 by EMS.
After an additional amp of D50 and blood glucose 195, his mental
status was still poor. He was also hypothermic with temperative
93 and he was taken to [**Hospital3 2783**]. His initial vitals
there were T 92.2 BP 105/60, HR 56, RR 12, O2 90. A head CT was
negative. A CXR there was concernign for fluid overload. An echo
showed EF 10-15%. He was intubated for concern for mental
status. The initial impression was that he was in cardiogenic
shock and he was started on a heparin gtt and given PR ASA
before transfer here.
.
On arrival here, his CXR was felt to be consistent with
pneumonia and heparin was stopped and he was given cefepime and
levofloxacin. Glucose was still low at 56 and he was given 1amp
D50. He arrived with peripheral dopamine. This was weaned off
initially but blood pressure trended down and a R IJ was placed
and levophed started. On transfer, VS were 97/59, 57, 15, 99%
vent FiO2 100%, PEEP 5, tv 528
Past Medical History:
CHF
Depression
COPD
GERD
Hyperlipidemia
DM
s/p R BKA
Social History:
- Tobacco: 1ppd
- Alcohol: denies
- Illicits: denies
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
General Appearance: Overweight / Obese
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube, OG
tube
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Not assessed), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Crackles : )
Abdominal: Soft, Distended
Extremities: Right lower extremity edema: 2+, Left lower
extremity edema: 2+, right BKA
Skin: Warm
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Sedated, Tone: Not assessed
[**Hospital3 **] exam: unchanged except for as below:
Weight at [**Hospital3 **] (after duiresis): 121kg
Lungs: mild crackles at the lung bases bilaterally, improved
Extremities: Left BKA, 1+ edema on right LE
HEENT: ET and OG tubes removed
Pertinent Results:
[**2183-11-5**] 06:45PM BLOOD WBC-5.2 RBC-3.26* Hgb-9.4* Hct-30.4*
MCV-93 MCH-28.8 MCHC-30.9* RDW-19.8* Plt Ct-355
[**2183-11-5**] 06:45PM BLOOD PT-20.6* PTT-150* INR(PT)-1.9*
[**2183-11-5**] 06:45PM BLOOD Glucose-58* UreaN-42* Creat-1.8* Na-141
K-3.3 Cl-110* HCO3-19* AnGap-15
[**2183-11-5**] 06:45PM BLOOD ALT-29 AST-28 AlkPhos-106 TotBili-1.5
Imaging:
-CXR ([**11-5**]) - Low-lying ET tube. Retraction by at least 1.5 cm
is advised. Advancement of NG tube result in more optimal
positioning. Scattered bilateral pulmonary opacities are
concerning for multifocal pneumonia, less likely pulmonary
edema. Findings D/w Dr. [**Last Name (STitle) 19409**].
-TTE ([**11-6**]) - The left atrium is moderately dilated. Late
saline contrast is seen in left heart suggesting intrapulmonary
shunting. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is moderately dilated. Overall left
ventricular systolic function is severely depressed (LVEF= 25 %)
secondary to akinesis of the posterior and lateral walls and of
the apex, and hypokinesis of the inferior free wall. The right
ventricular free wall thickness is normal. The right ventricular
cavity is dilated with depressed free wall contractility. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. At least
moderate [2+] tricuspid regurgitation is seen by color flow
Doppler. However, the inferior vena cava spectral Doppler signal
suggests that the tricuspid regurgitation could actually be 3+
or 4+. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
-Renal US ([**2183-11-7**]) - 1. Markedly limited examination secondary
to poor acoustic windows. No gross evidence of hydronephrosis.
2. Doppler examination was unable to be performed.
-CT head ([**2183-11-12**]) - 1. No acute intracranial process. 2.
Apparent lucency through the right frontal bone, upon
correlation with coronal and sagittal reconstructions, is felt
to likely represent a suture, less likely nondisplaced fracture.
Clinical correlation may be helpful.
-CXR ([**2183-11-19**]) - In comparison with study of [**11-16**], the patient
has taken a slightly better inspiration and the monitoring and
support devices have been removed except for the left subclavian
catheter. There is continued enlargement of the cardiac
silhouette with mild elevation of pulmonary venous pressure,
though this is substantially decreased from the previous study.
-Video swallow ([**2183-11-21**]) - Aspiration with thin liquids. For
complete report, please see speech and swallow note in OMR.
[**Month/Day/Year **] labs:
[**2183-11-26**] 07:20AM BLOOD WBC-5.6 RBC-3.03* Hgb-8.7* Hct-27.8*
MCV-92 MCH-28.8 MCHC-31.4 RDW-17.3* Plt Ct-425
[**2183-11-26**] 07:20AM BLOOD Glucose-44* UreaN-62* Creat-3.2* Na-146*
K-3.5 Cl-100 HCO3-34* AnGap-16
[**2183-11-26**] 07:20AM BLOOD Calcium-9.2 Phos-5.3* Mg-2.1
Brief Hospital Course:
60M with chronic systolic CHF (EF=25%), T2DM who p/w AMS,
bilateral opacities on CXR.
# Metabolic encephalopathy - Most likely result of hypoglycemia
and subsequent pneumonia. Unlikely from stroke given normal
head CT and lack of focal deficits. He was weaned off
midazolam, but remained significantly altered. He has had
prolonged delirium with benzos in the past. He was started on
seroquel 50mg TID with little improvement. His sedation was
switched to Precedex with relatively little change. Extubation
was attempted [**11-12**] but the patient was very altered and
agitated, eventually requiring re-intubation. With time his
mental status improved, and after extubation [**11-16**] his mental
status had cleared. Seroquel was stopped. We held additional
sedating medications and MS improved. He was noted to have
periods where he was sleepy while on the floor, this usually
occurred after he didn't wear CPAP overnight and improved when
he was compliant with this therapy.
# Septic shock - Most likely [**2-12**] pneumonia, ? community acquired
vs. aspiration. He was started on broad spectrum antibiotics,
levofloxacin/cefepime/vancomycin. His medication was dosed
renally and for CVVH. He underwent bronchoscopy on [**11-6**] which
showed thick purulent sputum. Urine legionella was negative.
BAL grew only yeast, which was not treated as the patient is
immunocompetent. Patient was treated for 8 days and abx were
stopped. He subsequently had a fever but was hemodynamically
stable. Cultures were negative. His R IJ was replaced by a PICC
line. The patient was afebrile x72hrs prior to leaving the ICU.
On the floor, he remained afebrile and hemodynamically stable.
# Multifocal pneumonia - Differential includes community
acquired vs. aspiration. He was covered broadly with cefepime,
vancomycin and levofloxacin. Treated for total of 8 days given
the severity of his pneumonia, as above. Speech and swallow
after extubation found that he could eat normal solids and
nectar pre-thickened fluids. Re-evalution with a video swallow
showed silent aspiration of thin liquids. At [**Month/Year (2) **], he has
only been cleared for nectar thick liquids and will need further
assessment by speech and swallow at rehab.
# Hypoxic respiratory failure - Most likely [**2-12**] pneumonia.
Intubated while in the ICU, successfully weaned and satting well
on RA at [**Month/Day (2) **].
# Acute on chronic systolic HF - EF was noted to be 25-30% over
the last few years per outside record. Repeat echocardiogram
confirmed systolic heart failure. Cardiac enzymes were mildly
elevated but also in the setting of ARF. Trial of dobutamine
was used during his initial MICU stay, but was not found to be
helpful. Diuresis was held given septic shock. He was
subsequently duiresed upon arrival to the floor. [**Month/Day (2) **]
weight was 121kg. He will be discharged on Lasix 80mg PO bid.
He is still thought to be total-body fluid overloaded and should
continue to diurese net negative. Unfortunately, he does not
know his dry weight. He should have daily fluid inputs and
outputs measured, as well as daily weights. He should also have
outpatient discussion about AICD.
# Acute on chronic renal failure - Most likely [**2-12**] ATN based on
urine lytes and sediments and poor forward flow given sCHF and
septic shock. Nephrology evaluated patient as he became anuric.
Received CVVH via a Left IJ dialysis catheter for 3 days,
finishing the evening [**11-9**]. Afterwards he received one session
of intermittent dialysis before his urine output improved and he
was able to be diuresed with doses of 80mg IV lasix. It remains
unclear what his new baseline creatinine will be. At [**Month/Year (2) **],
Cr has mildly improved to 3.5. His [**Month/Year (2) **] weight is 121kg.
He will follow-up with nephrology after [**Month/Year (2) **] and did not
require further hemodialysis on the floor. He was also started
on acetazolimide for persistent metabolic alkalosis with an
elevated bicarbonate level.
# Transaminitis. Thought to be secondary to congestive
hepatopathy. Resolved at [**Month/Year (2) **].
# Type 2 diabetes on insulin - Found to be hypoglycemic at
presentation, requiring D10. Improved with tube feeds, and
transitioned to regular sc insulin. At [**Month/Year (2) **], he will be
continued on Lantus and sliding scale insulin. His PO intake
had been very variable and we significantly decreased his Lantus
this admission. He will likely need this titrated as his PO
intake improved over time.
# Depression - He was continued on zoloft. Cymbalta was held
given ARF.
# COPD - Not on oxygen prior to admission, at [**Month/Year (2) **] he is
breathing comfortably on room air and maintaining sats. He did
not have significant wheezing during this admission. He was
continued on his home Advair and Spiriva.
# GERD - Continued on home PPI.
# Hyperlipidemia. Simvastatin was initially held. As
transaminitis improved, simvastatin and ezetimibe were restarted
#Code status during this admission - FULL CODE
#Transitional issues -
-Will need weekly Chem-10 to measure electrolytes given poor
renal function, particulary phosphate.
-A urinalysis and urine culture was sent prior to [**Month/Year (2) **],
this will need to be followed-up as an outpatient.
-Lisinopril and spironolactone were held during this admission
given his acute on chronic renal failure, these medications
should be re-considered at his follow-up nephrology appointment
as they are important for systolic CHF.
-Will need ongoing evaluation by speech and swallow for
aspiration with thin liquids
-Should continue to wear CPAP at night for OSA, will need a
machine at home after [**Month/Year (2) **] from rehab
-Will follow-up with nephrology regarding his acute on chronic
kidney disease
-Will need his insulin titrated after [**Month/Year (2) **], PO intake has
been variable and he is on significantly less Lantus than at
admission
-monitor for serotonin syndrome given cymbalta/zoloft
combination
-Continued diuresis with measurement of I/Os and daily weights.
-Discussion about AICD.
-OT follow up to improve functioning of his hands.
Medications on Admission:
Zoloft 100 mg Tab Oral 1.5 Tablet(s) Once Daily, at bedtime
Lantus 70 units Solution(s) Twice Daily (every 12 hrs)
Nizoral 2 % Shampoo Topical 1application Shampoo(s) twice weekly
lisinopril 5 mg Tab Oral 1 Tablet(s) Once Daily
Cymbalta 60 mg Cap Oral 1 Capsule, (E.C.)(s) Once Daily, at
bedtime
Coreg 6.25 mg Tab Oral 1 Tablet(s) Once Daily
simvastatin 20 mg Tab Oral 1 Tablet(s) Once Daily, at bedtime
Lasix 40 mg Tab Oral 1 Tablet(s) Once Daily
Novolin R 2-10 units Solution(s) sliding scale coverage
Spiriva Once Daily
Advair Diskus 250 mcg-50 mcg/dose Twice Daily
Zetia 10 mg Tab Oral 1 Tablet(s) Once Daily
Aldactone 25 mg Tab Oral 1 Tablet(s) Once Daily
Plavix 75 mg Tab Oral 1 Tablet(s) Once Daily
Neurontin 800 mg Tab Oral 1 Tablet(s) Three times daily
aspirin 81 mg Tab Oral 1 Tablet(s) Once Daily
Vitamin D -- Unknown Strength 1 tab Capsule(s) Once Daily
One Daily Multivitamin Tab Oral 1 Tablet(s) Once Daily
omeprazole 20 mg Tab Twice Daily
folic acid 1 mg Tab Oral 1 Tablet(s) Once Daily
Unisom 25 mg Tab Oral 1 Tablet(s) Once Daily, at bedtime
[**Month/Year (2) **] Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever or pain: Not to exceed 4000mg per
day.
3. albuterol sulfate 1.25 mg/3 mL Solution for Nebulization Sig:
One (1) nebulizer Inhalation every 4-6 hours as needed for
shortness of breath or wheezing.
4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
6. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
8. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
11. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
12. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection three times a day: Need for ongoing DVT
prophylaxis to be re-assessed by rehab physicians.
13. Lantus 100 unit/mL Solution Sig: Twenty Five (25) units
Subcutaneous twice a day.
14. insulin lispro 100 unit/mL Solution Sig: sliding scale units
Subcutaneous three times a day: 151-200 = 2 units
201-250 = 4 units
251-300 = 6 units
301-350 = 8 units
351-400 = 10 units
>400 = [**Name8 (MD) 138**] MD.
15. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
16. sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
17. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
18. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
19. multivitamin Tablet Sig: One (1) Tablet PO once a day.
20. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
21. Vitamin D-3 400 unit Capsule Sig: Two (2) Capsule PO once a
day.
22. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
23. acetazolamide 250 mg Tablet Sig: One (1) Tablet PO twice a
day.
24. Outpatient Lab Work
Weekly chem-10 at rehab
[**Name8 (MD) **] Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
[**Location (un) **] Diagnosis:
Primary diagnoses:
Multifocal pneumonia
Respiratory failure
Acute on chronic systolic heart failure
Acute kidney injury
Secondary diagnoses:
Type 2 diabetes
Hyperlipidemia
COPD
Depression
[**Location (un) **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
[**Location (un) **] Instructions:
Dear Mr. [**Known lastname 91050**],
It was a pleasure taking care of you during your admission to
[**Hospital1 18**] for pneumonia, CHF and kidney failure. You initially
presented after being found unresponsive. Your blood sugar was
low and you were given sugar. It was also found that you had a
severe pneumonia and you were treated with antibiotics. You
were also on a ventilator. Because of the infection and sepsis,
your blood pressure was low and you required pressors to
maintain your blood pressure. During this time when your blood
pressure was low, your kidneys were injured and you temprarily
required dialysis. Your kidney function has not returned to
[**Location 213**] and you will see a kidney doctor [**First Name (Titles) **] [**Last Name (Titles) **].
You will be discharged to a rehab facility to get your strength
back. You will follow-up with the kidney doctors as [**Name5 (PTitle) **] as
your PCP.
The following changes were made to your medications:
START acetazolomide 250mg by mouth twice daily
START calcium acetate 1334mg by mouth three times daily with
meals
START albuterol 1 nebulizer inhaled every 4-6 hours as needed
for wheezing or shortness of breath
CHANGE insulin glargine 25 units subcutaneous twice daily
CHANGE gabapentin 300mg by mouth twice daily
CHANGE Lasix 80mg by mouth twice daily
Followup Instructions:
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2183-12-2**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
ICD9 Codes: 0389, 5845, 5070, 2762, 496, 2724, 3051, 4280, 311, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1468
} | Medical Text: Admission Date: [**2119-1-30**] Discharge Date: [**2119-3-14**]
Date of Birth: [**2046-12-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Shellfish
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Back and flank pain
Major Surgical or Invasive Procedure:
[**2119-1-31**] Repair of thoracoabdominal aortic aneurysm with a 26 mm
Dacron tube graft(Vascutek Gelweave)using partial right heart
bypass.
[**2119-2-1**] Abdominal aortogram via open right common femoral
arterial approach.
Hemodialysis (on going)
Plasmapheresis (discontinued)
[**2119-2-23**] Insertion of RIJ Permacath
History of Present Illness:
This is a 72 year old female with known descending thoracic
aortic aneurysm. The patient was evaluated by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD
at [**Doctor Last Name **] [**Location (un) **] Hospital approximately one year ago and
offered elective repair. Patient declined surgery at that time.
On [**1-27**], she presented to outside hospital in [**State 108**]
complaining of severe back and flank pain. She admits to having
chronic back and flank pain for the past month prior to
presentation. A CT scan showed a large thoracic aortic aneurysm
measuring 12 centimeters; dissection could not be ruled out. A
left sided pleural effusion and moderate amount of pericardial
fluid were concomitantly noted. She was subsequently admitted to
the ICU and started on intravenous therapy for blood pressure
and heart rate control. She was stabilized and eventually
transferred to the [**Hospital1 18**] via med flight for cardiac surgical
intervention.
Past Medical History:
Thoracic Aortic Aneurysm
Hypertension
Hyperlipidemia
History of Heavy Tobacco Abuse
Carotid Artery Disease
Urinary Tract Infections
Bronchitis
Social History:
The patient lives in [**State 108**]. She has a 15-pack year smoking
history but quit 15 years ago. She denies EtOH use. She is
widowed and lives alone.
Family History:
The patient's mother died at 71 of stroke. Her father died of
myocardial infarction at 69
Physical Exam:
On admission:
v/s 37.0 C, 80 sinus, 119/67, 20, 97% room air
Gen: WD/WN, pleasant, NAD
Skin: no rashes
HEENT: PERRLA, no icterus, no trachial deviation, MMM
Neck: no masses, no LAD, no bruit
CV: RRR, no murmur
Pulm: CTAB
Abd: soft, NT/ND, no masses
GU: Foley to gravity
MS: strength equal bilaterally
Vascular: palpable distal pulses
Neuro: grossly non-focal
Pertinent Results:
[ truncated; please contact medical records department for full
details ([**Telephone/Fax (1) 65758**]]
[**2119-1-30**] 07:44PM BLOOD WBC-13.5* RBC-4.00* Hgb-11.3* Hct-33.9*
MCV-85 MCH-28.3 MCHC-33.3 RDW-15.2 Plt Ct-207
[**2119-1-31**] 02:44PM BLOOD WBC-23.2*# RBC-3.86*# Hgb-12.0#
Hct-32.1*# MCV-83 MCH-31.2 MCHC-37.5* RDW-15.3 Plt Ct-130*#
[**2119-2-1**] 10:51AM BLOOD WBC-20.2* RBC-4.38 Hgb-13.0 Hct-36.4
MCV-83 MCH-29.8 MCHC-35.8* RDW-15.9* Plt Ct-60*
[**2119-2-8**] 02:47AM BLOOD WBC-20.6* RBC-3.18* Hgb-9.2* Hct-26.7*
MCV-84 MCH-29.1 MCHC-34.7 RDW-17.4* Plt Ct-59*
[**2119-2-28**] 05:40AM BLOOD WBC-6.9 RBC-3.32* Hgb-9.9* Hct-29.4*
MCV-89 MCH-29.7 MCHC-33.5 RDW-20.9* Plt Ct-205
[**2119-2-28**] 06:32PM BLOOD WBC-7.3 RBC-2.80* Hgb-8.3* Hct-24.2*
MCV-86 MCH-29.5 MCHC-34.2 RDW-21.2* Plt Ct-178
[**2119-3-1**] 05:10PM BLOOD WBC-8.6 RBC-4.53# Hgb-13.2# Hct-39.3#
MCV-87 MCH-29.3 MCHC-33.7 RDW-19.0* Plt Ct-153
[**2119-3-2**] 08:05AM BLOOD WBC-9.8 RBC-4.53 Hgb-13.4 Hct-39.8 MCV-88
MCH-29.6 MCHC-33.7 RDW-19.1* Plt Ct-150
[**2119-3-6**] 05:02AM BLOOD Hct-34.6*
[**2119-1-30**] 07:44PM BLOOD PT-14.1* PTT-20.3* INR(PT)-1.2*
[**2119-3-2**] 08:05AM BLOOD PT-12.7 INR(PT)-1.1
[**2119-1-30**] 07:44PM BLOOD Fibrino-451*
[**2119-2-18**] 05:25AM BLOOD Fibrino-203
[**2119-1-30**] 07:44PM BLOOD Glucose-128* UreaN-19 Creat-0.8 Na-141
K-3.6 Cl-104 HCO3-22 AnGap-19
[**2119-2-1**] 03:30PM BLOOD Glucose-69* UreaN-35* Creat-2.3* Na-137
K-5.5* Cl-104 HCO3-23 AnGap-16
[**2119-2-3**] 03:25AM BLOOD UreaN-44* Creat-3.4* Na-138 K-5.0 Cl-104
HCO3-24 AnGap-15
[**2119-2-8**] 02:47AM BLOOD Glucose-108* UreaN-38* Creat-2.3* Na-135
K-4.3 Cl-100 HCO3-26 AnGap-13
[**2119-2-9**] 02:16AM BLOOD Glucose-107* UreaN-38* Creat-2.4* Na-144
K-3.8 Cl-107 HCO3-28 AnGap-13
[**2119-2-16**] 12:14AM BLOOD Glucose-110* UreaN-44* Creat-3.3*# Na-144
K-3.8 Cl-104 HCO3-29 AnGap-15
[**2119-2-18**] 03:13AM BLOOD Glucose-108* UreaN-29* Creat-3.1* Na-153*
K-3.8 Cl-113* HCO3-30 AnGap-14
[**2119-2-26**] 05:12AM BLOOD Glucose-60* UreaN-18 Creat-3.3* Na-140
K-4.0 Cl-103 HCO3-25 AnGap-16
[**2119-2-28**] 05:40AM BLOOD Glucose-71 UreaN-18 Creat-3.6* Na-141
K-4.0 Cl-107 HCO3-25 AnGap-13
[**2119-3-2**] 08:05AM BLOOD Glucose-77 UreaN-19 Creat-3.6* Na-142
K-4.2 Cl-105 HCO3-25 AnGap-16
[**2119-3-3**] 07:45AM BLOOD Glucose-71 UreaN-27* Creat-4.0* Na-139
K-6.7* Cl-104 HCO3-21* AnGap-21*
[**2119-3-4**] 05:45AM BLOOD Glucose-76 UreaN-14 Creat-2.6*# Na-143
K-3.1* Cl-105 HCO3-26 AnGap-15
[**2119-3-6**] 05:02AM BLOOD Glucose-92 UreaN-36* Creat-3.5* Na-138
K-4.6 Cl-103 HCO3-23 AnGap-17
[**2119-1-30**] 07:44PM BLOOD ALT-43* AST-66* LD(LDH)-382* AlkPhos-86
TotBili-0.7
[**2119-2-1**] 10:51AM BLOOD ALT-35 AST-131* LD(LDH)-1295* AlkPhos-64
Amylase-57 TotBili-3.1*
[**2119-2-3**] 03:25AM BLOOD ALT-39 AST-98* LD(LDH)-2323* AlkPhos-68
TotBili-1.9*
[**2119-2-22**] 02:57AM BLOOD ALT-19 AST-28 LD(LDH)-325* AlkPhos-70
TotBili-0.6
[**2119-3-1**] 05:10PM BLOOD ALT-20 AST-24 LD(LDH)-360* AlkPhos-86
Amylase-112* TotBili-0.4 DirBili-0.2 IndBili-0.2
[**2119-2-1**] 10:51AM BLOOD Lipase-37
[**2119-2-2**] 07:31AM BLOOD Lipase-22
[**2119-3-1**] 05:10PM BLOOD Lipase-103*
[**2119-1-30**] 07:44PM BLOOD Albumin-3.6
[**2119-2-1**] 10:51AM BLOOD Albumin-3.1* Phos-3.4 Mg-2.3
[**2119-2-2**] 07:31AM BLOOD Albumin-2.3*
[**2119-3-1**] 05:10PM BLOOD Albumin-3.0*
[**2119-2-10**] 03:27PM BLOOD calTIBC-164* VitB12-393 Folate-12.9
Hapto-<20* Ferritn-[**2103**]* TRF-126*
[**2119-2-21**] 10:34AM BLOOD Hapto-91
[**2119-1-30**] 07:44PM BLOOD %HbA1c-6.2* [Hgb]-DONE [A1c]-DONE
[**2119-2-3**] 04:00PM BLOOD Cortsol-54.4*
[**2119-3-3**] 04:10PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2119-2-1**] 03:41PM BLOOD C3-103 C4-17
MICROBIOLOGY:
[**2-15**] urine: > 100,000 yeast
[**2-17**] urine: 10-100,000 yeast
[**3-1**] blood: negative
[**2-20**] pleural fluid: negative
[**2-28**] urine Cx: negative
RADIOLOGY:
[**2119-1-30**] Carotid Ultrasound: 1. Occluded left internal carotid
artery.
2. Atherosclerotic plaque is present in the left common and
external carotid arteries.
3. Atherosclerotic plaque is present in the right internal
carotid artery
with findings of at least 40-59% stenosis (likely closer to 60%
stenosis).
[**2119-1-30**] MRA: 1. Extensive aneurysmal dilation of the descending
thoracic aorta measuring up to 11.1 cm. There is extensive
thrombus formation within the descending thoracic aorta with
areas of focal ulceration within the thrombus. The branch
vessels of the aortic arch are normal in appearance. There is no
clear evidence of dissection.
2. Supra- and infrarenal aneurysmal dilation of the abdominal
aorta with an intervening segment of more normal caliber aorta.
Extensive thrombus
formation, some of which appears to be of varying stages of
formation, is also present within the abdominal aorta. The
celiac, superior mesenteric, and renal artery origins appear
normal. There is no clear evidence of dissection.
3. Small left pleural effusion and associated atelectatic
changes in the left lung.
[**2119-1-30**] CXR: 1. Large descending thoracic aneurysm.
2. No evidence of acute cardiopulmonary process.
[**2119-1-31**] CXR: 1. Swan-Ganz catheter, and chest tubes in standard
positions without evidence of pneumothorax.
2. Opacification of the left lung secondary to a layering
pleural effusion
versus pulmonary hemorrhage.
3. Low position of the endotracheal tube tip located 1.5 cm
above the level of the carina.
[**2119-2-1**] Renal Ultrasound: 1. Color Doppler suggests diminished
renal blood flow bilaterally. Given patient's inability to have
CT or MR, if renal blood flow is of clinical concern, a nuclear
medicine blood flow study can be performed.
2. No evidence for obstruction. Trace free fluid about right
kidney.
[**2119-2-13**] Videoswallow Eval: Video oropharyngeal swallow exam was
performed in conjunction with speech and swallow therapy.
Varying consistencies of barium were administered under constant
video fluoroscopic monitoring. Aspiration of thin liquids
despite use of chin tuck was seen, likely secondary to impaired
vocal cord closure. There is significant vallecular residue. No
spontaneous cough was observed. Functional swallowing ability
was seen with ground solids and extra thick liquids if patient
swallowed with chin to her chest and alternating between 1 bite
and 1 sip rate. Following this study, there is also evidence of
retained barium still within the esophagus
[**2119-2-24**] CXR: Fluoroscopic guidance was provided for Dr. [**Last Name (STitle) 914**]
for Perm-A-
Catheter placement without a radiologist present. Two
fluoroscopic scout
images demonstrate a dual-chamber right Perm-A-Catheter
terminating in the
SVC. No final diagnostic images were obtained.
[**2119-2-28**] CXR: Right subclavian line terminating in the superior
vena cava.
Left lower lung lobe opacity consistent with atelectasis and
effusion.
Additional persistence of left mid lung zone opacity most
consistent with a loculated component to the left pleural
effusion, stable.
CARDIOLOGY:
[**2119-1-31**] TEE: Prebypass Study
Examination of the heart was limited because the thoracic
aneurysm was compressing on the left atrium and left ventricle.
Transgastric views prebypass showed normal LV and RV function.
The ascending aorta is normal in size with a well formed
sinotubular junction and there is no aortic regurgitation.
12 cm aneurysm seen in the thoracic portion of the descending
aorta with spontaneous echo contrast within the lumen.
Post Bypass
There is a graft seen on the thoracic portion of the descending
aorta. LV and RV function are preserved.
No atrial septal defect is seen by 2D or color Doppler.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are structurally normal. Mild (1+)
mitral regurgitation is seen.
[**2119-2-1**] TTE: The left atrium is normal in size. Left ventricular
wall thicknesses and cavity size are normal. Overall left
ventricular systolic function is mildly depressed with mild
global hypokinesis more prominent in the basal to mid septum
(may be due to conduction defect). The right ventricular cavity
is dilated. Right ventricular systolic function appears
depressed. The descending thoracic 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. Mild (1+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. The
estimated pulmonary artery systolic pressure is normal. There is
a moderate sized pericardial effusion. There are no
echocardiographic signs of tamponade.
CYTOLOGY:
[**2-20**] Pleural Fluid: negative for malignancy
Brief Hospital Course:
This is the brief summary of this prolonged hospital course for
this pleasant 2-year old female who underwent a thoracoabdominal
aneurysm repair on [**2119-1-31**] complicated by post-op renal failure
due to TTP requiring plasmapheresis and hemodialysis, as well as
pulmonary and infectious complications. On day of discharge the
patient was tolerating a regular diet, comfortable,
hemodynamically stable, and requiring rehab placement for
ongoing dialysis.
On [**2119-1-31**] Ms. [**Known lastname **] went to the operating room where she
underwent a left thoracotomy and thoracoabdominal aneurysm
repair with a #26 gelweave graft (please see the operative note
of Dr. [**Last Name (STitle) 914**] for full details). On POD #1 she had decreased
urine output and ATN was noted, a renal artery scan showed
obstruction of flow for which she was taken back to the
operating room for an abdominal angiogram via open right CFA
(please see the operative note of Dr. [**Last Name (STitle) **] for full details).
Patent BL renal arterties with 50% stenosis were found. She was
seen in consultation by renal medicine who recommended dialysis,
which began on [**2119-2-2**]. Her platelet count was low at 66,000, a
HIT screen was negative. She also had some confusion
post-operatively , after extubation on post-op day 5. Hematology
was consulted and her findings were consistent with TTP. He
platelet counts improved with plasmapheresis and eventually
normalized. She required intermittent neosynephrine and
nitroglycerine for BP management while on CVVHD, but eventually
was hemodynamically stable and restarted on lopressor as part of
her discharge regimen. Her renal failure improved and she was
able to make marginal urine (approximately 500 cc/day) prior to
discharge.
From a GI standpoint she was unable to tolerate a regular diet
initially after extubation. A bedside swallow evaluation on [**2-6**]
recomended continued tube feeds, but small amounts of pureed and
nectar thickened liquids with modifications. She was seen in
consultation by ENT and found to have vocal cord paralysis but
no immediate intervention was recommended. A Dobhoff tube was
placed for tube feeding, and eventually this was removed and a
regular diet was resumed. Nutrition consultation was obtained
and nutritional supplements such as Carnation instant breakfast
were recommended.
She had no major pulmonary issues post-operatively, but did
develop a left-sided pleural effusion. This was tapped for
approximately 1 liter on [**2119-2-20**] and she symptomatically did
better. She had no documented post-operative pneumonia.
From an infectious disease standpoint she had some fevers around
2 weeks post-operative. Full workup revealed only significant
yeast in her urine and she was treated appropriately with
Fluconazole. She also had empiric vancomycin around the
peri-operative period.
The patient worked with physical therapy and was able to
ambulate well with some assistance prior to discharge. Social
work services were obtained early in her hospital course and
case management assisted with finding appropriate
rehabilitation, as the patient originally is from [**State 108**].
The patient was discharged over 1 month post-operatively in
stable condition, tolerating a regular diet, ambulatory, with
good pain control, and normal cardio-pulmonary function. Her
major issues upon discharge included ongoing need for
hemodialysis, assistance with physical therapy, and assistance
with nutritional support. She has planned follow-up with Cardiac
Surgery. All questions were answered to her satisfaction upon
discharge.
Medications on Admission:
Verapamil 240 mg po qdaily
Flexaril
Vitorin (stopped 3 weeks prior)
Discharge Medications:
1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) 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. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-21**]
Puffs Inhalation Q6H (every 6 hours) as needed.
8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: One (1)
Tablet PO Q6H (every 6 hours) as needed.
12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
13. Insulin Lispro (Human) 100 unit/mL Solution Sig: One (1)
injection Subcutaneous ASDIR (AS DIRECTED): per sliding scale
(as printed).
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed.
15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
16. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
17. Diphenhydramine HCl 25 mg Capsule Sig: 0.5 Capsule PO Q6H
(every 6 hours) as needed for itching.
18. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
19. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed.
20. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Hospital1 789**] RI
Discharge Diagnosis:
Primary: Thoracic Aortic Aneurysm - s/p repair
Secondary:
Postoperative Renal Failure
TTP
Vocal Cord Paralysis
Failure to Thrive
Hypertension
Hyperlipidemia
History of Heavy Tobacco Abuse
Carotid Artery Disease
Preoperative Urinary Tract Infection
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, 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 with any
concerns or questions.
Followup Instructions:
Follow-up with your Cardiac surgeon, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] in [**2-22**]
weeks.
Follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 65759**] in [**12-23**] weeks.
Follow-up with ENT , Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], in [**12-23**] weeks
[**Telephone/Fax (1) 41**]
Nephrology management per rehabilitation hospital Nephrologist
Completed by:[**2119-3-7**]
ICD9 Codes: 5119, 4019, 5845 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1469
} | Medical Text: Admission Date: [**2162-3-8**] Discharge Date: [**2162-3-22**]
Date of Birth: [**2133-4-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Found Down
Major Surgical or Invasive Procedure:
-Placement of right sided IJ CVL
-Arterial line placement
-Lumbar puncture
History of Present Illness:
This is a 27 y.o. male with a history of polysubstance abuse,
depressive disorder NOS, and GERD who presents after being found
down at [**Hospital3 **] where he been admitted for detox.
Per [**Hospital1 **] notes, the patient endorsed an 8 mo history of
abusing multiple types of opiates including oxycontin,
methadone, and heroin. He had decided to quit and thus had
managed to obtain methadone with the intent to wean himself
gradually from that medication. Unfortunately, on [**2162-3-6**] he
accidentally overdosed on the methadone and was brought into
[**Hospital **] hospital for treatment (it is unclear exactly what were
the details of his overdose and how he was managed though it
appears he was discharged from the emergency room). After
discharge from the ED he self referred to [**Hospital1 **] for detox.
He was admitted without incident and was alert, oriented, and
appropriate. On the evening of [**2162-3-7**] he received his last dose
of methadone at 8:00 pm. He also received his citalopram and
omeprazole there by report and one dose of trazodone for sleep.
The next morning he was found around 9:00 am to be unresponsive
and tachypneic with pinpoint pupils. Primary concern was for
opioid overdose so the patient was given naloxone (total 0.8 mg)
with no improvement in mental status by report but his miosis
did resolve. He was then taken to the [**Hospital1 **] ED. Initially he was
hypertensive, tachycardic, tachypnic, febrile, and diaphoretic.
Though there was notable rigidity there was concern raised for
serotonin syndrome given SSRI and trazodone use. Toxicologic
screen was positive for methadone only and other labs were
notable an elevated lactate and acute kidney injury. He was
intubated and sedated with propofol and etomidate for for airway
protection. Subsequently became hypotensive. Broad spectrum abx
administered for suspected infectious etiology. He also
received cyproheptidine to reverse possible serotonin syndrome
and 6.8 L of fluid after an elevated CPK suggested
rhabdomyolysis. LP was also performed to evaluate for
meningitis.
Past Medical History:
1) GERD
2) Depressive disorder NOS
3) Polysubstance abuse
4) Hx of suicide attempt at age 15
Social History:
Notable for 2-3 years of abuse of opioids and cocaine. Per the
patient's reports at [**Hospital1 **] he does not feel cocaine is a
problem though he was concerned about his opioid abuse. Unclear
smoking history and alcohol abuse history. He lives with his
girlfriend in an apartment with their daughter. [**Name (NI) **] is
unemployed. One other son who lives with his mother.
Family History:
Unknown
Physical Exam:
Vitals: 98.7 117/81 71 18 100%RA
Pain: denies
Access: PIV
Gen: nad, sleepy this am
HEENT: mmm
CV: RRR, no m
Resp: CTAB, no crackles or wheezing
Abd; soft, nontender, +BS
Ext; no edema
Neuro: new baseline
Skin: mulitple tattoos
psych: easily agitated.
Pertinent Results:
Na 137, K 5.7, Cl 108, HCO3 20, BUN 32, Cr 2.5, Glu 124
CK: [**Numeric Identifier **] MB: 117 MBI: 0.5 Trop-T: 0.82
Ca: 6.5 Mg: 2.2 P: 2.5
.
WBC 17.8, Hgb 12.2, MCV 89, Hct 35.9, Plt 227
---N:78.7 L:14.5 M:6.2 E:0.4 Bas:0.1
.
PT: 17.6 PTT: 30.0 INR: 1.6
.
ABG 7.33/40/59/22
ALT: 3558, AST 4323, AP: 102, LDH 5900, Tbili: 0.5
[**Doctor First Name **]: 461 Lip: 31
.
discharge time:
wbc 12.8->10 (downtrending)
hgb 11.2 (stable [**11-7**])
BUN 24/1.6 (plateaued since [**3-18**])
mag 1.7
INR 1.4
AST 47, ALT 160 (overall improved from AST/ALT 6000s/4000s)
CK [**Numeric Identifier 16351**]-->400s
TSH 2.1
Serum Tox neg, Hep A/B/C neg
blood cx all NTD
C-diff neg
.
.
.
CSF:
1 WBC, 1 RBC (68% lymphs, 32% monos)
Protein 26, Gluc 90
.
UA:
Cloudy, trace LE, Lg Blood, (-) nitrite, 100 Prot, (-) gluc,
(-)ketone, [**7-7**] RBC, [**12-17**] WBC, moderate bacteria, [**12-17**]
granular casts
.
Other Studies:
CT Head w/o contrast:
IMPRESSION: Bilateral hypodense appearance of the globus
pallidus,
nonspecific, but may be related to patient's history of drug
overdose. An MRI is recommended for further evaluation.
Partial opacification of the bilateral ethmoid and right
maxillary sinus.
.
CXR:
IMPRESSION: Patchy airspace opacities within the bilateral hilar
and left basilar regions. Given the patient's history of
intoxication, these findings are suspicious for aspiration.
However, given the perihilar opacities, central pulmonary
vascular congestion cannot be excluded.
CT Head [**2162-3-11**]:
IMPRESSION:
1. Interval increase in the prominence of hypodensity in the
bilateral globus pallidus.
2. Stable partial opacification of the bilateral ethmoid
sinuses.
MRI/MRA head [**2162-3-12**]:
IMPRESSION:
1. Extensive areas of restricted diffusion involving the white
matter, corpus callosum, both globus pallidus and right
hippocampus indicative of
acute infarct/ischemia likely due to global hypoxia.
2. No evidence of midline shift or herniation.
MRA OF THE HEAD:
The head MRA demonstrates normal flow signal within the arteries
of anterior and posterior circulation.
EEG:
IMPRESSION: This is an abnormal portable EEG due to the slow
background,
suggestive of an widespread encephalopathy. The marked
rhythmicity of
the background activity suggests a predominant involvement of
the deep
brain structures. There were no epileptiform features seen and
no
lateralized findings, although the slow background could obscure
additional focal slowing. .
.
[**3-15**] CXR: nothing acute
Brief Hospital Course:
27 year old male with a history of polysubstance abuse,
depression with SIs, admitted [**3-8**] after found down (obtuneded),
with anoxic brain injury (per MRI/EEG). Hospital course
complicated by Rhabdo, ARF, Aspiration PNA->respiratory
failure/intubation. Medical issues stable, slow recovery from
anoxic brain injury, going to rehab for PT/OT/speech therapy.
1)Anoxic brain injury/found down: The ultimate etiology of the
patient's initial obtundation remains unclear. [**Name2 (NI) **] conflicting
stories from the various interested parties (girlfriend, family,
etc...) and conflicting reports about the patient's substance
use prior to arrival at [**Hospital1 **]. Per [**Hospital1 **] notes
patient received methadone at 8:00 pm and next seen 9:00 am next
morning at which time he was unresponsive and hypoxic. Possible
overdose vs seizure vs serotonin syndrome. Of course, given
history of opioid abuse there is concern the patient may have
overdosed. His drug screen was only positive for methadone. Of
note, his mental status did not resolve after receiving
naloxone, but it is possible that at that point anoxic brain
injury was primary mechanism of obtundation. Other possible
primary insults would include seizure (though not supported by
EEG) or serotonin syndrome due to trazodone in addition to his
SSRI. At presentation to the hospital as the patient was noted
to have clonus, hypertension, and fever there was increased
concern for serotonin syndrome so toxicology was consulted and
on their recommendation the patient received a course of
cyproheptidine (antidote to serotonin syndrome) with no clear
improvement. In the ED tox screen was negative except for
methadone and CT revealed only bilateral hypodensity in the
globus pallidus. The patient did spike a fever so also had an
LP, which showed no pleiocytosis or findings concerning for
meningitis. Osmolality was also checked and the patient had no
osmolal gap suggesting there had been no ingestion of
non-ethanol alcohols. Over the following days the patient's
other pathologies (respiratory distress/PNA, hypotension, ARF
etc...) continued to resolve but he continued to have altered MS
and not localize to noxious stimuli or follow commands. Repeat
CT showed persistent hypodensity of the globus pallidus
bilaterally. Neurology consult was called and thought this was
most consistent with anoxic brain injury but recommended MRI/MRA
and EEG. MRI/MRA showed findings consistent with anoxic brain
injury and EEG revealed extensive areas of restricted diffusion
involving the white matter, corpus callosum, both globus
pallidus and right hippocampus indicative of acute
infarct/ischemia likely due to global hypoxia. EEG showed
findings consistent with global encephalopathy without
lateralizing or epileptiform activity. The patient's family was
informed of these findings and a likely unfavorable prognosis.
Nevertheless, after extubation the patient did begin to answer
simple questions appropriately and speak to his family though he
did continue to not be aware of his name or situation
intermittently and reported he was unable to move his
extremities, but intermittently had reflexive movements. Upon
transfer to the medical floor, his mental status continued to
improve very slowly. He was able to speak coherently, raise his
limbs against gravity, take POs w/o aspiration. He was evaluated
by PT/OT and speech therapy who recommended rehabilitation for
further regaining of mobility/speech therapy. His current MS
waxes/wanes. He can be uncooperative when awake trying to climb
out of bed. At other times, he is calm. Also on klonipin for
tremors per neuro which has sedating effect, thus dose decreased
1mg -->0.5mg tid.
.
Other issues during hospitalization were: Hypoxemic respiratory
failure, extubated [**3-12**], [**3-1**] aspiration PNA/pneumonitis. sputum
cx with OP flora supported aspiration Dx. initially broad Abx
(vancomycin, pipercillin/tazobactam, and levofloxacin)--->
unasyn until [**3-16**] (7days). Currenlty doing well on RA.
.
Rhabdomyolisis with ARF/ATN, transamintitis. CKs up to 25K,
Creat peak 4.8, initially anuric, s/p 7L fluids with
improvement. Now creat plateued 24/1.6 (X5days) by time of
discharge, likely his new baseline. LFTs and CKs also much
improved, should have complete metabolic panel checked every few
days for next couple weeks. Needs f/u PCP [**Name Initial (PRE) 13303**].
.
Fever of Unknown Origin: The patient was persistently febrile
throughout first part of his hospital stay. Blood cultures
persistently negative and no other localizing signs except
possible aspiration pneumonia (thought unlikely as respiratory
status was improving). Had some diarrhea (on lactulose), c-diff
neg X2. He eventually defervesced without any intervention and
has been afebrile for several days
.
Rashes: The patient had areas of erythema on his medial knees at
presentation with some vesicles. These were cultured for herpes
and were negative. Thought most likely due to pressure injury
when found down. A wound care consult was called for concern
for skin breakdown, and he was placed on a First Step mattress.
.
Tremors and diaphoresis: He was noted to be tremulous and
diaphoretic during his stay. He had a normal TSH, and a
resolving fever and WBC count. He was placed on Klonopin for
tremors. this dose was reduced to 0.5mg tid on day of discharge
given increased somnolence with 1mg dose.
.
Depression and polysubstance abuse. He was followed by
psychiatry and social work during his stay. He did not express
suicidal ideations during his stay. He was briefly on a
one-to-one sitter. His celexa was not resumed on discharge, and
he will require psychiatric follow up as an outpatient.
Medications on Admission:
-Omeprazole 20 mg PO daily
-Citalopram 40 mg PO daily
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
2. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO TID (3 times
a day).
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
6. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Discharge Disposition:
Extended Care
Facility:
R at [**Location (un) 86**] radius
Discharge Diagnosis:
1. Anoxic brain injury
2. Transaminitis
3. Acute renal failure
4. Rhabdomyolysis
5. Depression
6. Polysubstance abuse
7. Tremors
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital and found to have anoxic brain
injury.
If you develop increased pain, fevers, chills, tremors,
confusion, or weakness, you should call your primary care doctor
or go to the emergency room.
Followup Instructions:
Please follow up with your psychiatrist and a primary care
doctor. To make an appointment with a primary care doctor in [**Hospital6 81315**], you can call [**Telephone/Fax (1) 250**].
ICD9 Codes: 5845, 2760, 5070, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1470
} | Medical Text: Admission Date: [**2130-2-3**] Discharge Date: [**2130-2-12**]
Date of Birth: [**2083-1-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Tracheobronchomalacia
Major Surgical or Invasive Procedure:
[**2130-2-3**]
Redo right thoracotomy, thoracic tracheoplasty
with mesh, right mainstem bronchus bronchoplasty with mesh,
left mainstem bronchus bronchoplasty with mesh, repair of
bronchus intermedius laceration, bronchoscopy with
bronchoalveolar lavage, pericardial fat pad buttress
History of Present Illness:
47yo male with ongoing dyspnea with exertion mostly and severe
bouts of dry high-pitch cough for years. He was evaluated for
on
multiple occasions but only about 9 months ago underwent
bronchoscopy showing tracheomalacia in the distal trachea.
Further work up was complicated by a trial of stent resulting in
R bronchial tear needing surgical repair with a muscle flap,
tracheostomy and prolonged ICU course, rehab, eventual trach
removal. On presentations he is bothered by a severe dry cough,
DOE and decreased activity toleraNCE. He had a trial stent
placedin early [**January 2130**]
which improved his symptoms dramatically. The stent was removed
for yeast laryngitis and he had completed a course of Diflucan.
Past Medical History:
PMH
Tracheomalacia
HTN
obesity
anxiety/depression
mild GERD
Hx of portal vein thrombosis which resolved
sinusitis
s/p Right thoracotomy with repair of bronchial tear with
intercostal muscle flap
Social History:
From [**State 4260**]
Married, supportive family.
No A/T/D
Family History:
Noncontributory
Physical Exam:
BP: 130/73. Heart Rate: 92. Weight: 197. Height: 65.5. BMI:
32.3. Temperature: 98.7. Resp. Rate: 16. Pain Score: 0. O2
Saturation%: 99.
Chest:CTAB, incisions healing well
COR RRR
Abd lg soft, NT
Ext calves soft, no edema
Pertinent Results:
[**2130-2-10**] 09:25AM BLOOD WBC-11.1* RBC-3.35* Hgb-9.8* Hct-29.0*
MCV-87 MCH-29.3 MCHC-33.9 RDW-14.9 Plt Ct-182
[**2130-2-10**] 09:25AM BLOOD Plt Ct-182
[**2130-2-10**] 09:25AM BLOOD Glucose-91 UreaN-15 Creat-0.8 Na-136
K-3.9 Cl-96 HCO3-28 AnGap-16
[**2130-2-6**] 01:53AM BLOOD CK(CPK)-4430*
[**2130-2-5**] 01:49PM BLOOD CK-MB-12* MB Indx-0.2
[**2130-2-10**] 09:25AM BLOOD Calcium-9.4 Phos-3.7 Mg-2.0
[**2130-2-7**] 09:40PM BLOOD Type-ART pO2-107* pCO2-47* pH-7.44
calTCO2-33* Base XS-6
[**2130-2-6**] 01:12PM BLOOD Lactate-0.8
[**2130-2-6**] 10:19AM BLOOD O2 Sat-87
[**2130-2-7**] 09:40PM BLOOD freeCa-1.08*
Brief Hospital Course:
The patient was admitted to the surgical service following Redo
right thoracotomy, thoracic tracheoplasty with mesh, right
mainstem bronchus bronchoplasty with mesh,
left mainstem bronchus bronchoplasty with mesh, repair of
bronchus intermedius laceration, bronchoscopy with
bronchoalveolar lavage, pericardial fat pad buttress. Please
see the dictated operative note for further details of the
patient's procedure. Postoperatively the patient was taken to
the surgical intensive care unit.
Intensive care Unit Course:
[**2-3**]: Admitted to the Surgical Intensive Care Unit status post
redo tracheobronchoplasty for tracheobronchomalacia. He was
extubated, weaned off pressor support. He continued to have
sinus tachycardia overnight. His CK was increased to 7,000, his
Creatinine was 1.3, he was making adequate urine
[**2-4**]: Chest tube put to water seal. Repeat CXR showed increased
pleural effusion on the right side, chest tube was put back to
suction. He was started on ativan as needed for agitation, which
is a home medication. His hematocrit had slow decline, unclear
source as no evidence of active bleeding. His creatine kinase
was downtrending from 8000 to 6000 with fluids.
[**2-5**]: Poor pain control in AM, was evaluated by the acute pain
service. The epidural was still working well and hence was
adjusted to Bupivicaine+Dilaudid rate 12 (max) with good effect.
CK from 7000->4500 in pm, his urine output was sufficient.
[**2-6**]: Pt became increasingly tachypneic, with increased oxygen
requirement. He received IV Lasix with good response and was
placed on BiPAP w/ subsequent improvement in CXR, oxygenation,
and symptoms. O2 sats remained stable on shovel mask overnight.
Hct trend 21.8-->21.7--19.8 w/ complaints of dizziness.
Transfused 1u PRBC w/ Hct increase to 23. Pain control tenuous;
epidural rate to 14, split and dilaudid PCA added.
[**2-7**]: Lasix given in the AM, with good UOP of about 600cc. Chest
tube pulled in AM, repeat CXR showed no reaccumulation of
effusion. HIs diet was advanced per thoracics attending. Lasix
repeated in the evening, with overall negative -400. Hct stable.
ABG stable. can most likely be transferred to the floor today.
[**2-8**]: Epidural DC'd, HSQ increased to TID. Not using Dilaudid PCA
(only took 0.5mg overnight), started Oxycodone w/ Dilaudid IV
PRN for breakthrough, made bowel regimen standing. He was
transferred to the floor.
Upon transfer to the floor,the patient was doing well. He had
no acute events, and hisoxygen was gradually weaned. His pain
was controlled with oral pain medication. He was tolerating a
regular diet. He was able to ambulate and void. A trending
ambulatory pulse oximetry was done on [**2130-2-11**] which demonstrated
that he was able to maintain his oxygenation at 93-96% on room
air. His mental status was clear and coherent at his baseline.
Hid home medications were restarted. He will be discharged and
will remain in the area at a nearby hotel until seen in follow
up, at which time he may be medically cleared to travel back to
[**State 4260**] with his wife.
Medications on Admission:
Nasonex 50 mg 2 puffs [**Hospital1 **]
Lipitor 40 mg PO Daily
Cymbalta 60 mg 1 tab PO daily
Nexium 40 mg 1 tab PO daily
Divalproex 500 mg 1 tab PO daily
Febofibrate 200 mg PO daily
Notriptyline 25 mg PO Daily
Lorazepam 1 mg POI Daily
Discharge Medications:
1. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime.
4. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Nasonex 50 mcg/actuation Spray, Non-Aerosol Sig: Two (2)
nasal sprays Nasal once a day.
6. fenofibrate 160 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
8. lorazepam 1 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety.
9. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
11. Oxycodone 5-10mg PO Q4H prn pain
Discharge Disposition:
Home
Discharge Diagnosis:
tracheobronchomalacia
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 lung surgery and you've
recovered well. You are now ready for discharge.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* You will continue to need pain medication once you are home
but you can wean it over a few weeks as the discomfort resolves.
Make sure that you have regular bowel movements while on
narcotic pain medications as they are constipating which can
cause more problems. Use a stool softener or gentle laxative to
stay regular.
* No driving while taking narcotic pain medication.
* Take Tylenol 650 mg every 6 hours in between your narcotic.
If your doctor allows you may also take Ibuprofen to help
relieve the pain.
* Continue to stay well hydrated and eat well to heal your
incisions
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk 4-5 times a day and gradually increase your activity as
you can tolerate.
Call Dr.[**Name (NI) 5067**]/Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you
experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other symptoms
that concern you.
Followup Instructions:
As you know, you should remain in the area until seen in follow
up in Dr.[**Name (NI) 2347**] clinic. At that time you may be cleared
for travel back to [**State 4260**].
Please call Dr.[**Name (NI) 92303**] Clinic at [**Telephone/Fax (1) 92304**] to schedule
your follow up appointment.
Completed by:[**2130-3-9**]
ICD9 Codes: 5119, 2851, 4019, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1471
} | Medical Text: Admission Date: [**2187-9-5**] Discharge Date: [**2187-9-13**]
Date of Birth: [**2112-9-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2074**]
Chief Complaint:
Ongoing chest pain and positive cardiac enzymes transfer for
cardiac catheterization
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
Pt is a 75 yo male with DM, ESRD, on HD for 18 months , HTN,
high cholesterol, PAF, with dual chamber pacer for heart block,
transferred to [**Hospital1 18**] for urgent cath due to ongoing CP and +
cardiac enzymes. Patient was admitted to [**Hospital3 **] yesterday with
N/V/D. He notes that he had bilateral upper chest pain 2 weeks
ago that was attributed to pleuritic CP secondary to pneumonia.
He did have a hacking cough with minimal sputum for the past 2
weeks. He was treated for CAP. On day of transfer to [**Hospital1 **], he c/o
SOB, sats 83-84% which resp to nonrebreather ->high 90's and
upon further questioning said that he had been having chest and
shoulder pain for several days at home. Cardiac enzymes were
drawn 1st trop I was 18.32, given plavix, lopressor, nitro drip.
Cardiac catheterization showed CO 4.09, CI 1.95, PCWP 21, RA
12, PA 51/22
LMCA normal
LAD: midsegment 80% lesion with modest calcium
LCX: non-domninant vessel with mid-segment 90% lesion after OM1.
OM 1 TO with bridging and retrograde L-L collaterals
RCA: dominant vessel with occlusion proximally. Distal flow from
L-R collaterals.
Transferred to CCU for observation and treatment of ?
pneumonia. He denies CP, SOB, abd pain, palpitations.
Past Medical History:
PMH:
1. A fib during dialysis
2.? wenkebach to complete heart block, 2:1 AV block; pacer
placed 3/12/043.DM
4. neuropathy
5. ESRD on dialysis for past 18 months
6. Retinopathy
7. Anemia
8. Hypercholesterolemia
9. Hypertension
Social History:
Social history: Lives with wife. HAs 3 children. Never smoked.
occasionally drinks
Family History:
non-contributory
Physical Exam:
Vitals:
General:
HEENT:
CV:
Pulmonary:
Abd:
Ext:
Neuro:
Pertinent Results:
Labs from OSH:
OSH cultures: bl cultures +micrococcus (contaminant)
CK 392
MB 52.9
index 13.5
TropI 18.32-
[**2187-9-6**] 02:15AM BLOOD WBC-10.6 RBC-3.52* Hgb-11.1* Hct-33.3*
MCV-95 MCH-31.7 MCHC-33.4 RDW-16.7* Plt Ct-218
[**2187-9-8**] 08:27PM BLOOD Hct-26.5*
[**2187-9-9**] 11:11PM BLOOD Hct-30.4*
[**2187-9-12**] 04:00PM BLOOD Hct-35.8*
[**2187-9-13**] 08:25AM BLOOD WBC-8.3 RBC-3.73* Hgb-11.7* Hct-35.0*
MCV-94 MCH-31.5 MCHC-33.6 RDW-16.6* Plt Ct-318
[**2187-9-6**] 02:15AM BLOOD PT-16.7* PTT-30.4 INR(PT)-1.9
[**2187-9-7**] 03:30AM BLOOD PT-21.0* PTT-118.7* INR(PT)-2.9
[**2187-9-8**] 05:59AM BLOOD PT-16.6* PTT-34.9 INR(PT)-1.8
[**2187-9-12**] 07:20AM BLOOD PT-17.2* PTT-78.1* INR(PT)-2.0
[**2187-9-6**] 02:15AM BLOOD Glucose-132* UreaN-48* Creat-6.9* Na-135
K-5.8* Cl-97 HCO3-24 AnGap-20
[**2187-9-9**] 09:13AM BLOOD Glucose-188* UreaN-44* Creat-5.1*# Na-136
K-5.7* Cl-96 HCO3-27 AnGap-19
[**2187-9-13**] 08:25AM BLOOD Glucose-271* UreaN-63* Creat-6.6*# Na-136
K-3.8 Cl-96 HCO3-25 AnGap-19
[**2187-9-6**] 02:15AM BLOOD CK-MB-79* MB Indx-12.4* cTropnT-4.84*
[**2187-9-6**] 09:43AM BLOOD CK-MB-47* MB Indx-9.2*
[**2187-9-6**] 06:22PM BLOOD CK-MB-23* MB Indx-6.0
[**2187-9-6**] 08:49PM BLOOD CK-MB-16* MB Indx-4.4
[**2187-9-8**] 08:27PM BLOOD CK-MB-11* cTropnT-9.13*
[**2187-9-6**] 02:15AM BLOOD Phos-4.6* Mg-2.3
[**2187-9-13**] 08:25AM BLOOD Albumin-3.4 Calcium-9.0 Phos-4.2 Mg-1.9
[**2187-9-7**] 03:30AM BLOOD Ferritn-1163*
[**2187-9-8**] 05:59AM BLOOD calTIBC-157* VitB12-789 Folate-10.5
Hapto-170 Ferritn-1512* TRF-121*
[**2187-9-8**] 05:59AM BLOOD TSH-2.5
[**2187-9-7**] 03:30AM BLOOD Vanco-13.5*
[**2187-9-5**] 09:33PM BLOOD Type-ART O2 Flow-15 pO2-89 pCO2-43
pH-7.38 calHCO3-26 Base XS-0 Intubat-NOT INTUBA Comment-NRB
[**2187-9-5**]
Cardiac catheterization: Final report pending. preliminary
report indicates severe 3 VD.
[**2187-9-6**] CXR: 1. Moderate congestive heart failure.
2. Patchy opacities in the right lung and left upper lobe. This
could be due to alveolar pulmonary edema or superimposed
infection.
Echocardiogram: EF 20-25% 1. The left atrium is moderately
dilated.
2. The left ventricular cavity size is normal. There is severe
global left ventricular hypokinesis. Overall left ventricular
systolic function is severely depressed. 3. The aortic valve
leaflets are moderately thickened. 4. The mitral valve leaflets
are mildly thickened. Mild (1+) mitral regurgitation is seen.
[**2187-9-7**]
Carotid U/S: Globular, partially shadowing plaque in both
proximal internal carotid arteries with less than 40%
hemodynamic effect on the right and around 40% hemodynamic
effect on the left.
Brief Hospital Course:
75 yo male with multiple medical problems admitted to [**Hospital **] hospital with temp. 101.5 and N/V/D found to have
NSTEMI with CHF/PNA. Tranferred emergently for cath and found to
have severe 3VD with no obvious culprit artery. + enzymes
thought to be due to demand ischemia
1. CAD: Patient was found to have severe 3VD on cardiac
catheterization and intervention was not thought to be of
benefit as there was no real culprit lesion. CT surgery was
consulted and patient had pre-op work-up but they concluded that
he was not a good candidate for surgery. He was medically
managed with aspirin, statin, [**Last Name (un) **] and beta blocker and plavix
was added once surgery was no longer an option. He will follow
up with Dr. [**Last Name (STitle) **] for further medical management and
consideration of possible intervention in the future.
2. Rhythm: On admission the patient was V paced. His pacer was
adjusted during his admission and be was a and V paces. He had
a long QT interval on catheterization so the azithromycin he was
on upon admission was discontinued and all other QT prolonging
medications were avoided. He did have one episode of torsades
during dialysis which quickly resolved. He had history of PAF
and was continued on coumadin. His INR was 2 on discharge and he
was continued on coumadin 5 mg QHS. His levels will be monitored
at dialysis as they have been in the past.
3. Pump: EF 20-25% on echocardiogram with significant akinesis
of the apex. He was continued on coumadin as stated above.
4. Infection: Culture results from OSH showed micrococcus in
blood whoch wa sthought to be a contaminant. He reecieved 3 days
of vancomycin at the OSH. Blood and urine performed during this
admission were negative. It was thought that this was most
likely a pneumonia as indicated by chest x-ray and symptoms. He
was originally treated with ceftriaxone and azithromycin x 2
days but decided to discontinue the azithromycin out of concern
for prolonged QT. He was continued on ceftriaxone and then
switched to cefpodoxime to complete a 10 day course. At
discharge he was afebrile for >5 days with resolving cough. He
will follow up with his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in 2 weeks.
3. Diabetes: His fingersticke were well controlled on Lantus and
insulin sliding scale during this admission. He was discharged
on his home lantus and sliding scale and will follow up with his
PCP [**Last Name (NamePattern4) **] 2 weeks.
4. ESRD: Patient received dialysis as regularly scheduled
(Tuesday, Thursday, Saturday). He ahd a brief episode of
torsades during dialysis most likley secondary to his prolonged
QT. Otherwise he tolerated dialysis well and will continue on
his regular schedule as an outpatinet at the [**Hospital1 1474**] Kidney
Center.
5. Anemia: Most likely anemia of chronic disease. He recievd 1
unit of packed RBCs during this admission as his HCT dropped as
low as 26.5. He had an appropriate increase in hematocrit and
it remained stable thereafter. On discharge his HCT was 35. He
will continue to recieve epogen with dialysis and should have a
colonoscopy as an outpatient.
6.Mental statusus changes: Patient had 1 episode of sundowning
with visual hallucinations and combativeness at the beginnning
of his admission. He received haldol with good response and had
no further episodes. It was thought that this was secondary to
his infection.
Medications on Admission:
1. Sertraline 50 mg po qd
2. ASA 325 mg po qd
3. Losartan 100 mg po qd
4. Insulin Glargine 21 U QHS, aspart 5 units afternoon dose,
aspart 13 units Sun, M,W,F
5.Famotidine 20 mg po qd
6. Calcium acetate 1334 mg po TID with meals
7. Norvasc
8. Vancomycin
Discharge Medications:
1. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Losartan Potassium 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day.
8. Insulin Glargine 100 unit/mL Solution Sig: Twenty One (21)
units Subcutaneous at bedtime.
9. Insulin Aspart 100 unit/mL Solution Sig: Five (5) units
Subcutaneous every 6-8 hours: afternoon dose.
10. Insulin Aspart 100 unit/mL Solution Sig: Thirteen (13) units
Subcutaneous Sun, mon, wed, fri: Take as you do usually.
11. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
13. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed.
14. Cefpodoxime Proxetil 200 mg Tablet Sig: One (1) Tablet PO
Q12H (every 12 hours) for 3 days: To complete a 10 day course.
Disp:*8 Tablet(s)* Refills:*0*
15. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Aspiration pneumonia
2. Demand cardiac ischemia
Discharge Condition:
afebrile, chest pain free, no shortness of breath
Discharge Instructions:
If you have any chest pain, shortness of breath, palpitations or
any other concerning symptoms call your doctor or go to the
emergency room.
The following changes have been made to you medications:
1. You are now on metoprolol XL 50 mg once daily
2. Do not take you Norvasc, you can discuss restarting it with
Dr. [**Last Name (STitle) **] at your next appointment
3. You are also on cefpodoxime 200 mg twice daily for 3 more
days to complete your 10 day course.
You can continue all the rest of your usual medications
including your insulin regimen.
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 3183**] on
Wednesday, [**9-26**] at 11am to discuss options for further
treatment you your heart disease.
You also have a follow up appointment with your primary doctor
Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 3183**] Wednesday, [**9-26**] at 11:45 am.
You should also discuss getting a sleep study as you were
observed having episodes when you were not breathing during
sleep.
Since you are on coumadin, you should have your INR checked when
you have dialysis on Sat [**2187-9-15**].
ICD9 Codes: 4280, 7907, 4271, 486, 5990, 2930, 2859, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1472
} | Medical Text: Admission Date: [**2143-2-6**] Discharge Date: [**2143-4-5**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 88 year old
woman status post an episode of dizziness and headache and
found to have a cerebellar hemorrhage at an outside hospital.
Patient had dizziness and vomiting at a bank in the afternoon
on the day of admission and was driving erratically. She was
brought to [**Hospital **] Hospital where she vomited coffee ground
material and head CT showed a cerebellar bleed. Patient then
deteriorated neurologically, became sleepy with slurred
speech, was intubated and sedated and transferred to [**Hospital1 1444**] for further management.
PAST MEDICAL HISTORY: AAA. Hypertension. COPD.
Hypothyroidism. Status post right ankle ORIF in [**2142-12-19**].
MEDICATIONS: Levoxyl, Lipitor, Evista, Diovan, Dyazide,
folic acid.
ALLERGIES: Aspirin and ACE inhibitors.
PHYSICAL EXAMINATION: Blood pressure was 110/50, heart rate
65, respiratory rate 14, sat 100% she was intubated. In
general, she responded to painful stimuli. Chest was clear
to auscultation. Heart regular rate and rhythm. Abdomen was
soft, nondistended, nontender. She had mild leg edema. She
was decerebrate posturing and unresponsive neurologically
when she came in.
LABORATORY DATA: White count 14, hematocrit 36.1, platelets
205. Sodium 137, chloride 102, CO2 30, BUN 25, creatinine
1.3. INR 1.0. CPK 174, MB 7.6, troponin less than 0.2.
Head CT showed a 4 cm left to midline cerebellar hemorrhage
with compression of the fourth ventricle.
HOSPITAL COURSE: The patient was admitted to the
neurosurgical intensive care unit where a ventricular drain
was placed without complications. Neurologically post drain
patient was following commands, showing two fingers, left arm
maybe slightly weaker than the right. Pupils were 6 down to
3.5 mm. She had possible doll's eyes. On [**2143-2-8**] patient
was awake, attentive. Speech with mild slurring. She was
oriented times three. Pupils left 6 down to 3, right 4.5
down to 2.5. EOMs were full. She had severe left upper
extremity ataxia without significant drift. Moving all
extremities with good strength. She was neurologically
stable. Her vent drain was leveled at 10 cm above the
tragus, keeping her systolic blood pressure less than 140.
She was on steroids to assist with brain swelling. She had a
repeat head CT on [**2143-2-8**] that showed good placement of the
ventricular catheter. Ventricles were slightly smaller,
although the fourth ventricle was still clotted with blood.
The patient continued to remain neurologically stable. On
[**2143-2-10**] the vent drain was not working and it was replaced.
Patient was extubated on the 19th after vent drain placement
and patient's neurologic status improved. Patient continued
to remain stable and the vent drain was replaced on [**2143-2-10**].
Patient was on ceftriaxone for vent drain prophylaxis. On
[**2143-2-12**] patient again was awake, alert, slight slurred
speech. No drift, but mild ataxia. Moving all extremities
with good strength.
The patient continued to remain stable until [**2143-2-13**] when she
had the sudden onset of left sided weakness and agitation.
Repeat head CT was basically unchanged. Her weakness
eventually resolved. She was seen by the stroke service who
felt the CT was basically unchanged. Patient also had an MRI
after the CT scan which did not show any infarct. Patient's
left sided weakness eventually resolved. On [**2-14**] patient was
awake, alert and oriented times three. EOMs were full.
Smile was symmetric. She had no drift at that point. She
was back to her baseline. Vent drain continued to drain
clear CSF. She was seen by physical therapy and occupational
therapy and was followed closely by the rehab service. On
[**2-18**] patient was awake, alert and oriented times three.
Patient did have slight left pronator drift. Her IPs were
[**4-22**]. She remained neurologically stable. We began weaning
the ventricular drain. It was raised to 15 cm above the
tragus on [**2-18**]. She was weaned off steroids and remained
on 2 liters of O2 via nasal cannula.
On [**2143-2-21**] the patient had a repeat head CT after having had
her vent drain clamped for 24 hours. It did show dilated
ventricles, therefore, the drain was opened and left at 20 cm
above the tragus. Patient remained neurologically stable
despite hydrocephalus. She was awake, alert and oriented
with no drift. On [**2143-2-28**] patient developed the acute onset
of left hemiparesis and lethargy. Repeat head CT showed
extension of the bleed in the right frontal area where the
vent drain had been placed. Therefore, patient was taken to
the O.R. for evacuation of this intracranial hemorrhage.
Post-op vital signs were stable. She was intubated and
sedated. Pupils were equal, round and reactive to light. On
the 14th patient opened her eyes to stimulation. She moved
her right leg, wiggled her right toes. She had left
hemiparesis. She withdrew slightly to pain on the left.
Pupils were 5 down to 3.5 mm and briskly reactive. She
continued to have the vent drain and now at 10 cm above the
tragus. From a neurologic standpoint she was ready to be
weaned from the ventilator as tolerated.
On [**2143-3-2**] the patient had a repeat head CT which showed no
change. Patient remained on Nipride. Blood gases were
stable with an elevated CO2 level. Patient was arousable and
oriented, following commands and moving all extremities to
command. MRA screening test was negative. Patient again had
an attempt at weaning her ventricular drain which she did not
tolerate the second time. Therefore, she was scheduled for
VP shunt placement. On [**2143-3-5**] patient's respiratory status
deteriorated and she required reintubation. On [**2143-3-8**]
patient had right VP shunt placed. Intra-op there were no
complications. Patient's post-op course was complicated by
patient's inability to wean from the vent. She was
arousable, wiggled her toes. Pupils were 6 down to 5 mm and
brisk. On [**3-14**] patient was moving all extremities to sternal
rub, following commands, squeezing on the right, although
weakly. Moving the left side.
The patient was extubated and had rising CO2 on her blood
gas. On [**3-16**] patient was arousable, following commands,
moving all extremities to command, right greater than left.
Continued to have rising CO2 of 70 on her blood gas. She
continued to be extubated and was on cool mist face mask at 4
liters. Due to the rising CO2, patient became more
lethargic. At that time family was approached for code
status. A family meeting was held on [**2143-3-18**]. They wished
for patient to be DNR/DNI, although as far as trach and PEG,
patient's family wanted to discuss it and would get back to
the team.
The patient's family ultimately decided that she should be
trached. Therefore, she had trach placement. Neurologically
on [**2143-3-21**] patient's pupils were 6 down to 5 mm. She opened
her eyes. She moved all extremities and lifted both arms up
off the bed to command. Patient's family did decide on trach
and PEG. Patient had a trach placed on [**2143-3-26**] without
complications. A PEG was placed the following day without
complications. Patient was transferred to the floor on
[**2143-3-31**] where she has remained neurologically stable. She
was awake. She was easily arousable, opened eyes, followed
commands, moved all extremities. Has been out of bed to
chair. Patient's O2 requirements began climbing on [**2143-4-2**]
and, therefore, repeat chest x-ray was obtained. Patient had
bilateral pleural effusions which she has had since early in
her admission. She had pleural tap done in the ICU and was
looking like she was going to require a second pleural tap.
The interventional pulmonary service was consulted on [**2143-4-4**]
and a pleural effusion tap was done on [**4-4**] without
complications.
The patient's condition has remained neurologically stable.
She is awake, alert and oriented times three, moving all
extremities. Is at times sleepy, but easily arousable. Has
been out of bed to chair. Has been continuously followed by
the rehab service and is felt to require a rehab stay prior
to discharge to home.
DISCHARGE MEDICATIONS:
1. Vancomycin 1 gm IV q.24 hours for line infection.
2. Epogen 40,000 units subcu q.Monday.
3. Synthroid 100 mcg p.o. q.day.
4. Zantac 150 mg p.o. b.i.d.
5. Miconazole powder 2% one application topically t.i.d.
6. Insulin sliding scale.
7. Colace 100 mg p.o. b.i.d.
8. Hydralazine 10 mg p.o. q.six hours p.r.n. for systolic
blood pressure greater than 160.
9. Metoprolol 25 mg p.o. t.i.d., hold for systolic blood
pressure less than 95, heart rate less than 60.
CONDITION ON DISCHARGE: Stable.
FOLLOWUP: She will follow up with Dr. [**Last Name (STitle) 1132**] in one month
with repeat head CT at that time.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2143-4-4**] 14:28
T: [**2143-4-4**] 16:52
JOB#: [**Job Number 50007**]
ICD9 Codes: 431, 5185, 5990, 5119, 4241, 496 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1473
} | Medical Text: Admission Date: [**2113-5-4**] Discharge Date: [**2113-5-11**]
Date of Birth: [**2038-11-17**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 74-year-old
Spanish-speaking gentleman who, prior to admission, had
symptoms of progressive angina; specifically, exertional
angina. The patient was referred by his primary care
physician for outpatient stress test and cardiac
catheterization.
He underwent echocardiography on [**2113-4-28**], and the
impression from that test was no echocardiographic evidence
of inducible ischemia to achieved workload. He also
underwent an exercise tolerance test on [**2113-4-28**], which
showed anginal-type symptoms with probable ischemic
electrocardiogram changes. On [**2113-4-24**], he also had an
echocardiogram which showed moderate aortic stenosis, mild
aortic regurgitation, mild mitral regurgitation, symmetric
left ventricular hypertrophy with preserved systolic
function. A note from this echocardiogram was that based on
the [**2109**] AHA endocarditis prophylaxis guidelines, that the
echocardiogram findings from this test indicated a moderate
risk, and that he should receive prophylaxis in the future.
PAST MEDICAL HISTORY: (Significant for)
1. Osteoarthritis of the lower back.
2. Hypertension.
3. High cholesterol.
MEDICATIONS ON ADMISSION: Meclizine 25 mg p.o. t.i.d.,
Cozaar 100 mg p.o. q.d., atenolol 100 mg p.o. b.i.d.,
Isordil 40 mg p.o. t.i.d., Relafen as needed, aspirin 325 mg
p.o. q.d.
ALLERGIES: The patient has no known drug allergies.
HOSPITAL COURSE: The patient underwent a cardiac
catheterization on [**2113-5-4**], which showed pulmonary artery
pressures systolic between 32 and 56, and diastolic between
18 and 26. The aortic pressures were 190/70. The left
ventricular pressures were 210/28. He was also found to have
an ejection fraction of 65%, 70% stenosis of the left main,
and 2-vessel disease. Based on this, and the patient's
history, it was decided that the patient would undergo a
coronary artery bypass graft which was planned for the
following day.
On [**2113-5-5**], the patient underwent a coronary artery
bypass graft times three with internal mammary artery to the
left anterior descending artery and saphenous vein graft to
the posterior descending artery and the obtuse marginal.
Indication for this was aortic stenosis and cardiac
catheterization results as well as worsening angina. The
aortic valve was replaced with a pericardial tissue heart
valve of a bovine origin.
One additional note is that, after cardiac catheterization,
the patient had an intra-aortic balloon pump placed
preoperatively, and then the following morning went to the
operating room. The patient's primary cardiologist,
Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 2031**], was involved with his care leading up to
the surgery. The patient had an uncomplicated perioperative
period. He was transferred to the Cardiothoracic Intensive
Care Unit. He did receive 1 unit of packed red blood cells.
The patient was stable and the balloon pump was removed, and
he was transferred to the floor on postoperative day two, and
on postoperative day three the patient was transfused with 2
units secondary a hematocrit of 19.8. With that hematocrit
he was also complaining of some dizziness, and this was
making ambulating difficult. However, gradually worked with
Physical Therapy and was ambulating around the hallway with
assistance, and his hematocrit on discharge was 26 and
steadily rising.
On the floor, the patient occasionally had a increased heart
rate with some premature ventricular contractions. This was
treated successfully with increased Lopressor, which he
tolerated, and the patient was in sinus rhythm on discharge.
The patient required aggressive respiratory treatments in
order to maintain his oxygen saturations, which he did
adequately. On discharge his lungs were clear with some mild
crackles at the bases.
MEDICATIONS ON DISCHARGE:
1. Lopressor 75 mg p.o. b.i.d.
2. Lasix 20 mg p.o. b.i.d.
3. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. b.i.d.
4. Isordil 40 mg p.o. t.i.d.
5. Lipitor 10 mg p.o. q.d.
6. Meclizine 25 mg p.o. t.i.d.
7. Cozaar 100 mg p.o. q.d.
8. Percocet 5 one to two tablets p.o. q.4-6h. p.r.n.
9. Aspirin 81 mg p.o. q.d.
10. Colace 100 mg p.o. b.i.d.
11. Zantac 150 mg p.o. b.i.d.
12. Dulcolax suppository 10 mg p.r. q.d. p.r.n.
13. Motrin 400 mg p.o. q.6h. p.r.n.
14. Serax 15 mg p.o. q.h.s. p.r.n.
15. Benadryl 25 mg p.o. q.h.s. p.r.n.
CONDITION AT DISCHARGE: Improved and stable.
DISCHARGE STATUS: The patient was to go to a rehabilitation
facility.
DISCHARGE DIET: Low-sodium/low-fat diet.
DISCHARGE GOALS: Physical therapy for increased mobility,
wound care as needed, respiratory care, and improvement of
his activities of daily living. Rehabilitation potential was
good.
DISCHARGE DIAGNOSES:
1. Status post coronary artery bypass graft times three.
2. Status post aortic valve replacement (Bovine).
3. Status post cardiac catheterization on [**2113-5-4**].
FO[**Last Name (STitle) **] INSTRUCTIONS:
1. Call Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**] office for followup.
2. Call primary care physician for followup in one to two
weeks.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 8344**]
MEDQUIST36
D: [**2113-5-11**] 12:36
T: [**2113-5-11**] 14:14
JOB#: [**Job Number 33853**]
ICD9 Codes: 4241, 4111, 4168, 4019, 2720, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1474
} | Medical Text: Admission Date: [**2157-12-13**] Discharge Date: [**2157-12-28**]
Date of Birth: [**2107-8-8**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Fentanyl / Morphine
Attending:[**First Name3 (LF) 10644**]
Chief Complaint:
low back pain
Major Surgical or Invasive Procedure:
chemoembolization
laminectomy
History of Present Illness:
50 y/o female with RCC metastatic to lumbar spine, liver,
pancreas who has been experiencing low back pain with radiation
to the L leg since [**10-3**]. Her pain upon admission was [**8-7**],
sharp. Pt's pain was persistent despite PO decadron and XRT
which was started in [**Month (only) 359**] at outside rad-onc. Pt also
reported progressive LLE weakness and urinary retention 2 days
prior to admission. MRI of spine at OSH showed compression at
L5 and T7. Of note, the patient did not have a BM since [**12-10**].
Sister reports that the patient has been having confusion since
starting steroids on [**12-14**]. Pt was transferred to [**Hospital1 18**] where
she was admitted to OMED service.
Past Medical History:
Onc Hx:
Diagnosed in [**2155-6-29**] when she presented with a left renal mass
on CT scan, undergoing nephrectomy with resection of metastatic
lesions in the pancreatic tail and retroperitoneum. In [**2156-6-29**]
she developed hilar lymphadenopathy and was initiated on the
Avastin/Tarceva trial in [**Month (only) **] with evidence of disease
progression after 24 weeks. She began SU11248 in [**2157-4-29**] with
disease progression on CT scans in [**2157-8-29**] with new liver
lesions and progression and lumbar vertebral mets. She received
high dose IL-2; however, this was complicated by myositis and so
dose was reduced. Eventually developing symptoms of cord
compression from vertebral mets and undergoing XRT to spine and
decadron.
.
Other med hx:
htn
anxiety d/o
s/p appy
s/p CCY
s/p right humoral fx
.
Allergies: codeine and morphine (nausea), fentanyl (pruritis)
Social History:
quit tobacco [**2148**], no ETOH.
Family History:
no renal cell CA
Physical Exam:
Initial VS: 97.3, 126/80, p124, rr18, 93% RA
ga: awake and pleasant, comfortable, NAD
heent: PERRLA, anicteric, EOMI, MMM, clear OP, symmetrical
smile, no carotid bruits, no cervical lad, + JVD to the ear @ 30
degrees.
lungs: crackles [**1-30**] way b/l
cv: tachy s1/s2, tachy, reg, no m/r/g
abd: hypoactive BS, SNT/ND, no HSM
ext: no edema, no calf pain, no cyanosis, full + 2 DP b/l;
[**6-2**] LE distal muscles/feet; 4/5 L - [**6-2**] R Hip flexors, maybe
secondary to pain; downgoing babinski; reduced proprioception on
R toe; diminished fine touch over L toe; nl sensation over b/l
medial and lateral maleolus;
spine: tender upper and midthoracic; no step off.
neuro: cn 2-12 intact
.
Previous motor IN ED:
lower ext upper ext
quad hamstr gastroc AT hip flex
R [**5-3**] 4/5 [**6-2**] 5/5 [**4-2**] [**6-2**]
L 4/5 [**5-3**] 5/5 [**6-2**] 3/5 [**6-2**]
no ankle clonus appreciated
sensation intact light touch lower ext bilat
DTR - patella 2+ bilat, achilles absent
Pertinent Results:
.
CT chest/abd/pelvis ([**11-16**])
1. Increase in size and number of hepatic metastases.
2. Increased size of left hilar lymph node. Other prevascular
and hilar
lymph nodes appear stable.
3. Increased size in left adrenal nodule concerning for
metastasis. New
right adrenal lesion concerning for metastasis.
4. Stable pulmonary nodules.
5. Stable round lesion in the right breast.
6. Slightly worsened bone erosion in L5 vertebra.
.
MRI spine [**12-13**]:
1. Pathological fracture of T7 due to metastasis with moderate
spinal cord stenosis and mild to moderate spinal cord
compression. While most of the spinal stenosis appears to be due
to bony metastatic disease, gadolinium enhanced study would help
for further characterization, if clinically indicated.
2. Heterogeneous signal intensity within the T5 through T12
vertebral bodies concerning for metastatic disease in this
patient with known renal cell carcinoma.
3. Focal isolated disc protrusions at C5/6, and C6/7 without
spinal canal compromise.
.
CTA of lungs [**12-19**]:
1. No evidence of pulmonary embolism.
2. Interval development of small to moderate bilateral pleural
effusions, right greater than left as well as by moderate
bibasilar atelectasis.
3. Stable appearance of mediastinal and hilar lymphadenopathy.
4. Multiple areas of low attenuation in the liver consistent
with metastatic disease.
5. Stable appearance of rounded right breast lesion.
6. Status post spinal fixation surgery in the lower thoracic
spine with a loss of vertebral height of the seventh thoracic
vertebra.
.
[**2157-12-13**] 08:00PM BLOOD WBC-7.8 RBC-5.09 Hgb-12.2 Hct-40.7
MCV-80*# MCH-24.1*# MCHC-30.1* RDW-24.5* Plt Ct-48*#
[**2157-12-26**] 07:35AM BLOOD WBC-6.7 RBC-3.84* Hgb-11.3* Hct-33.2*
MCV-87 MCH-29.3 MCHC-33.9 RDW-21.5* Plt Ct-78*
[**2157-12-13**] 08:00PM BLOOD Neuts-87.1* Bands-0 Lymphs-7.9* Monos-4.3
Eos-0.4 Baso-0.3
[**2157-12-19**] 06:56PM BLOOD PT-13.9* PTT-29.2 INR(PT)-1.3
[**2157-12-13**] 08:43PM BLOOD PT-14.7* PTT-26.6 INR(PT)-1.5
[**2157-12-17**] 01:20PM BLOOD Fibrino-160
[**2157-12-15**] 05:45AM BLOOD FDP-10-40
[**2157-12-26**] 07:35AM BLOOD Glucose-112* UreaN-16 Creat-0.8 Na-134
K-3.4 Cl-100 HCO3-22 AnGap-15
[**2157-12-13**] 08:00PM BLOOD Glucose-128* UreaN-30* Creat-1.0 Na-137
K-4.7 Cl-104 HCO3-22 AnGap-16
[**2157-12-19**] 04:10PM BLOOD CK(CPK)-66
[**2157-12-17**] 04:47PM BLOOD LD(LDH)-305*
[**2157-12-14**] 09:28PM BLOOD ALT-22 AST-30 AlkPhos-406* TotBili-0.5
[**2157-12-19**] 04:10PM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2157-12-19**] 01:35AM BLOOD CK-MB-2 cTropnT-0.03*
[**2157-12-26**] 07:35AM BLOOD Calcium-9.0 Phos-3.6 Mg-1.6
[**2157-12-14**] 09:28PM BLOOD Calcium-8.4 Phos-4.0# Mg-1.7
[**2157-12-21**] 07:25AM BLOOD TSH-8.4*
[**2157-12-21**] 07:25AM BLOOD T4-4.5*
[**2157-12-18**] 09:18PM BLOOD Type-ART Temp-38.0 pO2-86 pCO2-41 pH-7.40
calHCO3-26 Base XS-0 Intubat-INTUBATED
[**2157-12-14**] 04:59PM BLOOD Type-ART Temp-37.2 pO2-103 pCO2-34*
pH-7.38 calHCO3-21 Base XS--3 Intubat-NOT INTUBA
[**2157-12-17**] 05:10PM BLOOD Glucose-156* Lactate-2.3*
[**2157-12-14**] 04:59PM BLOOD Glucose-73 Lactate-1.6 Na-135 K-4.7
Cl-104
[**2157-12-18**] 09:18PM BLOOD Hgb-10.9* calcHCT-33
[**2157-12-17**] 12:31PM BLOOD Hgb-10.5* calcHCT-32
[**2157-12-18**] 09:18PM BLOOD freeCa-1.33*
[**2157-12-14**] 04:59PM BLOOD freeCa-1.30
Brief Hospital Course:
50 y/o female with RCC metastatic to lumbar spine, liver,
pancreas who had been experiencing low back pain with radiation
to the L leg since [**10-3**]. Also symptomatic with urinary
retention and worsening LLE weakness/pain. Received decadron
and XRT fpr spine compression at OSH w/o significant
improvement. Transferred to [**Hospital1 18**] for further evaluation and
treatment.
.
# cord compression - bony mets with acute worsening of spinal
compression as seen on MRI: T7 mild compression with
retropulsion of vertebral fragments into spinal canal, moderate
(50-75%) spinal canal stenosis, and soft tissue (tumor) and
compression of left L5 root. She was evaluated by ortho who
felt that her symptoms were stable and improving on IV steroids.
Dr. [**Last Name (STitle) **] of Interventional Rads embolized L5 and T7 tumor on
[**12-14**] to address increased vascularity, and then pt chose to
have semi-elective laminectomy with Dr. [**Last Name (STitle) 363**] from orthopedics.
This was discussed w/ the rad onc staff here to ensure that she
would not have problems w/ wound healing as she had recent XRT
to these areas. Her RadOnc doctor is Dr. [**Last Name (STitle) 58209**] [**Name (STitle) **] in
[**Location (un) 58210**], [**State 1727**].
.
Following her spine surgery, she had an uneventful recovery w/o
new fevers, n/v, dysphagia, headache, cp/sob/palpitations or
abdominal pain. Foley was left in place initially as she was
still not able to void on her own. She had a few days during
which she could urinate, but then foley had to be re-inserted
prior to discharge for urinary retention. She also did not have
a bowel movement for several days. In the week after her
surgery, her neuro exam stabilized, and she was able to ambulate
w/ some assistance. She worked w/ PT almost daily, and they
felt that her progress waxes and wanes. They recommended
[**Hospital 3058**] rehab for continued physical therapy. Her pain was
well-controlled w/ her pre-admission dose of fentanyl patch and
hydromorphone 2mg po q8prn. She was fitted for a TLSO brace and
decadron was discontinued. There was no further role for XRT
after surgery. She continues to have daily dressing changes at
her surgical site - healing well. She will need daily PT as she
has decompensated after a prolonged hospitalization.
.
# MS changes: the patient began to have visual hallucinations on
the decadron. She does not have an underlying psych d/o. After
discontinuing steroids, she noted having confusion after
receiving ativan. This was temporally related to ativan dosing;
she reports a history of having MS changes after ativan.
Considered CT of head to r/o metastatic disease, but she was
neurologically intact and remained mentally clear. Discontinued
prn ativan and gave xanax instead. Also, thyroid function
studies suggested that she has mild hypothyroidism; did not
treat at this time as she continued to have tachycardia on small
dose BB.
.
# Increased Temperature - Temp to 100.3 once after her surgery;
afebrile since then. Likely due to atelectasis as CTA did not
support PE or pna. Wound did not look infected. Urine cx
negative, and blood cx w/ no growth to date; catheter tip
growing coag neg staph which is likely staph epidermidis.
Sweats likely related to her cancer, but not concerning at this
time for new progression or mets.
.
# Tachycardia - Patient with ventricular bigemeny on EKG - has a
history of this. No chest pain or signs of cardiac failure. CE
negative x 2 more than 12 hours apart. She continued to have HR
in 110s w/ low BP. Started metoprolol 25mg po bid w/o
significant response in HR; BP remained stable. Did not pursue
further work-up at this time as this has been a long-standing
issue.
.
# RCC - Has received maximum chemo and XRT. Pt had foley in
place until 2 days prior to admission at which point she was
able to void on her own. She had some hematuria following
surgery, but this was attributed to foley trauma. Pt denies any
discomfort. Once stable will consider future tx with Dr. [**Last Name (STitle) **].
It appears that the family (sister is very involved) have the
idea that she will be cured. emailed [**Doctor Last Name **] about this.
.
# hypoxia/crackles on exam - this was first noted after the
chemoembolization in the PACU. Attempted some mild diuresis did
not improve her hypoxia. CXR was only notable for bilateral
atelectasis. In the days prior to her discharge, she was
satting 94% on RA and breathing comfortably.
.
# low platelets/elevated INR - no schistocytes on smear, no
renal failure or CNS symptoms or labs to suggest TTP, no DIC.
ITP is diagnosis of exclusion. Transfused platelets to maintain
>50 and gave vitamin K prior to spine surgery; platelets bumped
up to 154 and then slowly drifted down. No signs of hemolysis.
Last plt count was 78 and stable prior to discharge.
.
# Anemia - Patient with significant blood loss during surgery.
Responding appropriately to transfusions and has remained stable
at 30.
- follow CBC
.
# anxiety - has history of anxiety disorder. Had been on
effexor 75 qd and ativan 1mg q6 prn but she noted that she
becomes confused on ativan. Switched to xanax w/ resolution of
her MS changes. She continues to be anxious but responds well
to assurance and prn xanax.
.
# Pain - controlled on fentanyl patch 100mcg q72hrs and dilaudid
2mg po q8 prn. Pt attempting to wean herself off dilaudid - not
using many doses currently.
.
# Follow-up: Pt will call Dr. [**Last Name (STitle) **] for an appointment in the
next few weeks.
Medications on Admission:
Lomotil 1-2 tablets q.6h. p.r.n. diarrhea
Compazine 10 mg q.6h. p.r.n. nausea
Ativan 1 mg q.6h. p.r.n. nausea
Benadryl p.r.n.
Tylenol 650 mg q.4h. p.r.n. pain
oxycodone 5-10 mg q.6h. p.r.n. pain
Effexor 75 mg p.o. daily
Miacalcin nasal spray
fent patch 100 mcg/hr q72h
decadron 4mg [**Hospital1 **]
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. Fentanyl 100 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72HR(s)* Refills:*2*
3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for PAIN.
Disp:*90 Tablet(s)* Refills:*1*
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*2*
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO DAILY (Daily).
Disp:*60 Capsule, Sust. Release 24HR(s)* Refills:*2*
7. Alprazolam 0.25 mg Tablet Sig: 1-2 Tablets PO QID (4 times a
day) as needed for anxiety.
Disp:*100 Tablet(s)* Refills:*0*
8. 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*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
11. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Discharge Diagnosis:
renal cell carcinoma w/ metastasis to spine
s/p chemoembolization
s/p laminectomy
hypertension
anemia
anxiety
s/p appendectomy
s/p cholecystectomy
s/p R humoral fracture
Discharge Condition:
Stable
Discharge Instructions:
Please take your medications only as directed.
Call your physician or go to the ED if you have fever, chills,
inability to void or have BM, headache, weakness, confusion,
hallucinations, fainting, uncontrolled pain, chest pain,
shortness of breath or any other symptom that is concerning to
you.
Followup Instructions:
Please follow up w/ Dr. [**Last Name (STitle) **] in the next few weeks. You will
need to call for an appointment.
Completed by:[**2157-12-28**]
ICD9 Codes: 2875, 2851, 5180, 2761, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1475
} | Medical Text: Admission Date: [**2181-4-5**] Discharge Date: [**2181-4-12**]
Date of Birth: [**2107-8-22**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 73-year-old female who
has been experiencing exertional chest discomfort since last
Fall. She has chest discomfort after climbing one flight of
stairs or walking up an incline. She denies any rest
symptoms. She deferred medical treatment until [**Month (only) 404**]
because her husband was terminally ill and passed away this
Fall.
She went to her primary care physician in [**Name9 (PRE) 404**] and was
sent for a routine stress test which revealed 1-mm to 1.5-mm
ST depressions in the inferior and anterolateral leads at
peak exercise. She was subsequently referred for a stress
echocardiogram and had 3-mm ST depressions in leads II, III,
aVF, and in V4, V5, and V6; that normalized by 10 minutes of
recovery. The pre-stress echocardiogram showed basilar
inferior hypokinesis and an ejection fraction of 60%. The
post stress echocardiogram showed appropriate augmentation
with a question of inferobasilar hypokinesis.
She underwent cardiac catheterization at [**Hospital1 346**] on [**2181-3-28**] which revealed
severe aortic stenosis. No mitral regurgitation. An
ejection fraction of 66%. Clean coronary arteries except for
less than 20% ostial left main stenosis.
PAST MEDICAL HISTORY: (Her past medical history is
significant for)
1. History of hypertension.
2. History of hyperlipidemia.
3. History of osteoporosis.
4. History of basal cell carcinoma of the face.
5. Status post left oophorectomy.
MEDICATIONS ON ADMISSION: (Her medications on admission
were)
1. Fosamax 70 mg p.o. ever week.
2. Evista 60 mg p.o. once per day.
3. Cholestyramine two scoops once per day.
4. Gemfibrozil 600 mg p.o. twice per day.
5. Spironolactone 25 mg p.o. once per day.
6. Aspirin 81 mg p.o. once per day.
ALLERGIES: She has no known drug allergies.
SOCIAL HISTORY: Her social history is significant in that
she does not smoke cigarettes.
FAMILY HISTORY: Family history is significant for
cerebrovascular accident.
PHYSICAL EXAMINATION ON PRESENTATION: On physical
examination, she was a well-developed elderly white female in
no apparent distress. Vital signs were stable. The patient
was afebrile. Head, eyes, ears, nose, and throat examination
revealed normocephalic and atraumatic. Extraocular movements
were intact. The oropharynx was benign. The neck was supple
with full range of motion. No lymphadenopathy or
thyromegaly. Carotids were 2+ and equal bilaterally and
without bruits. The lungs were clear to auscultation
bilaterally. Cardiovascular examination revealed a regular
rate and rhythm. Normal first heart sounds and second heart
sounds. A [**2-15**] murmur was heard best at the second
intercostal space, left sternal border, and right sternal
border. She had no rubs. Her murmur radiated to both
carotids. Her abdomen was soft and nontender with positive
bowel sounds. No masses or hepatosplenomegaly. Extremity
examination revealed no clubbing, cyanosis, or edema. Pulses
were 2+ and equal bilaterally throughout except for the
posterior tibialis which was 1+ and equal bilaterally.
Neurologic examination was nonfocal.
HOSPITAL COURSE: On [**4-5**], the patient underwent an
aortic valve replacement with a 21-mm Mosaic porcine valve.
Cross-clamp times 65 minutes. Total bypass times was 91
minutes.
She tolerated the procedure well and was transferred to the
Cardiothoracic Surgery Recovery Unit in stable condition.
She was extubated postoperative night and was on some
Neo-Synephrine on postoperative day one.
On postoperative day two, she was off her drips. On
postoperative day three, she was transferred to the floor in
stable condition. Her wires were discontinued. Her chest
tube were discontinued on postoperative day two. She
continued to progress. She did go into postoperative atrial
fibrillation and was treated with Lopressor, and she
converted to a sinus rhythm but did have intermittent runs
atrial fibrillation and was anticoagulated.
DISCHARGE STATUS: On postoperative day seven, she was
discharged to home.
CONDITION AT DISCHARGE: Condition on discharge was stable.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg p.o. twice per day.
2. Percocet one to two tablets p.o. q.4-6h. as needed (for
pain).
3. Potassium 20 mEq p.o. twice per day (times seven days).
4. Lasix 20 mg p.o. twice per day (times seven days).
5. Aspirin 81 mg p.o. once per day.
6. Lopressor 75 mg p.o. twice per day.
7. Coumadin 1 mg p.o. q.h.s.
8. Evista 60 mg p.o. once per day.
9. Fosamax 70 mg p.o. every week.
10. Gemfibrozil 600 mg p.o. twice per day.
11. Cholestyramine two scoops once per day.
PERTINENT LABORATORY DATA ON DISCHARGE: Her laboratories on
discharge revealed hematocrit was 30.6, white blood cell
count was 9,400, and platelets were 500,000. Sodium was 131,
potassium was 4.1, chloride was 103, bicarbonate was 25,
blood urea nitrogen was 9, creatinine was 0.7, and blood
glucose was 87. Prothrombin time was 16.8 with an INR of
1.9.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. She was to be followed by Dr. [**Last Name (STitle) **] for an appointment
in one to two weeks and by Dr. [**Last Name (STitle) 70**] for an appointment
in six weeks.
2. She was to have her coagulations drawn and called in to
Dr.[**Name (NI) 26938**] office.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (NamePattern1) 11726**]
MEDQUIST36
D: [**2181-4-12**] 14:59
T: [**2181-4-12**] 17:21
JOB#: [**Job Number 49313**]
ICD9 Codes: 4241, 9971, 4019, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1476
} | Medical Text: Admission Date: [**2143-3-1**] Discharge Date: [**2143-3-11**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
symptomatic rectal prolapse
Major Surgical or Invasive Procedure:
perineal proctectomy for rectal prolapse
History of Present Illness:
The patient is a [**Age over 90 **]-year-old gentleman with a
history of metastatic hepatocellular carcinoma who had a
markedly symptomatic rectal prolapse. He had difficult time
sleeping, and he was incompetent of stool prior to surgery.
He was scheduled for surgery last year, but with this was
delayed. He responded to chemotherapy regimen for his
hepatocellular carcinoma, and he requested a rectal prolapse
surgery. Risks and benefit of that surgery were discussed in
detail. He understood that death was a risk. He signed a
surgical consent, held his chemotherapeutic regimen for 6
weeks and was offered surgery following that.
Past Medical History:
PMH: Met HCC, heart murmur, DM, HTN, neuropathy, hiatal hernia,
mild AS/MR, LVH.
PSHx: Liver rxn & ablation, partial gastrectomy & splenectomy
for GIB, T&A.
Social History:
Widower
Involved in many groups: Masons, other social clubs
Family History:
noncontributory
Physical Exam:
AFebrile, VSS
gen: NAD, resting comfortably in bed
CV: RRR
Pulm: bibasilar crackles, no respiratory distress
Abd: soft, NT, large ventral hernia, well healed scar
Ext: 2+ edema b/l LE extremities
no c/c
Pertinent Results:
[**2143-3-2**] 02:28AM BLOOD WBC-17.6*# RBC-3.46* Hgb-9.3* Hct-29.8*
MCV-86 MCH-26.8* MCHC-31.2 RDW-17.6* Plt Ct-435
[**2143-3-2**] 08:36PM BLOOD WBC-15.3* RBC-3.80* Hgb-10.4* Hct-33.2*
MCV-87 MCH-27.3 MCHC-31.3 RDW-16.4* Plt Ct-415
[**2143-3-3**] 11:20AM BLOOD WBC-12.5* RBC-3.37* Hgb-9.2* Hct-29.9*
MCV-89 MCH-27.4 MCHC-30.8* RDW-16.6* Plt Ct-378
[**2143-3-4**] 04:04AM BLOOD WBC-14.7* RBC-3.83* Hgb-10.8* Hct-33.3*
MCV-87 MCH-28.1 MCHC-32.3 RDW-16.3* Plt Ct-386
[**2143-3-5**] 05:15AM BLOOD WBC-13.0* RBC-3.60* Hgb-9.8* Hct-31.2*
MCV-87 MCH-27.2 MCHC-31.4 RDW-16.5* Plt Ct-413
[**2143-3-6**] 06:10AM BLOOD WBC-16.7* RBC-3.81* Hgb-10.3* Hct-32.8*
MCV-86 MCH-27.1 MCHC-31.5 RDW-17.5* Plt Ct-426
[**2143-3-2**] 08:36PM BLOOD ALT-195* AST-487* AlkPhos-973*
TotBili-0.5
[**2143-3-4**] 04:04AM BLOOD ALT-98* AST-261* LD(LDH)-177 AlkPhos-947*
Amylase-65 TotBili-0.5
[**2143-3-5**] 10:15AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**3-2**] CXR: FINDINGS: Metallic clips project over the middle upper
abdomen. The lung volumes are low. The size of the cardiac
silhouette is borderline. There is slight enlargement of the
azygos vein. There also is subtle peribronchial cuffing and
perihilar haziness, combined with moderate retrocardiac
atelectasis. Overall, these findings could be suggestive of
moderate fluid overload. There is blunting of the left
costophrenic angle, possibly caused by minimal pleural effusion.
The right costophrenic angle shows no evidence of pleural
effusion. There are no parenchymal opacities suggestive of
pneumonia. Moderate calcification of the aortic wall at the
level of the aortic arch.
[**3-3**] CXR: FINDINGS: As compared to the previous examination,
there is newly appeared blunting of the right costophrenic
angle, suggestive of newly appeared mild pleural effusion.
Otherwise, the radiograph is unchanged. There are metallic clips
projecting over the middle upper abdomen. There still is slight
enlargement of the azygos vein. Combined with subtle
peribronchial cuffing and perihilar haziness, these findings are
suggestive of moderate fluid overload. No focal parenchymal
opacities suggestive of pneumonia. Moderate calcification of the
aortic wall at the level of the aortic arch.
[**3-4**] CXR: IMPRESSION: Minimal improvement in moderate degree of
pulmonary edema. Small bilateral pleural effusions
[**3-5**] CXR: FINDINGS: In comparison with the study of [**3-4**], the
pulmonary vascularity is essentially within normal limits, as is
the size of the cardiac silhouette.
[**3-7**] CXR: COMPARISON: [**2143-3-5**]. As compared to the
previous examination, there is a subtle increase in bilateral
suprabasal atelectasis. There are no signs suggestive of
overhydration, no evidence of pleural effusion and no focal
parenchymal opacities suggestive of pneumonia.
Brief Hospital Course:
The patient was admitted to the surgery service for post
operative evaluation and treatment.
Neuro: The patient received Dilaudid and Tylenol with good
effect and adequate pain control. When tolerating oral intake,
immediately post operatively, the patient was transitioned to
oral pain medications.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored. On [**3-5**], the patient had
an episode of nausea and emesis, and an ECG was obtained, which
did show some ectopy/irregular rhythm, and ST changes for which
cardiac enzymes were cycles, and were negative.
Pulmonary: The patient was stable initially from a pulmonary
standpoint; vital signs were routinely monitored. Good
pulmonary toilet, early ambulation and incentive spirometry were
encouraged throughout this hospitalization. The patient was put
on Levofloxacin on [**3-6**] as he continued to have increased sputum
(often green) and a rising white blood count post operatively.
His white blood count decreased with the addition of
levofloxacin.
GI/GU/FEN:
Post operatively, the patient's diet was advanced, which was
tolerated well. Mr. [**Known lastname 10378**] did have some coughing during eating
initially, however passed a bed side swallow evaluation; he was,
however, put on aspiration precautions.
The patient began experiencing some diarrhea post operatively,
which was sent for c. diff and was negative; he was put on
Flagyl for presumed c. diff, and should continue the medication
until [**3-15**]. He was also put on cholestyramine, and metamucil
(and stool softeners were held) for diarrhea. The patient had
occasional small amounts of blood from the rectum/surgical site.
His hematocrit was closely monitored, however, and the blleding
was not significant.
The patient's intake and output were closely monitored, and IVF
were adjusted when necessary. The patient's electrolytes were
routinely followed during this hospitalization, and repleted
when appropriate.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. He was put on Flagyl for
presumed c.diff (though he was c. diff negative x 3), and
levofloxacin for a respiratory tract infection.
Endocrine: The patient's blood sugar was monitored throughout
this stay; insulin dosing was adjusted accordingly.
Hematology/Oncology: The patient's complete blood count was
examined routinely; 2 units of packed red blood cell
transfusions were required during this stay. He continues to
have a small amount of bleeding from the rectum, which is normal
post operatively, especially in his case, as he has had much
erosion to the area. His hematocrit should continue to be
checked periodically following discharge, and has been routinely
checked throughout this hospitalization.
The patient's sorafenib should be held for six weeks following
surgery, and was held during this hospitalization.
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, 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.
Medications on Admission:
Nexavar (sorafenib)2 tabs qam, 1 qpm, metop 25 mg'', vit D 400',
vit B50 complex 1'', MVI', erythromycin drops 0.5% OU qd,
loperamide 2'', ranitidine 150'', phenytoin 200', HCTZ 25',
glipizide 5'.
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed: Hold for diarrhea, loose stools.
2. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day): Hold for diarrhea, loose stools.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
5. Phenytoin Sodium Extended 100 mg Capsule Sig: Two (2) Capsule
PO DAILY (Daily).
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous ASDIR (AS DIRECTED): Per sliding scale.
8. Glipizide 5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO DAILY (Daily).
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed: Hold for sedation, RR<12.
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day) as needed for oral thrush.
12. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Powder in
Packet Sig: One (1) Powder in Packet PO TID (3 times a day).
13. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. B Complex Vitamins Capsule Sig: One (1) Tablet PO DAILY
(Daily).
15. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
16. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
17. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) Inhalation every 6-8 hours as needed.
18. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
19. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day).
20. Sodium Chloride 0.9% Flush 3 mL IV DAILY:PRN
Peripheral IV - Inspect site every shift
21. Sodium Chloride 0.9% Flush 3 mL IV DAILY:PRN
Peripheral IV - Inspect site every shift
22. Ondansetron 4 mg IV Q8H:PRN
23. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day): COntinue until [**2143-3-15**].
24. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) as needed for repiratory infection: COntinue
until [**2143-3-15**].
25. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO BID (2 times a
day) as needed for loose stools.
26. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO
twice a day as needed for diarrhea.
27. Ondansetron 4 mg IV Q8H:PRN
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
perineal proctectomy for rectal prolapse
Discharge Condition:
stable
Discharge Instructions:
Incision Care: Keep clean and dry.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to ambulate several times per day.
* No heavy ([**9-25**] lbs) until your follow up appointment.
Followup Instructions:
Please follow up with Dr. [**First Name (STitle) 2819**] in [**12-12**] weeks; call his office at
([**Telephone/Fax (1) 6347**] to schedule an appointment
ICD9 Codes: 5180, 5119, 3572, 4019, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1477
} | Medical Text: Admission Date: [**2108-6-21**] Discharge Date: [**2108-7-3**]
Date of Birth: [**2108-6-21**] Sex: M
Service: NEONATAL
HISTORY: Baby [**Name (NI) **] [**First Name8 (NamePattern2) 1692**] [**Known lastname 13720**] delivered at 32-1/7 weeks
gestation weighing 1820 grams and was admitted to the
Intensive Care Nursery for management of prematurity.
Mother is a 42 year old Gravida 4, Para 0, now 1 woman with
estimated date of delivery [**2108-8-16**]. Prenatal screens
included blood type O positive, antibody screen negative,
rubella immune, RPR nonreactive, hepatitis B surface antigen
negative, and Group B Streptococcus unknown.
The mother's medical history is notable for depression, not
on current treatment and hypothyroidism treated with Armour.
The pregnancy was complicated by fibroids and cervical
shortening treated with bed rest from 20 weeks gestation.
The mother received [**Name (NI) **] two days prior to delivery for
increased pain attributed to the uterine fibroids.
There was spontaneous onset of labor progressing to
spontaneous vaginal delivery under epidural anesthesia.
Membranes were ruptured two minutes prior to delivery for
clear fluid. The mother received [**Name2 (NI) 38886**] antibiotics
about an hour prior to delivery due to unknown GBS status and
prematurity.
There was no history for chorioamnionitis. No maternal fever
or fetal tachycardia.
The infant cried at delivery, was dried, bulb suctioned and
given free flow oxygen. Began retracting in the Delivery
Room but remained pink in room air. Apgar scores were 7 and
8 at one and five minutes respectively.
PHYSICAL EXAMINATION: On admission, weight 1820 grams,
which is 75th percentile; head circumference was 29.5
centimeters which was 25th to 50th percentile; length 45
centimeters which was 75th percentile. A non-dysmorphic
infant with anterior fontanel soft and flat, palate intact.
Red reflex normal. Moderate nasal flaring. Neck and mouth
normal. Mild retractions. Good breath sounds bilaterally
with few scattered crackles. Well perfused. Regular rate
and rhythm. Normal S1, S2, no murmurs. Femoral pulses
normal. Abdomen soft, nondistended, no organomegaly, no
masses. Bowel sounds active. Patent anus. Normal preterm
genitalia. Testes retractile but descended bilaterally.
Active responses to stimulation with normal tone for age.
Moving all extremities equally. Normal spine, limbs, hips
and clavicles.
HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: Placed on CPAP 6 centimeters of water, 30%
oxygen for grunting, flaring and retracting on admission.
The chest x-ray was consistent with transient tachypnea of
the newborn. Weaned off CPAP on day of life one. Has been
in room air since with comfortable work of breathing with
breathing rates 30 to 50s. Has an occasional apnea of
bradycardia spells not requiring treatment with
Methylxanthine.
2. CARDIOVASCULAR: Has been hemodynamically stable since
admission. No murmur. Heart rate 120s to 150s. Recent
blood pressures 60/53 with a mean of 41.
3. FLUIDS, ELECTROLYTES AND NUTRITION: Initially maintained
on intravenous fluid of D10W, started enteral feeds on day of
life two. Feeds were advanced gradually to full volume feeds
of breast milk 20, 150 cc. per kilo on day of life eight
without problems. At the time of dictation, he is receiving
24 calories per ounce of breast milk with human milk
fortifier.
4. GASTROINTESTINAL: Received phototherapy for indirect
hyperbilirubinemia from day of life two to day of life six.
Peak total bilirubin was 10.8, direct 0.4.
5. HEMATOLOGY: Hematocrit on admission as 44%.
6. INFECTIOUS DISEASE: Received 48 hours of Ampicillin and
gentamicin following delivery for a rule out sepsis course.
Initial CBC showed a white count of 11.5, 20 polys, no bands,
297,000 platelets. Blood culture was negative.
7. NEUROLOGICAL: As the infant is greater than 32 weeks at
birth, head ultrasound is not indicated. Examination is age
appropriate.
8. SENSORY: Will need hearing screen prior to discharge.
CONDITION ON DISCHARGE: Stable preterm infant tolerating
feeds.
TRANSFER DISPOSITION: Transferred to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
service.
PEDIATRICIAN: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 47145**] in [**Location (un) 1468**].
CARE AND RECOMMENDATIONS:
1. FEEDS: Advance calories as needed for weight gain.
2. MEDICATIONS: Ferrous sulfate 0.15 cc., p.o. daily.
3. State newborn screen sent on day of life three.
4. Has not received any immunizations.
DISCHARGE DIAGNOSES:
1. Appropriate for gestational age preterm male infant
delivered at 32-1/7 weeks.
2. Transient tachypnea of the newborn, resolved.
3. Apnea of prematurity.
4. Indirect hyperbilirubinemia, resolving.
5. Sepsis ruled out.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Last Name (NamePattern1) 38457**]
MEDQUIST36
D: [**2108-7-3**] 21:05
T: [**2108-7-3**] 21:58
JOB#: [**Job Number 48059**]
ICD9 Codes: 7742, V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1478
} | Medical Text: Admission Date: [**2136-4-15**] Discharge Date: [**2136-5-3**]
Date of Birth: [**2072-6-12**] Sex: F
Service: SURGERY
Allergies:
Percocet / Latex / Ciprofloxacin
Attending:[**Last Name (NamePattern1) 4659**]
Chief Complaint:
ABDOMINAL PAIN
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This 63 yo female with a history of prior trauma presented
with acute, sudden onset, intense pain in her epigastrium
associated with nausea and vomiting. The pain was very severe.
She had no diarrhea. She had no fever or chills.
The pain was ongoing and continues at the time of this
evaluation. It can be controlled with narcotic pain
medications.
.
The patient has history of severe trauma in [**2129**] after being hit
by a truck. She had multiple fractures that required surgical
repair. She also required a hip and knee replacement. At the
time of her initial trauma an IVC filter was placed
prophylactic.
She had a significant pelvic fracture putting her at high risk
for DVT. However, she did well with no clots at that time. She
has no previous history of clots. Recently she has been very
physically active working out at a gym 3 times a week and
swimming on weekends. She says she has been more fatigued
recently.
Past Medical History:
Obesity
Atrial Fibrilation
Hypertension
Social History:
social drinker, and denies tobacco
Family History:
non contributory to this admission
Physical Exam:
At discharge:
Vitals- T 98.4, HR 74, BP 100/56, RR 18, O2sat 98% RA
Gen- NAD, alert
Head and neck- AT, NC, soft, supple, no masses
Heart- RRR, no murmurs
Lungs- CTAB, no rhonchi, no crackles
Abd- soft, ND, NT, + BS
Ext- warm, well-perfused, no edema
Pertinent Results:
CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST [**4-15**]
1. Several loops of abnormally appearing bowel within the pelvis
and right
lower quadrant with surrounding interloop fluid and small amount
of free
pelvic fluid. Possible clot detected within the SMV including
ileocolic
branch suggesting venous ischemic etiology.
2. Degenerative changes within the spine.
.
CXR [**4-15**]
No CHF or pneumonia. Boot-shaped cardiac configuration
suggests LV enlargement though clinical correlation is advised.
.
FLOW CYTOMETRY REPORT/FLOW CYTOMETRY IMMUNOPHENOTYPING
INTERPRETATION
Red blood cells, granulocytes, and monocytes were examined for
phosphatidylinositol linked antigens. RBCs and granulocytes
express expected levels of DAF (CD55) and MIRL (CD59). These
findings do not support a diagnosis of paroxysmal nocturnal
hemoglobinuria (PNH).
.
CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS [**4-18**]
1. Interval increase in amount of free fluid in the abdomen and
pelvis.
2. Diffuse, more extensive dilated bowel loops are noted
compared to prior
study. No wall thickening or pneumatosis.
3. New left small pleural effusion.
4. Collapse of IVC inferior to the filter and decreased
opacification of
iliac veins compared to [**2136-4-15**].
5. Previously suggested thrombosis within the superior
mesenteric vein is
again identified, approximately unchanged compared to prior
study on [**2136-4-15**].
6. Significant interval improvement of thrombosis in portal
vein.
.
CT PELVIS W/CONTRAST [**2136-4-21**]
Findings suggestive of a mechanical small-bowel obstruction
(likely adhesion) with transition point likely within the mid
pelvis. Little change to degree of pelvic fluid when compared to
most recent comparison. No evidence of bowel perforation or
necrosis at this time.
.
KUB [**4-23**]
Persistent small-bowel obstruction.
[**2136-4-25**] 03:40AM BLOOD WBC-8.0 RBC-3.96* Hgb-12.0 Hct-35.5*
MCV-90 MCH-30.2 MCHC-33.7 RDW-13.2 Plt Ct-379
[**2136-4-15**] 08:30AM BLOOD Neuts-86.6* Lymphs-9.4* Monos-3.4 Eos-0.1
Baso-0.4
[**2136-5-3**] 06:00AM BLOOD PT-15.7* PTT-76.7* INR(PT)-1.4*
[**2136-4-16**] 11:05AM BLOOD Thrombn-55.4*
[**2136-5-1**] 09:40AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006
[**2136-5-1**] 09:40AM URINE Blood-NEG Nitrite-POS Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2136-5-1**] 09:40AM URINE RBC-1 WBC-14* Bacteri-FEW Yeast-NONE
Epi-<1
[**2136-5-1**] 09:40AM URINE Mucous-RARE
Brief Hospital Course:
In the ED she was found to have a mild elevation in lactic acid.
On CT scan she was found to have a clot in the SMV with evidence
of intestinal ischemia. The patient was admitted to the ICU and
was made NPO, with IVF/PCA/med, foley, antibiotics and was
placed on bed rest. The patient was started on a heparin drip
and titrated to a theraputic range. A PICC line was placed and
the patient was started on TPN. Patient's abd exams improved and
she c/o of less pain.
.
The patient was transfered to stonman 5 on HD 2. She was NPO,
with IVF/meds/TPN, PCA, foley and telemetry. The patient
appeared more distended on HD 3 a CTA/CTV was done indicating
([**4-18**]): Increased ascites and more distended bowel loops (no
thickening or pneumatosis); clot in SMV unchanged in size or
location; IVC below IVC filter collapsed (acute change); new L
pleural effusion.
.
Serial abd exams improved, however the patient c/o nausea and an
NGT was placed with bilious output. The patient stated that
nausea resolved. With decreased NGT output the NGT was removed.
With the return of bowel function the patient's diet was
advanced and her TPN was d/c'd. Foley was removed without any
issues. The patient later c/o of burning with urination a UC was
done and was positive, the patient was started on ABX.
.
The patient was started on coumading and all other PO meds when
diet was advanced.
Her heparin drip was d/c'd and she was started on lovenox (120)
/coumadin (10) bridge. The patient refused VNA stating she has
done this in the past. The [**Name8 (MD) **] RN went over lovenox teaching
with pt and the patient did well.
.
The patient will follow up with her PCP [**Last Name (NamePattern4) **] [**5-4**] and the D/C
summary was faxed to the office. Dr. [**Last Name (STitle) **] spoke directly with
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] by phone and reviewed the [**Hospital 228**] hospital
course and outpatient discharge plan with him. He will set up
Coumadin monitoring with the patient and will follow up on her
hematologic workup. She will also follow up in the Hem/coag on
[**5-25**].
Medications on Admission:
tegretol 100', lisinopril 40'
Discharge Medications:
1. Carbamazepine 200 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Warfarin 5 mg Tablet Sig: Take as directed Tablet PO ONCE
(Once): Take as directed.
Disp:*60 Tablet(s)* Refills:*2*
4. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
5. Enoxaparin 120 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours).
Disp:*60 * Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Small bowel ischemia secondary to Superior mesentaric branch
thrombosis
Small bowel obstruction
Urinary tract infection.
.
Secondary:
seizure disorder, multiple ortho injuries s/p trauma, OA, h/o
MRSA, HTN, Afib
Discharge Condition:
Stable.
Tolerating regular diet.
Pain well controlled.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Medications:
1. Coumadin:
-You were started on this medication secondary to a SMV clot.
-You should take as directed and follow up with your PCP to have
lab work done.
-Your coumadin level will be adjusted according to your lab
work.
.
2. Lovenox injections:
-You were started on this medication to secondary to your DVT.
-You should take this every 12 hrs.
-You have done this in the past and education was provided.
-Please follow up with your PCP regarding this medication and to
have lab work down.
Followup Instructions:
1. Please follow up with Dr. [**Last Name (STitle) **] as needed. [**Telephone/Fax (1) 8792**].
2. An appointment has been made for you to follow up with Dr.
[**First Name (STitle) **],[**First Name3 (LF) 20**], [**Telephone/Fax (1) 14751**], on [**2136-5-4**] at 2:15 to have lab work
draw.
.
You will see both the Hem/coag Attending and Fellow:
Provider: [**First Name4 (NamePattern1) 569**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2136-5-25**]
11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2503**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2136-5-25**] 11:00. [**Hospital Ward Name 23**] building [**Location (un) **].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]
Completed by:[**2136-5-4**]
ICD9 Codes: 5990, 5119, 2762 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1479
} | Medical Text: Admission Date: [**2134-7-31**] Discharge Date: [**2134-8-3**]
Date of Birth: [**2073-6-7**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Methadone / Tylenol / Penicillins / Oxycodone
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
fevers, lost PICC access, hypotension
Major Surgical or Invasive Procedure:
PICC line removal
PICC line placement
History of Present Illness:
HPI: Mrs [**Known lastname 38739**] is a pleasant 61 year old female with hx chronic
neck/back pain s/p multiple laminectomies/fusions complicated by
recurrent L5 osteomyelitis who presents from rehab facility with
fever >102 after having pulled her PICC line halfway out. Pt
states that she has had back pain for the last 4 years c/b
multiple MRSA infections which were thought to have started
while the pt was immunocompromised while on meds for SLE. She
has been on and off IV abx about 20x for the last 3-4 years,
with the most recent course started 2 wks ago by Dr [**Last Name (STitle) **] at [**Hospital1 2025**].
Pt also with fevers to 103 at rehab, which was worked up
yesterday with CXR (+ for PNA), and UA/cxs (negative). She was
started on levoflox for PNA. Of note, last two doses of
vancomycin for osteo were held at rehab for supratherapeutic
levels.
.
On arrival to our ED, vitals were 98.9 94 91/56 20 94% RA. While
in the ED she had a fever to 100.4 for which she received 325
asprin and was subsequently afebrile. UA at rehab was negative
at rehab. She was given vancomycin for osteomyelitis,
levofloxacin was not given. Pt refused UA, Urine cx, cxr in the
ED. Lactate here was 1.6, no leukocytosis. PICC was pulled, tip
cxs, blood cxs pending. Given hypotension, she was bolused 2 L
NS. Pt was asymptomatic from hypotension and mentating well. She
also got 4 mg morphine for pain.
.
On the floor pt c/o ongoing back pain and is asking for IV
dilaudid. Although aaox3, she is tangential and drowsy.
.
ROS:
(+) Per HPI, + sinus congestion/allergy sxs.
(-) Denies chills, night sweats, recent weight loss or gain.
Denies headache, sinus tenderness, rhinorrhea. Denied cough,
shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No black/bloody or tarry stools. No recent
change in bowel or bladder habits. No dysuria. Denied
arthralgias or myalgias.
Past Medical History:
-SLE c/b lupus cerebritis
-Chronic low back pain (spinal stenosis)
-Status post [**Location (un) 931**] rods, removed and replaced
-Chronic neck pain; status post C3 and C4 fusion
-Osteoporosis
-Hx hypertension, has been on lisinopril in the past, but not
currently on medications
-Hypercholesterolemia per chart hx, pt states it has resolved
-History of positive purified protein derivative; status
post isoniazid
-Status post resection of basal cell carcinoma on the
left side of nose
-Maxillary sinus incision and drainage
-s/p implantable intrathecal pump
-hx seixures
-pt endorses enlarged lymph nodes in axilla and lungs, states
she says that they need to be biopsied
-intubation for sepsis 1.5 years ago
-hx MRSA skin infections
-hx anemia, has required blood transfusions in the past.
Colonoscopy attempted but not completed due to back pain.
Social History:
Social History: Pt recently moved from TN with her husband who
is a minister. About a month ago, her husband left for [**Country 5881**] to
do work for the church and left her at a rehab in [**Hospital1 1559**]. She
was subsequently admitted to [**Hospital1 2025**] approx 2 wks ago, treated for
osteomyelitis and discharged to [**Hospital3 **]. Her husband will
be returning from [**Country 5881**] at the end of the month and they plan
on staying in [**Location (un) 86**]. Pt uses a wheelchair to get around. She
previously worked as a public health nurse and taught nursing,
stopped 4 yrs ago when back problems started. Denies tobacco,
EtOH, drugs.
Family History:
Father with hx of cardiac disease, prostate CA, stomach CA
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp:98 BP: 121/75 HR:90 RR:12 O2sat: 98% RA
GEN: pleasant, comfortable, NAD, somewhat somnolent and
tangential
HEENT: PERRL, pupils sluggish, EOMI, anicteric, MMM, op without
lesions, no supraclavicular or cervical lymphadenopathy, no jvd.
2-3 cm abrasion across bridge fo nose
CV: RR, S1 and S2 wnl, no m/r/g
RESP: CTA b/l with good air movement throughout
ABD: nd, +b/s, soft, nt, intrathecal pump palpable on L side of
abdomen. Multiple surgical scars
EXT: no c/c/e. Several 1-2 cm abrasions on [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **]: as above
NEURO: AAOx2 (thinks it is still [**Month (only) **]). Cn II-XII intact.
Decreased strength in LEs [**3-3**] pain. No sensory deficits to light
touch appreciated.
DISCHARGE PHYSICAL EXAM:
VS: Temp: 97.6 BP: 100/58 HR: 76 RR: 18 O2sat: 96% RA
GEN: AOx3, comfortable, pleasant
HEENT: anicteric sclera, MMM, OP clear, no supraclavicular or
cervical lymphadenopathy, no jvd. 1-2 cm stable abrasion across
bridge fo nose
CV: RR, S1 and S2 wnl, no m/r/g
RESP: CTAB, no w/r/r exam limited by poor inspiratory effort [**3-3**]
to MSK pain (which is her baseline)
ABD: Soft, NT/ND, normal BS, no organomegaly
EXT: No c/c/e. Few 1-2 cm abrasions on LEs
NEURO: Cn II-XII intact. Decreased strength in LEs [**3-3**] pain. No
sensory deficits to light touch appreciated.
Pertinent Results:
ADMISSION LABS:
[**2134-7-31**] 05:00PM BLOOD WBC-7.3 RBC-3.58* Hgb-8.4*# Hct-26.6*#
MCV-74*# MCH-23.5*# MCHC-31.7 RDW-13.9 Plt Ct-165
[**2134-7-31**] 05:00PM BLOOD Neuts-71.3* Lymphs-20.2 Monos-5.5 Eos-2.5
Baso-0.5
[**2134-7-31**] 05:00PM BLOOD Ret Aut-2.1
[**2134-7-31**] 05:00PM BLOOD Glucose-126* UreaN-14 Creat-0.7 Na-139
K-3.5 Cl-102 HCO3-26 AnGap-15
[**2134-7-31**] 05:00PM BLOOD Iron-10*
[**2134-8-1**] 04:57AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.0
[**2134-7-31**] 05:00PM BLOOD calTIBC-410 Ferritn-16 TRF-315
[**2134-7-31**] 05:00PM BLOOD Vanco-9.9*
[**2134-8-1**] 04:57AM BLOOD Vanco-10.0
[**2134-7-31**] 05:21PM BLOOD Lactate-1.6
MICRO:
[**2134-7-31**] 7:40 pm CATHETER TIP-IV PICC TIP.
**FINAL REPORT [**2134-8-2**]**
WOUND CULTURE (Final [**2134-8-2**]): No significant growth.
[**2134-8-1**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2134-7-31**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2134-7-31**] BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY
[**2134-8-2**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2134-8-2**] BLOOD CULTURE Blood Culture, Routine-PENDING
REPORTS:
CXR AP [**2134-8-1**]:
CLINICAL HISTORY: Left PICC line placed, check position.
The exact position of the PICC line cannot be determined because
of overlying hardware. It is likely that it lies in the right
atrium but somewhat more oblique film would clarify this. The
lung fields are clear.
CXR AP [**2134-8-1**]:
CLINICAL HISTORY: PICC line placed, check position.
The tip of the PICC line lies within the right atrium and should
be withdrawn into the SVC.
IMPRESSION: PICC line in right atrium.
CXR AP [**2134-8-2**]:
IMPRESSION:
1. Increased opacity in the right perihilar and right
cardiophrenic regions
and minimal increased opacity in the left infrahilar region,
nonspecific. The
differential diagnosis includes infectious and inflammatory
processes and
parenchymal scarring. The markings appear slightly more
pronounced than on
the film from one day earlier. However, doubt overt CHF.
2. Hila are prominent bilaterally.
DISCHARGE LABS:
[**2134-8-3**] 12:51PM BLOOD Vanco-11.1
[**2134-8-2**] 08:30AM BLOOD Glucose-125* UreaN-9 Creat-0.6 Na-140
K-3.5 Cl-105 HCO3-25 AnGap-14
[**2134-8-2**] 08:30AM BLOOD Plt Ct-162
[**2134-8-2**] 08:30AM BLOOD WBC-6.2 RBC-3.77* Hgb-8.6* Hct-27.9*
MCV-74* MCH-22.9* MCHC-31.0 RDW-14.1 Plt Ct-162
[**2134-8-3**] 06:22AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007
[**2134-8-3**] 06:22AM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
Brief Hospital Course:
ACTIVE DIAGNOSES:
.
#Fever/Chills/Hypotension (Possibly PICC infection, Chronic
Osteomyelitis, or Pneumonia): Pt was recently discharged from
[**Hospital1 2025**] ([**7-23**]) where she was admitted and found to have chronic
osteomyelitis, PICC line infection, and pneumonia.
Interestingly, following her D/C from [**Hospital1 2025**] She was sent to rehab
with a fresh PICC line with a goal of 6 weeks of IV Vancomycin
and a 1 week course of Levofloxacin which she completed prior to
this adission. She was sent here from [**Hospital3 2558**] rehab for
spiking fevers with chills and hypotension as well as having
pulled her PICC line partway out. It was removed, the tip was
cultured (negative final culture) and blood Cx's were drawn
(NGTD at time of d/c, still pending). She was transferred to the
MICU for concerns of hypotension with BP's in the 90's (which is
about her her baseline according to the patient) where she
became afebrile and her pressures stabilized after fluids. In
the MICU it was discovered that 4/5 blood cultures from [**Hospital1 2025**] on
[**7-14**] and [**7-15**] were positive for Gordonia species. ID was
consulted and she was re-started on her IV vancomycin. It was
thought that this represented a line infection at [**Hospital1 2025**] and that
the line had been discontinued and that she had recieved at
least 2 weeks of IV vancomycin which is adequate treatment for
such an infection. She refused various elements of the work-up
including a physical exam on transfer to the floor, urine
cultures, echocardiogram to evaluate for possible endocarditis,
bone scan, and other further imaging. Her course was marked by
daily fever spikes (as high as 103 on this admission) including
a spike to 101.3 the morning of the day of discharge which she
described as her baseline for several years when in the
hospital, in rehab, or at home. She indicated on numerous
occasions her desire to avoid further workup and to return to
[**Hospital3 2558**] for rehab despite spiking fevers, even
threatening to leave AMA if need be on several occasions. She
remained hemodynamically stable throughout her admission and
agreed to keep her follow-up appointments at [**Hospital1 2025**] with infectious
disease (Dr. [**First Name8 (NamePattern2) 2855**] [**Last Name (NamePattern1) **], who prescribes and manages her
vancomycin and to whom all management questions should be
directed: [**Hospital1 2025**], [**Street Address(2) 38740**] [**Location (un) 86**], [**Numeric Identifier 18228**] [**Telephone/Fax (1) 38741**],
appt on [**8-18**]), orthopaedic surgery (Dr. [**Last Name (STitle) 38742**] [**Name (STitle) **], appt on
[**9-8**]), and GI for repeat EGD (Dr. [**Last Name (STitle) 38743**] [**Name (STitle) **], appt on [**9-8**]).
.
CHRONIC DIAGNOSES:
.
#Chronic Pain: This issue remained stable during her admission.
She was continued on her outpatient pain regimen with the
exception of an increase in her PO dilaudid dose to 4mg PO Q3hrs
PRN for breakthrough pain. She was discharged on her home dose
of dilaudid of 2mg PO Q3hrs PRN.
.
# Anemia: This pt states she has anemia likely of chronic
disease as a result of chronic osteomyelitis. She currently does
not have an PCP as she is new to [**Location (un) 86**]. It is important for her
to establish a PCP and undergo workup for her anemia including
colonoscopy and GYN evaluation.
.
#Lupus Cerebritis with related seizure disorder: She remained
stable and exhibited no seizure activity on her home Keppra
dose. We would recommend follow-up with her PCP once established
or her neurologist
.
#GERD: Stable during this admission, continued on her home
prilosec.
TRANSITIONAL ISSUES:
This patient needs to maintain her follow-up appointments with
infectious disease, Dr. [**First Name8 (NamePattern2) 2855**] [**Last Name (NamePattern1) **], who prescribes and manages
her vancomycin and to whom all management questions should be
directed: [**Hospital1 2025**], [**Street Address(2) 38740**] [**Location (un) 86**], [**Numeric Identifier 18228**] [**Telephone/Fax (1) 38741**],
appt on [**8-18**], orthopaedic surgery Dr. [**Last Name (STitle) 38742**] [**Name (STitle) **] at [**Hospital1 2025**], appt
on [**9-8**], and GI for repeat EGD with Dr. [**Last Name (STitle) 38743**] [**Name (STitle) **] at [**Hospital1 2025**] with
her appt on [**9-8**]. She should also establish a PCP for management
of her multiple medical problems including but not limited to
her anemia and seizure disorder.
Medications on Admission:
-multivitamin
-aspirin PRN fever
-lasix 20 mg on [**7-31**] and [**8-1**]
-levaquin 500 mg x7 days (which was completed prior to
admission)
-folic acid 1 mg daily
-dilaudid 2 mg PO q 3 hrs PRN breakthrough pain
-ativan 1 mg [**Hospital1 **]
-prilosec 40 mg PO BID
-senna 2 tabs PO BID
-gabapentin 1200 PO TID
-keppra 750 PO BID
-ms contin 60 mg q 6 hrs
-dulcolax supp 10 mg PR PRN constipation
-Miralax 17 mg PO daily PRN constipation
-Vancomycin-unclear dose and duration from [**Name (NI) **] records, pt states
she started 2 wks ago with intention to complete 6 wk course
Discharge Medications:
1. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours): This medication was
prescribed by Dr. [**First Name8 (NamePattern2) 2855**] [**Last Name (NamePattern1) **],
[**Hospital1 2025**], [**Street Address(2) 38740**] [**Location (un) 86**], [**Numeric Identifier 18228**] [**Telephone/Fax (1) 38741**]
All management questions should be directed to him.
.
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. gabapentin 600 mg Tablet Sig: Two (2) Tablet PO four times a
day.
7. levetiracetam 500 mg Tablet Sig: 1.5 Tablets PO BID (2 times
a day).
8. morphine 30 mg Tablet Extended Release Sig: Two (2) Tablet
Extended Release PO Q6H (every 6 hours).
9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
11. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every
3 hours) as needed for pain.
12. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for Constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
- PICC line complication
Secondary:
-Chronic osteomyelitis
-Chronic pain
-GERD
-Lupus cerebritis with related seizure disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname 38739**],
You were admitted to [**Hospital1 69**] for
fevers/chills, low blood pressure, and compromise of your PICC
line (it was almost pulled out) in rehab. Your PICC line was
removed, you were treated with fluids, antibiotics, and pain
medications and your condition improved. You are being
discharged back to rehab to continue your recovery. At the time
of discharge your PICC line culture was negative and your final
blood culture results were pending.
The following changes have been made to your medications:
-RE-START Vancomycin 1gm IV twice daily
-STOP Furosemide
We wish you the best of luck and a speedy recovery.
Followup Instructions:
Infectious Disease Follow Up:
Dr. [**First Name8 (NamePattern2) 2855**] [**Last Name (NamePattern1) **] on [**8-18**] 10:40AM
[**Street Address(2) 38740**]
[**Location (un) 86**], [**Numeric Identifier 18228**]
[**Doctor Last Name **] building [**Location (un) **]
[**Telephone/Fax (1) 38741**]
Orthopaedic Surgery Follow Up:
Dr. [**Last Name (STitle) 38742**] [**Name (STitle) **] on [**8-31**] 10:00am
[**Hospital1 2025**] Yawkey Center, [**Hospital Unit Name **]
[**Street Address(2) 38740**]
[**Location (un) 86**], [**Numeric Identifier 18228**]
[**Telephone/Fax (1) 38744**]
Gastroenterology Follow Up:
Dr. [**Last Name (STitle) 38743**] [**Name (STitle) **] on [**9-8**] at 3pm
[**Doctor Last Name 406**] [**Location (un) **]
[**Street Address(2) 38740**]
[**Location (un) 86**], [**Numeric Identifier 18228**]
[**Telephone/Fax (1) 38744**]
Department: RHEUMATOLOGY
When: THURSDAY [**2134-9-9**] at 2:30 PM
With: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2134-8-3**]
ICD9 Codes: 2720, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1480
} | Medical Text: Admission Date: [**2159-6-12**] Discharge Date: [**2159-6-15**]
Date of Birth: [**2077-11-19**] Sex: F
Service: MEDICINE
Allergies:
Lipitor / Tape
Attending:[**First Name3 (LF) 3561**]
Chief Complaint:
s/p cardiac arrest
Major Surgical or Invasive Procedure:
cpr
History of Present Illness:
81 yo F w/ CAD s/p CABGx4, HTN, DM, ESRD on HD (TUTHSAT), PVD,
CHF (EF30%), PPM for SSS, NSCLC, admitted for elective
angiography of the LE [**1-6**] to foot ulcerations (vanc/gent at
dialysis). Now being transferred to the MICU s/p cardiac arrest.
Pt. was taken down to angiography today but could not tolerate
the procedure d/t back pain she was given approx 5mg of iv
morphine throughout the day. At dialysis 3.5L were removed. On
the floor, she was found slumped over and unresponsive although
reportedly still breathing. A code blue was called. She was in
PEA arrest for approximately 3 minutes during which time she
received compression and bag ventilation. She did not receive
any medications. The family was present during the arrest and
the husband requested that resuscitation be held. Soon after
stopping CPR, a femoral pulse was detected and the pt. was
breathing spontaneously. She then awoke and was able to carry on
a conversation, falling asleep intermittently. A discussion was
held with the family regarding her code status and she was made
DNR/DNI (documented in the chart by micu attending). However,
she was transferred to the micu for close monitoring.
Past Medical History:
1. Coronary artery disease
- s/p NSTEMI ([**10-6**]) with resulting CABG x4 (bypass from the
ascending thoracic aorta sequentially to the large diagonal and
obtuse marginal with reversed vein and to the small posterior
descending branch of the circumflex, with the second segment of
vein and to the left anterior descending with the left internal
mammary artery)
2. End-stage-renal disease, on HD
3. Congestive heart failure, ECHO ([**2159-3-23**]) with EF of 30%
4. Hypertension
5. Peripheral vascular disease
6. Sick sinus syndrome w/conduction abnormalities s/p DDD pacer
placement [**2159-3-28**]
7. Hyperlipidemia
8. Diabetes
9. Cataracts
10. Osteoporosis
11. PMR
12. Gout
13. Basal Cell Carcinoma
14. Hypothyroidism
Social History:
At baseline the patient uses a walker and her mobility is
limited. Her mobility typically is not limited by dyspnea but
rather by claudiaction. Lives with husband. Social history is
significant for the absence of current tobacco use, but she used
to smoke cigarettes but quit 20 years ago. Approximately 60 pack
year history. There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death, but her mother had a CABG and died at age 86.
Her father had diabetes and died at age 72. Her brother has
prostate cancer. She has two children who are healthy.
Physical Exam:
VITALS - T 95.8 BP 82/13 HR 60 RR
GEN - ill appearing thin elderly F laying in bed. somnolent, but
follows directions.
HEENT- nc in place. pupils 1mm bilaterally and reactive
CV- distant heart sounds. regular
PULM- CTA bilat
ABD- soft, NT/ND, normoactive bs
EXT- LE are cold, DP not dopplerable.
skin- sacral decubitis erythema with palpable crepitus.
NEURO- awakes to voice and is interactive, but then quickly
falls asleep.
Brief Hospital Course:
cardiac arrest: unclear precipitant. could possibly be [**1-6**] to
narcotics leading to respiratory depression, hypotension and
cardiac arrest. CPR was started, however the husband asked for
this to be stopped. There was spontaneous return of circulation
and the pt. was transferred to the MICU. The Pt was given IVF.
The family did not wish for any invasive procedures or further
intervention. The pt. expired with the family at the bedside.
Medications on Admission:
tylenol prn
asa 325 qdaily
clonidine 0.1 [**Hospital1 **]
carvedilol 12.5mg [**Hospital1 **]
colace [**Hospital1 **]
hydrocort cream prn hemorrhoids
RISS w/ lantus
isosorbide mononitrate er 60mg po qdaily
synthroid 37.5mg qdaily
nephrocaps 1 cap qdaily
nitroglycerin SL prn
zofran 4mg q8hrs prn
sevelamer 800mg po tid w/ meals
senna prn
tucks prn
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2160-5-1**]
ICD9 Codes: 5856, 412, 4275, 4280, 4589, 2724, 2449, 2749 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1481
} | Medical Text: Admission Date: [**2145-10-16**] Discharge Date: [**2145-10-25**]
Date of Birth: [**2125-8-16**] Sex: M
Service: SURGERY
Allergies:
morphine / Penicillins / Latex
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p Motorcycle crash
Major Surgical or Invasive Procedure:
[**2145-10-16**] ELEVATION OF LEFT SKULL FRACTURE; CRANIOPLASTY WITH
TITANIUM MESH; REPAIR OF FRONTOBASILAR FRACTURE, FRONTAL SINUS
MUCOSECTOMY, LEFT ORBITAL RECONSTRUCTION, REPAIR OF
SCALP/FOREHEAD DEFECT.
[**2145-10-18**] IRRIGATION AND DEBRIDEMENT OPEN SKULL FRACTURE,
SYNTHESIS LOW PROFILE PLATE EXCHANGE
[**2145-10-22**] ORIF left zygomatic maxillary fracture
History of Present Illness:
20 M unhelmeted MCC vs tree. Questionable LOC. On initial
presentation GCS 15,verbal, following commands, and moving all
extremities with full strength. However left pupil midriatic,
non reactive. Degloving injury of the forehead with open skull
fracture. Electively intubated in ED due to emesis.
Past Medical History:
PMH: pectus excavatum, R humeral fracture from bike accident at
age 15
PSH: R humeral fracture repair at age 15
Social History:
unknown
Family History:
non-contributory
Pertinent Results:
IMAGING:
[**10-16**] CTA head: 3 cm left frontal calvarial depression into the
left frontal lobe with adjacent small intraprenchymal hematoma.
No large mass effect or vascular territorial infarction seen.
Mild pneumocephalus [**12-23**] open left frontal fracture/avulsion.
CTA: Patent anterior and posterior circulation, COW, ACA, MCA,
and PCA with no dissection, flow limiting stenosis, or vascular
malformations detected. Active extravasation seen within the
superficial soft
tissues next to the avulsed frontal bone (4:157). No
intracranial active extravasation.
[**10-16**] CT max-face: 1.Large avulsion fracture of the left frontal
bone, resulting in exposure of the left frontal lobe and
pneumocephalus. 2. Extensively comminuted and displaced
fractures of the left frontal bone with depression of fracture
fragments approximately 3 cm into the left frontal lobe, with a
small amount of adjacent intraparenchymal hemorrhage. No shift
of intracranial midline structures. 3. Extensively comminuted
and displaced fractures involving the left face as noted above.
4. Proptosis of the left globe, with stretching of the left
optic nerve and left lateral rectus muscle secondary to marked
lateral and posterior rotation
of the orbital plate. A fracture fragment impinges upon the left
inferior rectus muscle. Left lens is dislocated. 5. Blood
products within the ethmoid, left maxillary, and sphenoid
sinuses.
[**10-16**] CT C-spine prelim: No acute fx or traumatic malalignment
of the cervical spine
[**10-16**] CT torso prelim: NO acute intrathoracic, intraabdominal,
or intrapelvic process
[**10-17**] CT head w/o contrast: Post-surgical changes in the left
frontal region with mild post-operative hemorrhage and
pneumocephalus. Minimal local mass effect. Persistent left
frontal lobe contusion. Assessment for subtle cerebral edema can
be limited given the noisy iamges- correlate clinically. No
intracranial osseous fragments.
No evidence of subfalcine or transtentorial herniation.
No new hemorrhage or acute large territorial infarction.
CT sinus/mandible/maxillofacial: Post-surgical repair of the
left frontal bone fractures. No osseus fragments remain in the
intracranial structures. Mass effect upon the left extra-ocular
muscles appears decreased. Persistent lateral stretch of the
left optic nerve. Stable multiple fractures of the left orbit
and maxillary sinus. Hemorrhagic fluid remains in the paranasal
sinuses.
[**10-18**] CXR: Right lower lobe opacity worrisome for infectious
process is noted, although it could represent atelectasis.
[**10-18**] MRI C spine: 1. No focal signal abnormality noted in the
cord.
2. No marrow edema noted in the cervical vertebrae. 3. No
evidence of subluxation. 4. Hyperintense signal noted on STIR
images in the interspinous soft tissues from C1-C2 to C6-C7
levels which likely represent edema or injury to the
interspinous ligament which is less likely. 5. Hyperintense
signal noted on STIR images in the posterior paraspinal soft
tissues from C2 to C7 level which may represent edema.
Brief Hospital Course:
Mr. [**Known lastname **] was transferred to the TICU after going to the
operating room with Neurosurgery for elevation of the left
frontal bone & cranioplasty with titanium mesh as well as ORIF
of the left orbit. DIlantin prpohylaxis was initiated. He
remained intubated post-operatively. Left globe pressures were
monitored but were not felt to be elevated. His anti-seizure
propylaxis was recommended to continue after discharge until
follow up as outpatient with Neurosurgery.
On POD 2 he retuned to OR with plastics for washout and plate
replacement. Postoperatively he spiked a fever to 101.5 and a
full workup was perfomed. His hematocrit was 20 and he was
transfused 2u PRBC's. He was not extubated due to significant
facial swelling. On [**10-19**] a spine consult was called given
possible interspinous ligament injury and it was determined that
he did not have ligamentous injury and the hard collar was then
removed.
He extubated on POD 4 and a code purple was called given severe
agitation. He then stabilized over the course of the next
several days with zyprexa and was transferred to the floor.
Once transferred to the regular surgical floor he continued to
progress. His mental status improved significantly during his
floor course and there were no further issues with agitiation
and/or aggressive behaviors for the remainder of his stay. His
Zyprexa dose was decreased.
He was seen by Opthmaology for the shattered left orbit with
left blowout fracture
traumatic mydriasis and for evaluation before undergoing repair
of his facial fractures by Plastics. Several eye drops were
recommended and clearance to proceed with his Plastics procedure
was given.
He was taken to the operating room on [**10-22**] by Plastics for open
reduction and internal fixation of left zygomatic-malar complex
fracture. There were no complications. He was left with many
facial sutures which were treated with Bacitracin ointment. He
will follow up with Plastics for removal of the sutures after
discharge.
He participated with Physical and Occupational therapy and
intially the thought was that he would require [**Hospital 91373**] rehab
stay. Given his significant improvement and after discussions
with his family the decison was made that he was safe to
transition home with 24 hour supervision that his family was
able to provide.
Medications on Admission:
none
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl Topical
TID (3 times a day): apply to facial wounds.
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for agitation.
Disp:*60 Tablet(s)* Refills:*1*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
8. bacitracin 500 unit/g Ointment Sig: One (1) Appl Ophthalmic
TID (3 times a day): apply to OS.
Disp:*1 tube* Refills:*2*
9. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic SIX TIMES A DAY (): left eye.
Disp:*1 bottle* Refills:*2*
10. scopolamine HBr 0.25 % Drops Sig: One (1) Drop Ophthalmic
[**Hospital1 **] (2 times a day): left eye.
Disp:*1 bottle* Refills:*2*
11. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID (3 times a day).
Disp:*180 Tablet, Chewable(s)* Refills:*1*
12. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 2203**] VNA
Discharge Diagnosis:
s/p Motorcycle crash
Injuries:
Depressed left skull fracture
Degloving injury to left forehead
Shattered left orbit with left blowout fracture
Traumatic mydriasis
Left maxillary sinus fractures
Delirium
Acute blood loss anemia
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 on [**2145-10-16**] after a motorcyle
crash where you sustained a traumatic brain injury and injury to
your left eye - both of which required an operation to repair.
You will likely need to undergo further surgery and this will be
determined when you return to the hospital for your follow up
appointments.
Please follow these discharge instructions:
.
AVOID any activities that may cause injury to your head - do not
ride any motorcycles, bicycles or other modes of transportation
other than in a car or bus.
.
Medications:
* You have been prescribed an anit-seizure medication called
Keppra to continue for at least a month. You will then follow up
with these specilaist to determine how much longer this
medication is needed.
* Resume your regular medications unless instructed otherwise.
* You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging. Please note that
Percocet and Vicodin have Tylenol as an active ingredient so do
not take these meds with additional Tylenol.
* Take prescription pain medications for pain not relieved by
tylenol.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication.
* Take Colace, 100 mg by mouth 2 times per day, while taking the
prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
.
Call the office IMMEDIATELY if you have any of the following:
* Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
* A large amount of bleeding from the incision(s).
* Fever greater than 101.5 oF
* Severe pain NOT relieved by your medication.
.
Activities:
* No strenuous activity
* Exercise should be limited to walking; no lifting, straining,
or excessive bending.
* It is recommended that you wear a soft collar when out of bed
for 4 weeks.
* Unless directed by your physician, [**Name10 (NameIs) **] not take any medicines
such as Motrin, Aspirin, Advil or Ibuprofen etc
.
Comments:
* Please sleep on several pillows and try to keep your head
elevated to help with drainage.
* Please maintain SOFT diet until your follow up clinic visit
and you can ask your surgeon whether you can advance your diet
at that time. Avoid soft diet foods with 'little pieces' (ie;
oatmeal) that can get stuck in surgical wounds.
* Please avoid blowing your nose.
* Sneeze with your mouth open
* Try to avoid sipping liquids through a straw
* Use your oral rinse as directed.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2477**], MD Phone:[**Telephone/Fax (1) 31444**]
Date/Time: [**2145-10-29**] 1:30
Dr.[**Name (NI) 2989**] clinic is located on the [**Hospital Ward Name **], [**Hospital Ward Name 23**]
building, [**Location (un) 470**], Surgical Specialties.
.
Name: [**First Name11 (Name Pattern1) 275**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Specialty: Internal Medicine
Location: PMG PHYSICIAN ASSOCIATES
Address: [**Location (un) 88267**] [**Apartment Address(1) 40744**], [**Location (un) **],[**Numeric Identifier 88268**]
Phone: [**Telephone/Fax (1) 36604**]
We are working on a follow up appointment with Dr. [**Last Name (STitle) 39360**] for
within the next 2 weeks. You will be called at home with the
appointment. If you have not heard within 2 business days or
have questions, please call the number listed above.
Department: [**Hospital3 1935**] CENTER
When: MONDAY [**2145-11-1**] at 2:15 PM
With: [**Name6 (MD) 6131**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Name6 (MD) **] [**Name8 (MD) 739**], MD
Specialty: Neurosurgery
Location: [**Hospital1 18**]-DIVISION OF NEUROSURGERY
Address: [**Doctor First Name **], STE 3B, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 1669**]
We are working on a follow up appointment with Dr. [**Last Name (STitle) 739**]
for within the next 30 days. You will be called at home with the
appointment. If you have not heard within 2 business days or
have questions, please call the number listed above.
Department: COGNITIVE NEUROLOGY UNIT
When: THURSDAY [**2145-12-9**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6403**], MD [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
We are working to have you seen by Dr. [**First Name (STitle) **] for within the
next 2 weeks, sooner than the appointment booked above. You will
be called at home with the appointment. If you have not heard
within 2 business days or have questions, please call the number
listed above.
Completed by:[**2145-10-27**]
ICD9 Codes: 2851, 2930 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1482
} | Medical Text: Admission Date: [**2143-2-16**] Discharge Date: [**2143-2-25**]
Date of Birth: [**2073-7-25**] Sex: F
Service: MEDICINE
Allergies:
Lipitor / Zocor
Attending:[**First Name3 (LF) 3276**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Please see admission note for full details of history. Ms.
[**Name14 (STitle) 102143**] is a 69 year old female with past medical history of
right lower lobe squamous cell carcinoma, status-post resection
in [**2141**], treated with chemotherapy and thoracentesis in [**11/2142**],
who brain radiation in [**12/2141**], and recent admission for
pneumonia in [**12/2142**] treated with levofloxacin. Likely
leptomeningeal spread.
.
She presented to the ED [**2-16**] with dyspnea and increasing home O2
requirement. Her home nurse had also recently noted low BP,
causing her to miss her daily amiodarone and metoprolol. Her
dyspnea progressed from exertional to at rest over days. She
also had a chest discomfort, nonpleuritic. No fevers, chills, or
change in chronic productive cough. ROS otherwise negative.
.
Her initial vital signs were a temperature of 97.0, [**Month/Year (2) **]
pressure of 110/59, heart rate of 132, respiratory rate of 20,
and 91% on room air. She was given 2 mg of morphine, 4 mg of
zofran, 150 mg bolus of amiodarone IV, 200 mg of PO amiodarone,
5 mg of roxicet, 325 mg of tylenol, amiodarone drip, fentanyl 50
mcg, and 750 mg of levofloxacin. In the ED, she was initially
tachycardic with a heart rate as high as 140, but this converted
to sinus at a rate of 70 after administration of amiodarone.
There was concern for worsening metastatic disease or PE, so she
underwent a chest CT. It was negative for a pulmonary embolism,
however it did demonstrate a worsening multifocal pneumonia and
worsening metastatic disease as compared to PET/CT from
[**2143-1-21**]. During the time in the ED, her systolic [**Year (4 digits) **] pressure
ranged from 70-90's. She was given one liter of IVF. She was
transfered to the ICU for further management given her
hypotension and high oxygen requirement.
.
In the [**Hospital Unit Name 153**], there was concern for amiodarone pulmonary
toxicity, so this medication was stopped. Cardiology followed
her and recommended continuation of low-dose beta blocker.
Antibiotics were broadened to Bactrim (for possible PCP given
chronic steroid use) and levofloxacin. There was consideration
of broncoscopy for the purpose of BAL for culture, but the
patient declined. Currently she is on a non-rebreather with good
O2 Sats. She is also on stress-dose steroids given chronic
prednisone. She was given 2 units of pRBC.
.
Goals of care were addressed and revised to include DNR and no
invasive measures. Palliative care is following. She will be
transferred to the OMED team given no desire for ICU-level
aggressive measures.
. HR 60 110/53 16 97% NRB. Got levoflox already today. 1L
positive. Also given 2u pRBC's.
.
Main goal at this time is for hospice, palliative care on board.
Not bronched per patient request. Will accept abx, but nothing
invasive.
.
Past Medical History:
Oncology History:
T2 N1 squamous cell lung cancer in the right lower lobe s/p
resection [**2142-6-11**]. Pathology notable for a positive margin,
lymphatic, and venous invasion. She is s/p chemo radiation and
resection of the right-sided lesion. She is s/p four cycles of
carboplatin and paclitaxel with the fourth cycle of chemotherapy
on [**2142-10-16**]. [**2142-11-27**] [**Year (4 digits) 4338**] of head with concern for
metastatic disease with a 5-mm enhancing lesion in the left
frontal lobe and a new 6 x 6 x 5 mm enhancing lesion in the
right parietal lobe with mild associated edema concerning for
cortical or leptomeningeal metastatic disease.
.
[**2142-12-7**] thoracentesis to drain left pleural effusion given
symptomatic cough. No evidence of malignancy with resolution of
cough but continued shortness of breath with exertion. CXR on
[**2142-12-11**] showed a persistent small left pleural effusion.
.
[**2142-12-18**] whole brain radiation therapy and radiation therapy to
her sacral metastasis with intermittent pain requiring dilaudid,
nausea and dry heaves requring compazine. She continued to have
chronic lower extremity weakness which has not changed in
severity.
.
[**2142-12-31**] Patient completed course of radiation to C2 Whole Brain
and Sacrum. She received a total dose of 3000 cGy to each site.
Of note she has had increased sacral pain and worsening nausea
and dry heaves. She was attempting Zofran, and dilaudid 2 mg Q6
as needed for pain. She also reported slight worsening of her
shortness of breath. No pleuritic chest pain. At that time o2
sat 94%RA.
Social History:
Married. Smoked in the past but quit 25 years ago, denies
alcohol or illicit drug use.
Family History:
The patient's father died of CAD as did her mother. Two
brothers have CAD. A sister has had multiple TIAs.
Physical Exam:
Vital Signs BP 110/53, HR 76, O2 Sat 96% on NRB
GENERAL: pleasant woman, appears comfortable
HEENT: slopecia, pupils small but reactive, no scleral icterus
NECK: supple, JVP not appreciated
LUNGS: decreased breath sounds and dullness to percussion over
left base, diffuse bronchial breath sounds over b/l lung fields
CARDIAC: regular, no murmurs
ABDOMEN: soft, nontender, nondistended
EXTR: warm, no edema, ecchymoses over right tibia.
NEURO: alert and oriented
PSYCH: pleasant, appropriate
.
Pertinent Results:
[**2143-2-16**] CTPA
1. No evidence of pulmonary embolism.
2. Persistent diffuse ground-glass opacity in the right upper
lobe and
worsened ground-glass within the lingula are concerning for
worsening
multifocal infection.
3. Increased size of pulmonary nodules concerning for worsening
metastatic
disease.
[**2143-2-18**] Echo
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with severe hypo/akinesis
of the basal half of the inferiorseptum, inferior, and
inferolateral walls. The remaining segments contract normally
(LVEF = 50 %). [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] 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 structurally normal. At least moderate
(2+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is an anterior space
which most likely represents a fat pad.
IMPRESSION: Suboptimal image quality. Normal left ventricular
cavity size with regional systolic dysfunction c/w CAD. At least
moderate mitral regurgitation suggestive of papillary muscle
dysfunction.
Compared with the prior study (images reviewed) of [**2142-6-13**], the
severity of mitral regurgitation has increased.
Brief Hospital Course:
Ms. [**Known lastname 94074**] is a 69 year old female with past medical history
of squamous cell carcinoma and atrial fibrillation who presented
with dyspnea and was found to have multifocal pneumonia.
.
#) Multifocal pneumonia: Likely related to underlying cancer,
possibly post-obstructive. O2 Sats were mostly in the upper 90s
on nonrebreather. Patient initially wanted like to continue
antibiotics, but has declined elective intubation for BAL
cultures after sputum cx contaminated. Thus she was transferred
to OMED given no desire for aggressive measures. There goals of
care were further revised ot include comfort measures only.
Antibiotics were stopped. Stress dose steroids were quickly
tapered. She was given nebulizer treatments as needed for
comfort. Because there was a question of mild volume overload,
she was also given lasix 20 mg IV as needed, which seemed to
help. A foley was placed to improve comfort of urination given
that she was becoming short of breath with any transfer.
.
#) Atrial fibrillation: Patient presented to ED in AF with RVR
in the setting of missing amiodarone. Converted to NSR with
amiodarone and beta blocker. She was not anticoagulated
secondary to history of GI bleed. Cardiology followed her. When
goals of care were revised to comfort, metoprolol PO was
continued to prevent recurrence of atrial fibrillation with RVR.
Prior to discharge she again developed atrial fibrillation but
was not uncomfortable. Metoprolol was continued.
.
#) Squamous cell lung carcinoma: Followed by Dr. [**Last Name (STitle) 3274**] as an
outpatient. Brain metastases have responded to XRT, but
worsening pulmonary disease burden. Patient is followed by Drs.
[**Last Name (STitle) 3274**] and [**Name5 (PTitle) **] here at [**Hospital1 18**]. There were no plans for
further chemotherapy, as the cancer was considered end-stage.
.
#) Anemia: She received 2 units pRBC in the ICU. When goals of
care were revised no futher labs were drawn.
.
#) Chronic renal insufficiency: Creatinine was initially below
baseline 1.1-1.2. Lab tests were stopped
.
#) Polymyalgia rheumatica: On 10 mg prednisone daily at home.
Received stress-dose steroids here in the setting of infection.
This was quickly tapered back to her home dose, which may be
continued to prevent recurrence of PMR.
.
#) Coronary artery disease: Aspirin, [**Last Name (un) **] were stopped after
goals of care were revised.
.
#) Gout: No active symptoms. Allopurinol was stopped.
.
#) Contact: [**Name (NI) **], daughter # [**Telephone/Fax (1) 102144**]
.
#) Code: Code status at discharge was DNR, DNI, no ICU transfers
or aggressive measures, with primary goal of care being comfort.
Medications on Admission:
per outpatient OMR note from [**2143-1-29**], reconcilled at that
time)
- ALLOPURINOL 100 mg daily
- AMIODARONE 200 mg daily
- CANDESARTAN 16 mg once a day
- HYDROMORPHONE 2 mg, [**11-23**] Tablet every 6 hours as needed for
pain
- METOPROLOL TARTRATE 12.5 mg twice a day
- NITROGLYCERIN - 0.3MG PRN
- NYSTATIN 100,000 unit/mL Suspension, 5 ml QID
- ONDANSETRON 4 mg Tablet, QID
- PREDNISONE 10 mg Tablet daily
- PROCHLORPERAZINE EDISYLATE [COMPAZINE] 10 mg Tablet TID PRN
- ASPIRIN 81 mg
- CALCIUM 600 + D, 1 Tablet three times a day
- DOCUSATE SODIUM PRN
- SENNOSIDES-DOCUSATE SODIUM PRN
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 656**] House
Discharge Diagnosis:
primary: metastatic squamous cell carcinoma of the lung, atrial
fibrillation with rapid ventricular response
secondary: coronary artery disease, chronic kidney disease,
Discharge Condition:
with facemask oxygen requirement
Discharge Instructions:
You came to the hospital because you were short of breath. You
were treated with oxygen. Your heart was also in an irregular
fast rhythm and you were given medications to control this. You
and your family decided to transisition to hospice care. Please
follow the attached medication list which may be adjusted at the
[**Hospital1 656**] House as needed.
Followup Instructions:
Please follow up at your hospice facility.
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **] MD [**MD Number(1) 3282**]
Completed by:[**2143-2-26**]
ICD9 Codes: 486, 412, 5859, 2749, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1483
} | Medical Text: Admission Date: [**2115-6-4**] Discharge Date: [**2115-6-10**]
Date of Birth: [**2063-9-29**] Sex: M
Service: C-MED
HISTORY OF PRESENT ILLNESS: The patient is a 51-year-old
male with ankylosing spondylosis, but no prior cardiac
history who presented with a history of worsening and more
frequent shortness of breath, dizziness, and palpitations
both on exertion and at rest.
This started two months ago when climbing up stairs. On the
day prior to admission, the patient experienced this five to
eight times and was brought to the [**Hospital3 3583**] Emergency
Department. There, his heart rate went from 140 to 250, and
the patient experienced shortness of breath and chest
heaviness. A total of 30 mg of adenosine was given and had
no affect and 50 mg of diltiazem. The patient was electively
cardioverted back to a normal sinus rhythm and then received
400 mg of amiodarone and was started on Lopressor 25 mg twice
per day.
An echocardiogram at the outside hospital revealed an
ejection fraction of 20% and global hypokinesis. The patient
was brought to [**Hospital1 69**], and a
cardiac catheterization was performed. The catheterization
revealed clean coronary arteries but increased pressures;
including a wedge pressure of 30, and an ejection fraction of
20%, and confirmed global hypokinesis.
That evening the patient had atrial fibrillation with a rapid
ventricular response, and was started on amiodarone. He
spontaneously reverted to sinus rhythm.
The following day, the patient was taken for an elective
electrophysiology study and for atrial flutter ablation. The
ablation was successful, but the patient went into
atrial fibrillation. Ibutilide was started with an
increase QTc noted on electrocardiogram of greater than 700
milliseconds. A temporary pacing wires were was left in the
coronary sinus. In retrospect it was noted that the patient's
QT interval had prolonged significantly even prior to ibutilide,
after only a few doses of amiodarone. Amiodarone and ibutilide
were discontinued, and the patient was transferred to the
Coronary Care Unit for monitoring.
PAST MEDICAL HISTORY: (Past medical history is significant
for)
1. Ankylosing spondylolysis since the age of 23.
2. Hypercholesterolemia (which the patient denies).
[**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3812**]
Dictated By:[**Last Name (NamePattern1) 6006**]
MEDQUIST36
D: [**2115-6-10**] 16:35
T: [**2115-6-15**] 01:19
JOB#: [**Job Number 52053**]
ICD9 Codes: 4254, 4240, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1484
} | Medical Text: Admission Date: [**2163-9-19**] Discharge Date: [**2163-9-19**]
Date of Birth: [**2163-9-19**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby Girl [**Known lastname 56982**] was born at 38
and 6/7 weeks gestation by cesarean section for breech
presentation and known meningomyelocele. She was born to a
44 year old gravida III, para 0, now I, woman who prenatal
screens were blood type A positive, antibody negative,
rubella immune, RPR nonreactive, hepatitis B surface antigen
negative, and GBS status unknown. Mother had been taking
Folate 1.8 mg p.o. daily. Mother had a previous spontaneous
loss and a therapeutic loss. This pregnancy was complicated
by prenatal diagnosis of myelocele and bilateral clubfeet at
18 weeks gestation. A prenatal ultrasound at 23 and 6/7
weeks gestation showed a single well defined cyst overlying
the posterior at approximately L4. It measured 0.9 by 0.9
centimeters. There were also bilateral clubfeet. She had a
fetal magnetic resonance imaging which supported the finding
of the ultrasound. There was no hydrocephalus, no Chiari
malformation or other fetal anomalies. She was followed by
the Fetal Care Clinic at [**Hospital3 1810**]. An
amniocentesis showed normal chromosome 46XX. She also had a
negative FISH for chromosomes 13, 18, and 21. The family
also was followed by Dr. [**Last Name (STitle) **] at [**Hospital3 1810**],
neurosurgery.
The infant emerged with spontaneous cry and good tone. Apgar
eight at one minute and nine at five minutes. Rupture of
membranes occurred at the time of delivery. There was no
intrapartum sepsis suspected.
Her birth weight was 3365 grams (75th percentile), birth head
circumference 35.5 centimeters (90th percentile), her length
estimated at 53 centimeters, difficult to measure due to her
flexed hip position.
PHYSICAL EXAMINATION: Her admission physical examination
revealed an active, nondysmorphic, term appearing infant.
Anterior fontanelle soft, open and flat. Positive bilateral
red reflexes. Neck supple without masses. Lungs clear,
respirations comfortable. Heart was regular rate and rhythm,
no murmur. Abdomen soft, nondistended, nontender, with
present bowel sounds. Spine with approximate 2.0 centimeter
by 2.5 centimeter outpouching with cystic areas present with
open myelocele. Patent anus but no anal wink. Extremities
warm and well perfused. No obvious spontaneous movement of
the lower extremities with bilateral clubfeet. Decreased
reflexes at the knees. Normal genitourinary examination.
Normal tone in the upper extremities.
HOSPITAL COURSE: Respiratory status: She has always
remained in room air with oxygen saturation greater than 95
percent. Respirations are comfortable. She has had no
apnea, bradycardia or desaturation.
Cardiovascular status: Her blood pressure has been stable
with systolic 168 to 81. Diastolic 38 to 50. Mean blood
pressure 50 to 62. She has no murmur.
Fluids, electrolytes and nutrition status: Her blood glucose
was 90. She has a double lumen umbilical venous catheter
with tip position confirmed at the diaphragm with xray
Dextrose solution at 80 ml/kg/day.
Hematology: At admission, her hematocrit is 48.6. She has
received no blood product transfusion.
Infectious disease status: Blood culture was sent. At the
time of admission, her white blood cell count was 12.5 with a
differential of 43 polys, 0 bands and 47 lymphocytes,
platelet count 316,000. She is on Ampicillin and Gentamicin.
Audiology: Hearing screening has not been done but is
recommended prior to discharge.
Psychosocial: Parents have been to the Neonatal Intensive
Care Unit to visit and are updated on the infant's condition.
CONDITION ON DISCHARGE: The infant is discharged in guarded
condition.
DISCHARGE STATUS: She is transferred to [**Hospital3 1810**]
for repair of her myelocele.
PRIMARY PEDIATRIC CARE: Her primary pediatric care will be
provided by Dr. [**First Name8 (NamePattern2) 1743**] [**Last Name (NamePattern1) 56983**] of [**Hospital 5344**] Pediatrics,
telephone number [**Telephone/Fax (1) 56984**].
RECOMMENDATIONS AFTER DISCHARGE:
1. The infant is NPO.
2. Medications: Ampicillin 150 mg/kg/dose every twelve
hours, Gentamicin 4 mg/kg/dose every 24 hours.
3. State Newborn Screen was sent prior to transfer.
4. She has received no immunizations.
DISCHARGE DIAGNOSES: Myelocele.
Bilateral clubfeet.
Rule out sepsis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2163-9-19**] 18:21:45
T: [**2163-9-19**] 19:01:56
Job#: [**Job Number 56985**]
ICD9 Codes: V290 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1485
} | Medical Text: Admission Date: [**2135-5-31**] Discharge Date: [**2135-6-4**]
Date of Birth: [**2058-11-16**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
S/P FALL
Major Surgical or Invasive Procedure:
S/P Craniotomy for subdural hematoma
History of Present Illness:
76F found down on floor by son who stopped by to take his
mother to dinner. Patient does not recall event very well.
According to son, he believes that patient fell at least 36
hours
ago since the newspapers for the last 2 days were not opened.
Past Medical History:
HTN, OA
Social History:
lives alone. No EtOH/smoking
Family History:
non-contributory
Physical Exam:
O: T: 97.1 BP: 151/61 HR: 94 R 20 O2Sats 99%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: Perrl B EOMs grossly 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.
Recall: 0/3 objects at 5 minutes.
Language: Speech somewhat slurred with good comprehension and
repetition. Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-16**] Biceps B, [**3-17**] Triceps and
Deltoid. [**2-14**] B IP,Q, [**4-16**] dorsiflexion/plantar flexion. No
pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes downgoing bilaterally
Coordination: sluggish finger-nose-finger
Pertinent Results:
CT HEAD W/O CONTRAST [**2135-5-31**] 12:49 AM
NON-CONTRAST HEAD CT: There is a 1.5 cm subdural hematoma of
mixed density, likely hyperacute on acute, along the right
hemisphere causing 1.3 cm leftward shift of normally midline
structures and effacement of the subjacent sulci. The right
lateral ventricle is compressed and the contralateral is
slightly dilated, suggestive of early trapping. Small amount
high density material is seen within sulci of right temporal
lobe likely representing subarachnoid blood. There is probably
subfalcine herniation. The visualized paranasal sinuses and
mastoid air cells remain normally aerated. No fractures are
identified within the osseous skeleton.
IMPRESSION: Subdural hematoma along the right hemisphere with
accompanied subfalcine herniation.
Post-craniotomy CT HEAD W/O CONTRAST [**2135-5-31**] 1:30 PM
FINDINGS: Since the prior examination of [**2135-5-31**] at 1:00
a.m., there has been reduction in the size of the right cerebral
convexity subdural hematoma. Right frontal craniotomy is again
present. There has been an improvement in the degree of leftward
midline shift. Only minimal leftward midline shift remains. No
significant herniation is identified. Small amounts of
pneumocephalus are present.
IMPRESSION: Status post evacuation of the right subdural
hematoma with a mild residual remaining. There has been
improvement in the degree of subfalcine herniation and mass
effect. No new intracranial hemorrhage is noted.
Brief Hospital Course:
Patient was admitted to ICH for right-side subdural hematoma on
[**2135-5-31**] and underwent right frontal craniotomy for evacuation of
hematoma. She was successfully extubated post-op. No intra- or
post-op complication. She was transfered to regular floor on
[**2135-6-2**].
On [**2135-6-1**] she passed swallow test to be advanced to regular
diet with thin liquid and pills can be taken in whole with thin
liquid.
Her foley catheter was d/ced on [**6-3**] and she is able to urinate
on her own.
Her mental status has improved to oriented to person/place/time.
She is able to ambulate with assistance.
PT/OT are consulted and recommended discharging to rehab.
Medications on Admission:
Aspirin 325mg, Welchol, synthroid, atenolol/chlorthalidone,
atenolol, MVI, Aleve
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
Right sided subdural hematoma
Discharge Condition:
Neurologically stable
Discharge Instructions:
?????? Have your incision checked daily for signs of infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
PLEASE HAVE YOUR STAPLES REMOVED BETWEEN [**2135-6-11**] AND [**2135-6-14**],
EITHER AT YOUR REHAB FACILITY OR IN DR[**Doctor Last Name **] OFFICE (PLEASE
CALL [**Telephone/Fax (1) 1669**] FOR AN APPOINTMENT IF YOU ARE COMING TO DR [**Doctor Last Name **] OFFICE FOR STAPLE REMOVAL)
Followup Instructions:
YOUR STAPLES NEED TO BE REMOVED BETWEEN [**2135-6-11**] AND [**2135-6-14**].
PLEASE CALL [**Telephone/Fax (1) 1669**] FOR AN APPOINTMENT IF YOU ARE COMING TO
DR[**Doctor Last Name **] OFFICE FOR STAPLE REMOVAL.
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) **] TO BE SEEN IN 4 WEEKS with head CT.
ICD9 Codes: 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1486
} | Medical Text: Admission Date: [**2105-7-2**] Discharge Date: [**2105-7-4**]
Service: MEDICINE
Allergies:
Ciprofloxacin
Attending:[**First Name3 (LF) 2901**]
Chief Complaint:
Anemia/Hypotension
Major Surgical or Invasive Procedure:
Pericardiocentesis
History of Present Illness:
86y/o F with h/o AFIB, Lacunar CVA, s/p nephrostomy tube for
nephrolithiasis, and recent ICU admission for sepsis who
presents with weakness for the past few days. She was brought
to the ED from [**Hospital3 **] because her nephrostomy tube had
fallen out.
.
Per the patient she had been feeling well, until a few days
prior to admission when she felt weak. She could describe no
antecedent events, or etiology for her sense generalized
fatigue. She did not report any lightheadedness, dizziness,
palpiations or chest pain. At times her breath can be
"smothering" but she has not had any recent SOB. Per the
patient, her bowel and bladder habbits are unchanged, and she
has not noticed any hematuria, dysuria, hematochezia, BRPR,
melena, hematemesis, nausea, or emesis. She denies any recent
fevers, chills, weakness, parasthesias, or numbness. Her
coumadin dose was held today, and decreased yesterday.
.
In the ED initial vital signs were T96.9 P116 88%RA with
tachypnea. At the time she was comfortable, aware, and talking
with headphones and a mircophone. Her stool was guiac negative,
her abdomen exam was benign, and a CXR demonstrated atelectasis.
Her HCT dropped from a baseline of 29 to 21, and her K was
elevated at 5.8 in the setting of a elevated Cr of 2.8 Further
imaging of the abdomen demonstrated diverticulosis, a
non-obstructive stone, a pericardial effusion, and no
retroperitoneal bleed. On transfer, she was ordered two units
of blood and her vitals were: T 98.5, BP 120/65, HR 90s, RR25
Sa: 95%3LNC.
On arrival to the floor she was comfortable, alert, and
oriented. She had no pain, although she reported feeling weak.
Vital signs: T35.9 P86, BP 61/46 (on Lower Leg), RR21 SA 91
3LNC. Her Access is PIV and PICC.
Past Medical History:
1. Severe hearing loss, associated with tinnitus.
2. Osteopenia.
3. Depression/anxiety, followed by Dr. [**Last Name (STitle) 3532**].
4. History of breast cancer.
5. Meningioma.
6. Hypertension.
7. Obesity.
8. Osteoarthritis.
9. Lumbar spinal stenosis.
10. Nepthrolithasis with nephrostomy tube
11. Sepsis
12. Afib w RVR
PAST SURGICAL HISTORY:
1. Cholecystectomy [**2089**].
2. Cataract surgery [**2095**].
3. Left radical breast mastectomy [**2064**].
Social History:
Lives in [**Location (un) **] in [**Location 1268**]. Husband lives in [**Location **]
x 17 years, deceased last year. No children. Previously used to
work in Pathology. No EtOH, tobacco, or illicits.
Family History:
NC
Physical Exam:
GEN: NAD, alert and interactive. Requested microphone use for
communication
VS: 96.6, 82, 88/63, 19, 94%
HEENT: mucous membranes [**Last Name (un) **], no OP lesions, No discernable JVP
at 50 degrees, neck is supple,
CV: No carotid bruits. Decreased upstroke and volume.
Irregularly irregular with faint S1 and S2. No S3 or S4. No
hyperdynamic PMI
PULM: Short shallow breaths. Dullness to percussion on the
left, with left basilar crackles.
ABD: BS+, soft, NTND, no masses or HSM, no flankdullness.
LIMBS: Cool extremities with 3+ LE, no tremors or clubbing
SKIN: No rashes. Two stage II decubs on posterior side.
Nephrostomy site c/d/i.
NEURO: CNII-XII nonfocal, strength 5/5 R and [**3-2**] Left arm and
leg. No facial droop or smile asymmetry.
Pertinent Results:
[**2105-7-2**] 07:00PM URINE COLOR-Brown APPEAR-Cloudy SP [**Last Name (un) 155**]-1.025
[**2105-7-2**] 07:00PM URINE BLOOD-LG NITRITE-POS PROTEIN->300
GLUCOSE-NEG KETONE-15 BILIRUBIN-MOD UROBILNGN-1 PH-5.0 LEUK-NEG
[**2105-7-2**] 07:00PM URINE RBC->50 WBC-21-50* BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2105-7-2**] 07:00PM URINE AMORPH-MANY
[**2105-7-2**] 07:00PM URINE EOS-NEGATIVE
[**2105-7-2**] 06:35PM GLUCOSE-135* UREA N-34* CREAT-2.8*#
SODIUM-131* POTASSIUM-5.8* CHLORIDE-96 TOTAL CO2-21* ANION
GAP-20
[**2105-7-2**] 06:35PM estGFR-Using this
[**2105-7-2**] 06:35PM ALT(SGPT)-43* AST(SGOT)-47* ALK PHOS-89
[**2105-7-2**] 06:35PM CALCIUM-8.8 PHOSPHATE-4.9*# MAGNESIUM-2.4
[**2105-7-2**] 06:35PM PT-44.1* PTT-34.5 INR(PT)-4.7*
[**2105-7-2**] 06:09PM COMMENTS-GREEN TOP
[**2105-7-2**] 06:09PM GLUCOSE-115* LACTATE-2.3* NA+-136 K+-4.8
CL--106 TCO2-19*
[**2105-7-2**] 06:05PM WBC-12.2* RBC-2.36*# HGB-6.8*# HCT-21.4*#
MCV-91 MCH-28.7 MCHC-31.6 RDW-14.8
[**2105-7-2**] 06:05PM NEUTS-85.5* LYMPHS-8.5* MONOS-5.7 EOS-0.2
BASOS-0.2
[**2105-7-2**] 06:05PM PLT COUNT-427
.
Imaging:
.
TTE [**2105-7-3**]: There is mild symmetric left ventricular hypertrophy
with normal cavity size and global systolic function (LVEF>55%).
The aortic valve leaflets (?#) appear structurally normal with
good leaflet excursion. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is a moderate to large sized
circumferential pericardial effusion (2.5cm inferior and 2.0 cm
lateral to the left ventricle, 1.5cm anterior to the right
atrium and right ventricle) with eccentuated respiratory
variation in transmitral Doppler E wave suggestive of impaired
ventricular filling. but no right atrial or right ventricular
diastolic collapse (may be absent in settings of pulmonary
artery hypertension).
Compared with the prior study (images reviewed) of [**2105-6-16**], the
pericardial effusion findings are new and c/w impaired
filling/early tamponade physiology
.
TTE [**7-4**] 11:08am
There is a large pericardial effusion. There is right
ventricular diastolic collapse, consistent with impaired
fillling/tamponade physiology
.
TTE [**7-4**] 11am
Post pericardiocentesis. There is a small to moderate sized
pericardial effusion. There are no echocardiographic signs of
tamponade. Compred to the pre-tap study from today, the
pericardial effusion is smaller and tamponade has resolved.
Brief Hospital Course:
86y/o F with h/o AFIB, Lacunar CVA, s/p nephrostomy tube for
nephrolithiasis, and recent ICU admission for sepsis who
presents with weakness for the past few days. She was admitted
through the ED from [**Hospital3 **] because her nephrostomy tube
had fallen out. Pericardial effusion was incidentally found on a
CT abd/pelvis.
Pt was transferred to CCU for findings suggestive of cardiac
tamponade physiology on ECHO [**7-3**]. Her clinical status worsened
overnight. In the morning of [**7-4**] pt underwent emergent bedside
pericardiocentesis. She went into resp failure and was placed on
ventilatory support. The decision to make her [**Date Range 3225**] was made by
her HCP and she was kept on morphine drip titrated for comfort.
She went into asystolic arrest on [**7-4**] 6:30pm. She was DNR per
her HCP.
.
# Pericardial effusion - Echocardiography shows moderate to
large pericardial effusion with impaired ventricular filling c/w
early tamponade physiology. Diff dx of pericardial effusion
includes viral, neoplastic (hx of breast CA), uremic, CHF, fluid
overload from renal failure. Uremic unlikely as BUN of 38, and
in ARF, baseline Cr of 0.7-1.0. AM of [**7-4**] echo showed
increased severity of tamponade and pt appeared cold and
nonperfusing. Bedside pericardiocentesis performed with
resolution of tamponade on post-pericardiocentesis ECHO. She
continued to decompensate and was placed on respiratory support
per HCP wishes.
.
#. Hypotension: Initially presented to the floor with labile
blood pressures, but pressures were fluid responsive and
thereafter remained stable; there was no clinical evidence
suggestive of sepsis. She was transferred to CCU for management
of cardiac tamponade. She was noted to be hypotensive with low
urine output which did not resolve after pericardiocentesis. She
was started on pressors, intubated and continued to be
hypotensive sbp 60-100. Decision was made by her hcp to make her
[**Date Range 3225**] and she was taken off all support except morphine drip
titrated for comfort.
.
# Dyspnea - Unsure etiology. Bilateral pleural effusions on CT
scan and X-ray likely [**12-30**] tamponade physiology and elevated L
sided pressures. No history of asthma, COPD or CHF. Denies
anxiety. Pt too unstable to undergo pleurocentesis. She was
intubated per HCP wishes and maintained at FiO2 100% and PEEP 8.
She continued to desat 80s. The decision was made by her HCP to
change her status to [**Name (NI) 3225**] and she was taken off ventilatory and
pressor support.
.
#. ARF: Presented with Cr 3.1 from BL 0.7. Had a previous CT
stone protocol showing a non-obstructive pattern; no recent CT
contrast. Received Vancomycin prior to admission at [**Hospital 4382**] facility. Urine lytes, culture, were sent; CK and Vanc
levels were drawn. Urology is aware of the patient's disposition
and was following for possible replacement of nephrostomy tube.
Pt was admitted to CCU for management of pericardial effusion.
Pt had decreasing urine output via foley cath and on AM of [**7-4**]
it was noted that she had no output overnight. Oliguria likely
[**12-30**] hypotension and lack of perfusion from cardiac tamponade.
.
#. Bilateral Pleural Effusions. Likely due to tamponade
physiology.
.
# Anemia: likely [**12-30**] large bleed a/w pericardial tamponade
.
#. UTI: UA nitrate positive. Started on Zosyn with empirically
dosed Vancomycin. Urine and blood cultures sent.
.
#. AFIB with h/o RVR: Coumadin and ASA were held in the setting
of a bleed and the patient was rate controlled with Metoprolol 5
mg IV prn. All antihypertensives and antiarrhythmic meds were
held in the setting of shock and respiratory failure.
.
#. Elevated INR: Vitamin K IV and FFP given
pre-pericardiocentesis to reverse her anticoagulation.
Medications on Admission:
Venlafaxine 150 mg daily
Ascorbic Acid 500 mg daily
Aspirin 81 mg daily
Senna 2 tabs [**Hospital1 **]
Albuterol Sulfate neb q4PRN wheezing
Magnesium Hydroxide 400 mg/5 ml PO qam
Simvastatin 40 mg PO daily
Olanzapine 2.5 mg [**Hospital1 **]
Docusate 100 mg [**Hospital1 **]
Lisinopril 10 mg daily
Vitamin D 1000 units daily
MV daily
Nexium 20 mg daily
Lasix 40 mg daily
Bisacodyl 10 mg Sup.
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Pericardial tamponade
Respiratory failure
Renal failure
Shock
Discharge Condition:
Expired [**2105-7-4**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]
ICD9 Codes: 5849, 5119, 2851, 5990, 2762, 4280, 4019, 2767, 311 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1487
} | Medical Text: Unit No: [**Numeric Identifier 70003**]
Admission Date: [**2130-12-15**]
Discharge Date: [**2131-2-2**]
Date of Birth: [**2130-12-15**]
Sex: F
Service: NB
HISTORY: Baby is a 34-1/7 week gestational age twin girl [**Year (4 digits) **] to
a 35 year-old G1P0-1 mother with prenatal
labs: blood type O+, antibody negative,
hepatitis B surface antigen negative, rubella immune, RPR
nonreactive and GBS unknown whose prenatal course was
significant for conception by IVF of di-di twins. Mom had
preterm labor at 28 weeks with a shortened cervix and
received betamethasone and was placed on bed rest until the
date of delivery. Mom also had an elevated blood pressure
diagnosed several weeks before delivery which was followed at
home. On the date of admission mom went to her [**Name (NI) **] office for an
appointment and was found to have a blood pressure of 152/96 and
was brought to [**Hospital1 69**] for
further evaluation. In the hospital her blood pressures were
140s/90s and she had proteinuria with no symptomatology
including no headache, no visual changes, no epigastric pain
and at that time there were no signs of preterm labor.
Secondary to her preeclampsia her OB elected to deliver the
infants. This twin was [**Hospital1 **] at 2220 at C-section with Apgars
of 8 and 8. Infant emerged pale which quickly improved with
facial CPAP. Heart rate was always over 100, no respiratory
distress and she was brought to the Neonatal Intensive Care
Unit for further evaluation.
PHYSICAL EXAMINATION: On admission weight was 1670 grams,
10th to 25th percentile. Head circumference was 29.25 cm,
10th to 25th percentile, and length was 43.5 cm, 25th to 50th
percentile. Temperature 98.4. Heart rate 170. Respiratory
rate 72, blood pressure 62/33 with a mean of 45 and FpO2 95%
on room air. Baby was active with anterior fontanelle open
and flat. She was nondysmorphic and intact palate. She was
slightly pale. Breath sounds were clear with mild
intercostal, subcostal retraction. No active grunting or
distress. Baby had normal S1, S2, no murmur. Abdomen was
soft, nontender, nondistended. Extremities were well
perfused. Tone was appropriate for gestational age and
patient had a patent anus with normal female genitalia.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
Respiratory: Baby was [**Name2 (NI) **] in room air and remained on room
air throughout her admission. She never had respiratory distress
or needed any oxygen or ventilatory support. She has had a
history of desaturation and bradycardia with feeds which has
resolved with maturation.
Cardiovascular: Baby's blood pressure has been normal
throughout her stay. Heart rates have been normal and she
more recently has been found to have an intermittent murmur,
most likely secondary to anemia.
Fluids, electrolytes and nutrition: The baby was started
NPO on IV fluids, started on breast milk on DOL #2
which was advanced as tolerated. She currently is on full ad
lib feeds of [**Name2 (NI) 68900**] 20 gaining weight well. Her weight
at discharge is 3145 grams.
GI: Baby had a peak bilirubin on day of life 3 of 7.3 and was
on phototherapy for 2 days and it was discontinued and she
has had no further bilirubin issues. More recently on day of
life 45 ([**1-29**]) she had 1 grossly blood streaked stool and
was worked up for sepsis and allergy. Work up for sepsis was
negative. It is believed to be a milk protein allergy, of which
there is a maternal family history, and she was changed from
Similac to [**Month (only) 68900**] which she continues. She continues to have
heme positive stool but has not had any grossly blood stools
since [**1-29**].
Hematology: Baby's initial hematocrit was 44.1 and her most
recent hematocrit was 26 on [**1-30**] with a retic count of
4.7. She had been started on iron on day of life 12 and she
continues on iron to date.
Infectious disease: Baby had a CBC at birth but was never
started on antibiotics and she has never had any infectious
issues except a fungal diaper rash for which she was treated
with nystatin and is resolved. On DOL 45 on [**1-29**] with the
bloody stool she was worked up for sepsis and had a blood culture
and CBC which was negative.
Neurology: Because baby was [**Name2 (NI) **] at 34 weeks, a head
ultrasound was never done initially secondary to gestational age
and baby has been acting neurologically appropriate. However, her
head circumference has increased significantly and she is
currently at the 90th percentile. On day of life 47 ([**1-31**])
we did a head ultrasound which showed a resolving grade 1 IVH
along with some extra-axial fluid that was there for unknown
reasons. The radiologist recommended a repeat head ultrasound in
[**1-16**] months or at your discretion. The baby has a normal
neurological examination and has been referred for EI.
Sensory: Audiology: Hearing screening was performed with
automated auditory brain stem responses and she passed that
on [**1-18**].
Ophthalmology: Because baby was 34 weeks at birth she has not
received an eye examination to date.
CONDITION ON DISCHARGE: Excellent.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name (STitle) **] at [**Hospital 3307**]
Pediatrics. Phone # ([**Telephone/Fax (1) 68584**].
CARE RECOMMENDATIONS:
Feeds at discharge: As stated before baby is on [**Name (NI) 68900**] 20
gaining weight well. It was questionable whether she would
continue to gain weight well on 20 kilo-calorie formula because
previously she had been on 24 kilocalorie formula, so we
recommend following her weights closely and considering
increasing her calorie density. Otherwise she is tolerating the
formula and doing well with the hemoccult positive stools but
without grossly bloody stools.
Medications: She is on iron sulfate 0.3 cc p.o. q day which
we recommend continuing.
Care seat position screening test was done on [**2-1**]
which she passed.
Immunizations received: Baby has received her hepatitis-B
immunization on [**2130-2-7**].
Immunizations recommended:
1. Synagis RSV prophylaxis should
be considered from [**Month (only) **] through [**Month (only) 958**] for infants who
meet any of the following 3 criteria: 1) [**Month (only) **] at less than 32
weeks, 2) [**Month (only) **] between 32 and 35 weeks with 2 of the
following: Day care during the RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school age siblings; or 3) with chronic lung disease.
2. Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the
child's life immunization against influenza is
recommended for household contact and out of home care-
givers.
State Newborn Screening status: The baby received a state
newborn screen on [**12-18**] which was normal.
FOLLOW UP APPOINTMENTS: Baby will be following up with Dr.
[**First Name (STitle) **] at [**Hospital 3307**] Pediatrics on [**Last Name (LF) 766**], [**2131-2-4**].
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Milk protein allergy.
3. Status post hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) 69933**]
MEDQUIST36
D: [**2131-2-2**] 08:22:32
T: [**2131-2-2**] 09:06:17
Job#: [**Job Number 70004**]
ICD9 Codes: 7742, V290, V053 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1488
} | Medical Text: Admission Date: [**2161-8-30**] Discharge Date: [**2161-9-7**]
Date of Birth: [**2093-4-15**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Sulfa (Sulfonamide Antibiotics) / Penicillins /
Tylenol 8 Hour
Attending:[**First Name3 (LF) 594**]
Chief Complaint:
Several days of melena, associated with weakness and fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms [**Known lastname **] is a 68 yo F w/PMH significant for EtOH and GERD here
following recent discharge from [**Hospital1 18**] on [**2161-8-28**]. Both patient
and daughter report worsening black, tarry diarrhea since
discharge. Patient states that she feels weak, lethargic,
fatigued, and unable to care for herself. Has had decreased PO
intake today and over weekend. Of note, diarrhea stopped today
after d/c'ing tube feeds. Both patient and daughter wish to go
to acute rehab facility, however, patient believes that she
needs to cared for in hospital prior to rehab. Reports mild
abdominal pain and non-productive cough improving since last
discharge. Denies N/V, fever, chills, inability to tolerate oral
intake, HA, syncope, chest pain, SOB, wheeze,
On the floor: Pt went into bouts of SVT to 170's w/PVC's and
eventual short runs of V. tach. K WNL, but Mg not checked in ED
so given 2mg Mg and other electrolytes sent. Pt entirely
asymptomatic. Left pt in sinus rhythm w/single PVC's.
Past Medical History:
Hypertension
PVD
Social History:
She smoked a pack a day of cigarettes for over 20 years and has
hyperglycemia, although she says she does not have diabetes. She
has never had a stroke or heart attack.
She has had eye surgery.
Family History:
N/C
Physical Exam:
Admission Exam:
VS: 98 ??????F (36.7 ??????C), Pulse: 85, RR: 18, BP: 118/67, O2Sat: 98,
O2Flow: 3L NC
GENERAL: Jaundiced and in no acute distress, with NC and feeding
tube in place. Conversive and in good spirits
HEENT: Sclera icteric. Mucous membranes dry
CARDIAC: Irregularly irregular. Tachycardic. NS1&S2. NMRG
LUNGS: CTA b/l with no wheezing, rales, or rhonchi.
ABDOMEN: Mild distension and firm, with mild diffuse tenderness
to palpation No HSM appreciated.
EXTREMITIES: 3+ pitting edema. Warm and well perfused, no
clubbing or cyanosis.
NEUROLOGY: no asterixis, A+Ox3. CN 2-12 intact, sensation
grossly intact. moving all extremities freely.
Discharge Exam:
GENERAL: Jaundiced and breathing with accessory muscles, with NC
and feeding tube in place.
HEENT: Sclera icteric. Mucous membranes dry
CARDIAC: Irregularly irregular. Tachycardia. NS1&S2. NMRG
appreciated
LUNGS: rales at base bilaterally.
ABDOMEN: Mild distension and firm, with mild diffuse tenderness
to palpation No HSM appreciated.
EXTREMITIES: 4+ pitting edema to lower back. Warm and well
perfused, no clubbing or cyanosis.
NEUROLOGY: no asterixis, A+Ox3. CN 2-12 intact, sensation
grossly intact. moving all extremities freely.
Pertinent Results:
Admission Labs:
[**2161-8-30**] 12:00PM BLOOD WBC-22.0* RBC-2.63* Hgb-9.0* Hct-28.1*
MCV-107* MCH-34.1* MCHC-31.9 RDW-19.2* Plt Ct-234
[**2161-8-30**] 12:00PM BLOOD Neuts-93.4* Lymphs-3.5* Monos-2.6 Eos-0.4
Baso-0.2
[**2161-8-30**] 12:00PM BLOOD PT-14.6* PTT-33.5 INR(PT)-1.4*
[**2161-8-30**] 12:00PM BLOOD Glucose-105* UreaN-35* Creat-1.5* Na-132*
K-4.7 Cl-95* HCO3-26 AnGap-16
[**2161-8-30**] 12:00PM BLOOD ALT-57* AST-186* AlkPhos-421*
TotBili-23.1*
[**2161-8-30**] 12:00PM BLOOD Albumin-2.9* Calcium-9.1 Phos-2.8 Mg-2.0
.
Discharge Labs;
[**2161-9-7**] 03:14AM BLOOD WBC-24.5* RBC-2.42* Hgb-8.4* Hct-26.5*
MCV-110* MCH-34.9* MCHC-31.8 RDW-20.3* Plt Ct-199
[**2161-9-7**] 03:14AM BLOOD Neuts-92.5* Lymphs-3.5* Monos-3.4 Eos-0.4
Baso-0.1
[**2161-9-7**] 03:14AM BLOOD PT-17.3* PTT-39.6* INR(PT)-1.6*
[**2161-9-7**] 03:14AM BLOOD Glucose-88 UreaN-72* Creat-1.8* Na-137
K-4.5 Cl-103 HCO3-22 AnGap-17
[**2161-9-7**] 03:14AM BLOOD ALT-49* AST-148* LD(LDH)-259* CK(CPK)-16*
AlkPhos-261* TotBili-20.9*
[**2161-9-7**] 03:14AM BLOOD Albumin-2.6* Calcium-8.7 Phos-4.9* Mg-2.3
.
Pertinent Labs:
[**2161-9-4**] 08:15AM BLOOD CK-MB-2 cTropnT-<0.01
[**2161-9-6**] 11:20AM BLOOD CK-MB-2 cTropnT-<0.01
[**2161-9-7**] 03:14AM BLOOD CK-MB-2 cTropnT-<0.01
[**2161-8-30**] 07:00PM BLOOD calTIBC-177* Ferritn-439* TRF-136*
[**2161-9-4**] 02:11PM BLOOD Type-ART pO2-96 pCO2-33* pH-7.45
calTCO2-24 Base XS-0 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**]
.
Micro:
[**2161-9-5**] BLOOD CULTURE-pend
[**2161-9-5**] BLOOD CULTURE-pend
[**2161-9-4**] BLOOD CULTURE-pend
[**2161-9-4**] BLOOD CULTURE-pend
[**2161-9-3**] STOOL OVA + PARASITES-neg
[**2161-9-3**] STOOL OVA + PARASITES-neg
[**2161-9-3**] STOOL OVA + PARASITES- MICROSPORIDIA
STAIN-PRELIMINARY; CYCLOSPORA STAIN-FINAL;
Cryptosporidium/Giardia (DFA)-neg
[**2161-8-31**] STOOL C. difficile; FECAL CULTURE-FINAL;
CAMPYLOBACTER CULTURE-[**2161-8-30**] URINE URINE CULTURE-neg
[**2161-8-30**] BLOOD CULTURE-neg
[**2161-8-30**] BLOOD CULTURE-neg
Imaging;
[**2161-8-30**] EKG:Sinus tachycardia with ventricular premature beats.
Low QRS voltages throughout. Diffuse ST-T wave abnormalities
grossly unchanged from previous tracing.
.
[**2161-8-30**] CHest AP: As compared to the previous radiograph, there
is minimal increase in transparency of the lung parenchyma,
potentially reflecting improved ventilation. At the right lung
base, however, a combination of pleural effusion and parenchymal
opacity persists. These changes might be consistent with
pneumonia. The changes have neither increased nor decreased in
severity and extent as compared to the previous examination.
A prexeisting retrocardiac atelectasis is less severe than on
the previous image. Unchanged moderate cardiomegaly, unchanged
course and position of a nasogastric tube.
.
[**2161-8-31**] TTE: Small to moderate circumferential pericardial
effusion without evidence for tamponade physiology. Normal
biventricular cavity sizes with preserved global and regional
biventricular systolic function.
Compared with the prior study (images reviewed) of [**2161-8-18**],
the pericardial effusion is larger. If clinically indicated,
serial evaluation is suggested.
.
[**2161-8-31**] RUQ U/S: Echogenic liver consistent with fatty
infiltration. Other forms of liver disease, including more
significant hepatic fibrosis, cirrhosis, or steatohepatitis,
cannot be excluded on the basis of this examination. No evidence
of biliary obstruction. Stones and gallbladder sludge, but no
evidence of acute cholecystitis. Increasing splenomegaly, 15.5
cm (13.1 cm on [**8-12**]). Trace left-sided pleural effusion.
.
[**2161-9-1**] CT Torso: Worsening right lower lobe consolidation,
superimposed on post-radiation changes, with trace right and
small left simple pleural effusions. Differential considerations
include increasing atelectasis or scarring, versus possibly
superimposed infection. Moderate pericardial effusion, increased
somewhat. Heterogeneous hepatic perfusion consistent with the
history of hepatitis. Cholelithiasis without evidence of
cholecystitis.
.
[**2161-9-2**] CT Head:No evidence of intracranial hemorrhage; given the
patient's history of malignancy, if metastases are of a concern,
MR is more sensitive in detecting small metastatic lesions
.
[**2161-9-4**] LENI Scan: No bilateral lower extremity deep venous
thrombosis. Extensive superficial soft tissue edema.
.
[**2161-9-7**] CXR Portable: enlargement of the cardiac silhouette with
pulmonary vascular congestion and bilateral pleural effusions
with compressive atelectasis at the bases. Intestinal tube
remains in position
Brief Hospital Course:
68 year old woman with past medical history of lung cancer s/p
chemotherpay and radiation 3 years prior, and alcohol abuse with
acute alcoholic hepatitis recently admitted with it, who
returned with worsening diarrhea and found to have worsening
liver function and renal function and respiratory status despite
treatment who changed her goals of care to comfort measures only
given her poor prognosis and is discharged home with hospice.
Active Issues:
#Alcoholic hepatitis: Pt returned to [**Hospital1 18**] for worsening
fatigue, lethargy, and diarrhea after being discharged 5 days
prior. There was no significant change in bilirubin or
leukocytosis on this admission from the last (T. bili:23,
WBC:22). Increased bili and WBC originally thought to be [**2-26**]
occult infection, so pt placed on broad spectrum abx. CT
positive for ?RLL PNA and she was treated for HCAP with broad
spectrum antibiotics. Her hepatitis continued to worsen with
worsening bilirubin and she was started on pentoxyfilline
without improvement in her liver function.
#Tachypnea/dyspnea: Although pt had baseline need for 3L O2, she
developed progressive tachypnea and SOB during her hospital
stay. She was worked up for PE, pneumonia and pericardial
effusion. It was felt that ultimately this worsening dyspnea was
due to her anasarca and she was attempted to be diuresed.
However with her worsening renal function she was not responding
to IV diuretics and discussion with the renal team suggested
that ultrafiltration would be the next step to diuresis.
However, given that this was a form of dialysis and not in line
with the patient's goals of care this was not pursued. She was
discharged to home hospice with morphine sulfate for air hunger.
#Acute renal failure- patient was originally pre-renal on
admission, her renal function improved temporarily. In the
setting of worsening liver function and IV contrast for a CT
scan she developed worsening renal function with associated
oliguria. Renal was consulted with her oliguria and she was no
longer diuresing to higher doses of lasix. It is possible that
this represented a pre-renal azotemia vs. hepatorenal syndrome.
#Pneumonia- patient was found to have a possible new infiltrate
on her right lower lobe in the area of previous scaring from her
radiation so it was unclear if this was truely a pneumonia.
Given her clinical status and worsening respiratory complaints
she was treated for hospital associated pneumonia. Antibiotics
were discontinued at the time of discharge given her goals of
care.
#Diarrhea: Multiple stool studies performed, and all negative.
Diarrhea was dark, but not true melena. Thought to be [**2-26**]
malabsorption from alcoholic GI insult and liver disease.
#Paroxysmal A.fib: Pt had multiple episodes of atrial
fibrillation with rapid ventricular rate and was started on
metoprolol 25mg po TID.
-She will be sent home on metoprolol 25mg po TID to control her
rate
Chronic Issues:
#Pericardial Effusion: H/o stable effusion. Pulsus <10, and no
signs/symptoms of tamponade
#H/o lung cancer: H/o stage III lung cancer s/p XRT and chemo.
CT findings suggest ?recurrence.
Transitional Issues:
Patient to be discharged to home with hospice.
Medications on Admission:
. Information was obtained from .
1. Isosource 1.5 Cal *NF* (lactose-free food with fiber) 40
ml/hr enteral daily
Cycle 24 hours. No residual check. Flush with 30mL water q6h
2. Albuterol 0.083% Neb Soln 1 NEB IH TID
3. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **]
4. FoLIC Acid 1 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO BID
7. Thiamine 100 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. Bengay 1 Appl TP [**Hospital1 **]:PRN muscle pain
10. Aspirin (Buffered) 81 mg PO DAILY
11. Furosemide 40 mg PO DAILY
Hold for SBP<90
12. Spironolactone 100 mg PO DAILY
Hold for SBP< 90
Discharge Medications:
1. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 neb inhalation
every 6 hours Disp #*60 Cartridge Refills:*0
2. Lidocaine 5% Patch 1 PTCH TD DAILY
Apply to back
RX *lidocaine 5 % (700 mg/patch) apply one patch to affected
area once a day Disp #*30 Transdermal Patch Refills:*0
3. Metoprolol Tartrate 25 mg PO Q8H
hold for MAP<55 or hr<60
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a
day Disp #*30 Tablet Refills:*0
4. Morphine Sulfate (Oral Soln.) 5-20 mg PO Q1-2H air hunger
hold for sedation or rr<10
RX *morphine 20 mg/5 mL [**1-29**] ml by mouth q1-2h Disp #*1 Bottle
Refills:*0
RX *morphine 10 mg/5 mL [**3-6**] ml by mouth q1-2h Disp #*1 Bottle
Refills:*0
5. OLANZapine (Disintegrating Tablet) 2.5-5 mg PO TID:PRN
anxiety
RX *olanzapine 5 mg 0.5-1 tablet(s) by mouth up to three times a
day Disp #*60 Tablet Refills:*0
6. Tiotropium Bromide 1 CAP IH DAILY
7. Bengay 1 Appl TP [**Hospital1 **]:PRN muscle pain
8. Albuterol 0.083% Neb Soln 1 NEB IH TID
Discharge Disposition:
Home With Service
Facility:
Hospice of the [**Location (un) 1121**]
Discharge Diagnosis:
Acute Renal Failure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you while you were here at
[**Hospital1 18**].
You were readmitted to the hospital with diarrhea and developed
worsening breathing and continued worsening function of your
liver. Your kidneys were then injured with your worsening liver
function and you decided to refocus your care to being comfort.
You are being sent home to be on hospice who will continue to
help treat your symptoms to make you feel more comfortable.
Followup Instructions:
with hospice
ICD9 Codes: 5849, 486, 4019, 4439, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1489
} | Medical Text: Admission Date: [**2168-9-6**] Discharge Date: [**2168-9-13**]
Date of Birth: [**2117-4-25**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Chest tightness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
51yo M w/ HTN, diastolic CHF, hyperlipidemia, sleep apnea,
asthma who had initially presented to an OSH on [**2168-9-5**] with
chest tightness ([**4-5**]), SOB, hypoxia (02 sat to 88%). His
initial EKG showed 2mm ST-T elevations in II, III, aVF and
bigeminy which resolved with SL NTG. He also had elevated
cardiac enzymes (tropT of 1.04). He was given [**Month/Year (2) **], plavix,
heparin, integrilin and transferred to [**Hospital1 18**] for cath. Here his
CE were: CK 1009, CKMB 55, trop T 4.23. At cath, he was found to
have CAD of a non-dominant RCA, probable prox. LPDA stenosis as
well as mild stenoses of the OM and mid LAD. There was also
iatrogenic dissection of the RCA w/o compromise of the lumen or
flow and possible distal embolization/additional dissection of
the AM1. No interventions were made (lesion not amenable to
PCI).
.
Post-cath, the patient had 500cc of guaiac positive coffee
ground emesis, he was orthostatic at the time. An NGT placement
was attempted, however the pt. desated and vomited and the NGT
was not placed. At this time, integrillin and heparin were
stopped and IV PPI was started. A few hours later, the pt.
became hypotensive to the 70's and hypoxic (74% on RA), he again
vomited approx 100cc of coffee ground emesis. His hypotension
responded well to a 500cc fluid bolus and his 02 sats improved
to 95% on a face mask(10L). The patient was then tranferred to
the CCU.
Past Medical History:
allergies: NKDA
.
HTN
diastolic CHF
asthma
chronic back pain
BPH
obstructive sleep apnea (on home CPAP)
congenital mild mental retardation? (per PCP)
COPD per PCP, [**Name10 (NameIs) **] [**Name11 (NameIs) 11149**] available, also has elements of
restrictive disease secondary to obesity
cerebral palsy
depression
s/p MVA in [**2161**]--c/b heart failure and mechanical ventilation
**unclear if pt has h/o murmur--PCP describes [**Name9 (PRE) 1105**]/VI systolic
murmur at base on some visit notes back to [**2165**], but no murmur
noted on PCP's exam [**2168-6-26**]
Social History:
Denies tobacco or alcohol use currently. Heavy user in the past
however quit both > 20yrs ago. He lives in [**Location 620**] with brother
and brother's partner. Minimal exercise. The patient works at
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Workshop in [**Location (un) 620**] (adult care worker).
Contact: Brother, [**Name (NI) **] [**Name (NI) 55764**] cell # [**Telephone/Fax (1) 55765**]
Family History:
Mother had an aneurysm, father had [**Name (NI) 19917**] disease.
Physical Exam:
VS-BP 116/49 HR 65 02 sat 96%
Gen: obese male, awake and alert, 02 face mask in place,
comfortable
heent: face mask in place
neck: elevated JVD to his ear with +hepato-jugular reflex
CV: holosystolic III/VI SEM heard best at the LLSB with
radiation to the axilla.
chest: bibasilar rales bilaterally
abd: obese, NT, ND. BS normoactive
ext: non-edematous
pulses: 2+ DP b/l
Pertinent Results:
[**2168-9-10**] 07:10AM BLOOD WBC-8.5 RBC-3.92* Hgb-12.4* Hct-37.5*
MCV-96 MCH-31.7 MCHC-33.2 RDW-14.0 Plt Ct-219
[**2168-9-7**] 02:28PM BLOOD PT-17.0* PTT-28.6 INR(PT)-1.6*
[**2168-9-9**] 02:07PM BLOOD Glucose-94 UreaN-12 Creat-0.5 Na-140
K-4.2 Cl-98 HCO3-36* AnGap-10
[**2168-9-6**] 01:15AM BLOOD CK(CPK)-1009*
[**2168-9-6**] 05:15AM BLOOD CK(CPK)-654*
[**2168-9-6**] 04:49PM BLOOD CK(CPK)-376*
[**2168-9-6**] 05:17PM BLOOD CK(CPK)-367*
[**2168-9-7**] 04:43AM BLOOD CK(CPK)-241*
[**2168-9-7**] 12:18PM BLOOD CK(CPK)-223*
[**2168-9-7**] 12:18PM BLOOD CK-MB-12* MB Indx-5.4 cTropnT-1.07*
proBNP-2251*
[**2168-9-7**] 04:43AM BLOOD CK-MB-14* MB Indx-5.8 cTropnT-0.90*
[**2168-9-6**] 05:17PM BLOOD CK-MB-17* MB Indx-4.6 cTropnT-1.05*
[**2168-9-6**] 04:49PM BLOOD CK-MB-17* MB Indx-4.5
[**2168-9-6**] 05:15AM BLOOD CK-MB-41* MB Indx-6.3* cTropnT-3.04*
[**2168-9-6**] 01:15AM BLOOD CK-MB-55* MB Indx-5.5 cTropnT-4.23*
[**2168-9-7**] 12:18PM BLOOD TSH-0.23*
.
[**2168-9-7**] bedside ECHO: initial read per fellow- suboptimal
quality due to body habitus-moderate to severe eccentric MR,
preserved LV fxn with inferior hypokinesis, RV normal, PA
pressures normal, trace TR, no significant pericardial effusion,
no observed VSD. Mild LVH. LVEF of 55-60%.
.
[**2168-9-7**] TTE:
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). There is at least
moderate resting left ventricular outflow tract obstruction. The
findings are consistent with hypertrophic obstructive
cardiomyopathy (HOCM). Trace aortic regurgitation is seen. There
is systolic anterior motion of the mitral valve leaflets. At
least moderate (2+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2168-9-7**],
the findings are similar (the resting LVOT gradient is slightly
lower and the overall LVE is slightly greater). Peak Resting
LVOT gradient: *60 mm Hg (nl <= 10 mm Hg)
.
[**2168-9-6**] Cardiac cath: LAD with mild calcification, ? of mild-mod
mid LAD plaque after D1, LCX with mild-mod stenosis at origin of
OM, prabable prox. moderate stenosis of LPDA, RCA with
dissection possibly on top of pre-existing proximal RCA plaque.
diffuse disease (80%) of AM2, AM3.
.
EKG on admission to CCU: NSR, normal axis, TWI in III, avF, V6.
?qwave in III, normal intervals.
right sided EKG: no ST elevations or depression in the
pre-cordial leads.
.
CTA Chest [**9-12**]:
There is no intimal flap within the thoracic aorta to suggest
aortic dissection. No filling defects are identified within the
central
pulmonary arteries to suggest acute or chronic pulmonary
embolism. The main pulmonary artery measures 3.9 cm in greatest
dimension suggestive of pulmonary arterial hypertension. There
is a small pericardial effusion. Coronary artery calcification
is notable within the left anterior descending coronary artery
and left circumflex artery. There is cardiomegaly. No
axillary, mediastinal or hilar adenopathy is detected.
There is near-complete atelectasis/collapse of the left lower
lobe. There is atelectasis within the right lower lobe. There
is abnormal elevation of the right hemidiaphragm. This study was
not performed to evaluate structures below the diaphragm.
However, there is a simple-appearing cyst within the left lobe
of the liver measuring 1.9 x 1.3 cm. Partially visualized
spleen and stomach is unremarkable.
.
Echo [**2168-9-13**]:
Focused study for patent foramen ovale: No ASD/PFO present via
color Doppler, or saline administration. Moderate pericarial
effusion located posterior to the inferolateral wall. Mild
resting LVOT gradient that increases with Valsalva manuever.
Brief Hospital Course:
51 yo M w/ HTN, hyperlipidemia, [**Hospital **] transferred to [**Hospital1 18**] for
cath for inferior-STEMI. No intervention at cath. Noted to have
coffee-ground emesis post-cath with hypoxia and hypotension,
transferred to CCU.
.
#CAD:
Presented with inferior STEMI, no [**Hospital1 **] at cath, medically
managed.
Patient discharged on plavix 75mg [**Last Name (LF) **], [**First Name3 (LF) **] daily, atorvastatin,
and metoprolol. He has follow-up with his primary care doctor
in 2 weeks and with cardiology in mid-[**Month (only) 359**]. He had no
further episodes of chest pain during his hospitalization.
.
#Hypotension:
Pt had transient episode of hypotension in the setting of a
recent inferior MI and 2 episodes of bloody emesis. His blood
pressure responded to IV fluids and home lasix was held, and his
BP remained stable throughout the rest of his hospitalization.
It was felt that his hypotension was due to preload dependence
due to inferior MI, volume depletion after large volume emesis.
In addition, it was noted that the patient had a possible new
systolic murmur at the time of his hypotensive episode. Echo
demonstrated a pressure gradient of 60 across his LVOT,
suggestive of hypertrophic cardiomyopathy, which would make him
further preload dependent. His murmur did indeed appear and
disappear during his hospitalization, and cardiac MR was
arranged for him as an outpatient.
.
#Hypoxia/Obstructive Sleep Apnea:
Patient was noted to have oxygen desaturation to the low 80s
without symptoms during his hospitalization, and it was felt
that he was most likely chronically hypoxic and hypoventilating
at home. He required 3L of oxygen by nasal cannula during the
day and 12L oxygen with 12cm H20 CPAP at night to maintain his
oxygen sats. Pulmonary was consulted, and it was felt that his
poor oxygenation status was due to a combination of factors,
including severe OSA, possible restrictive disease secondary to
his obesity and possibly his cerebral palsy, asthma, and h/o
diastolic congestive heart failure. Repeat Echocardiogram was
negative for intracardiac shunt. CTA was obtained and was
negative for pulmonary embolism, but did demonstrate near total
collapse of his left lung. The patient received chest PT and
was discharged with incentive spirometry. He was also continued
on his home regimen of singulair, advair, [**Doctor First Name 130**], and
albuterol. He will have follow-up with Sleep clinic, and a
sleep study was scheduled for him. In addition, he has
follow-up with his pulmonologist, Dr. [**Last Name (STitle) 22882**], in [**Month (only) 359**].
.
#CHF-acute on chronic diastolic heart failure:
Pt has known diastolic dysfunction and is on lasix 60mg qdaily
at home. Echocardiogram after his MI revealed preserved EF
(55%) with basal and mid inferior LV hypokinesis. His clinical
exam was c/w heart failure, demonstrating JVD and pretibial
edema. Patient was restarted on his home lasix at 60mg po daily
at time of discharge.
.
# Episode of 30-40 beats of non-sustained Ventricular
Tachycardia:
This occurred about 48 hours after his MI, and pt was
hemodynamically stable throughout. Electrophysiology was
consulted, and advised that the patient have a Lifewatch monitor
upon discharge. The patient had no further episodes of VTach
during admission. He will have follow-up with Dr. [**Last Name (STitle) **] in
3 months.
.
#GI bleed:
Pt had two episodes of coffee ground, guaiac positive emesis on
[**9-6**]. His stools were guaiac negative. He has no hx of GI
bleeding, gastritis, GERD, though he does have remote h/o ETOH
abuse. Although his Hct initially dropped from 42 to 37, his
Hct remained stable thereafter and he had no further episodes of
GI bleeding. GI was consulted and felt that he was not a
candidate for EGD. Per their recommendations, he was continue
on a PPI given twice daily for 1 month, after which time he
should be switched to a once a day dose. His primary doctor can
follow his hematocrit; he should not need an EGD unless he has
further episodes of GI bleeding.
.
#HTN:
Patient has been maintained on nadolol for years for his
hypertension. In discussion with his PCP, [**Name10 (NameIs) **] choice of this
medication appeared to be historical. Given the patient's poor
respiratory status and h/o reactive airway disease, he was
switched to metoprolol with good blood pressure control. It was
noted that the patient had been taking pseudoephedrine twice a
day chronically. He was advised to stop this medication as it
can increase the blood pressure.
.
#Hyperlipidemia:
Patient was put on high dose statin and discharged on 80mg
atorvastatin.
.
# Incidental ?liver cyst on CT chest:
- Described as "simple-appearing cyst within the left lobe of
the liver measuring 1.9 x 1.3 cm." Radiology did not make
specific recommendations about follow-up, but the pt's PCP
should pursue this as deemed appropriate.
Medications on Admission:
. Advair 1 puff [**Hospital1 **]
Advair 1 puff [**Hospital1 **]
Nadolol 20mg po daily
Singulair 10mg po daily qpm
Lasix 60mg po daily
Potassium 30meq po daily
Citalopram 40mg po daily
Aspirin 81mg daily
Tylenol PRN back pain
Decongestants, [**Hospital1 **] pseudoephedrin
Fexofenadine 60mg po BID
Discharge Medications:
1. oxygen
Patient needs home oxygen by nasal cannula at 3L during the day
and to be given with his CPAP at 12L overnight.
2. CPAP machine
CPAP machine with nasal mask to be set at 12cm pressure support
overnight; provide 12L oxygen during night with CPAP.
3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
4. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
9. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
11. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Albuterol 90 mcg/Actuation Aerosol Sig: [**12-29**] Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*3*
13. Atrovent HFA 17 mcg/Actuation Aerosol Sig: Two (2)
Inhalation four times a day as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*3*
14. Outpatient Physical Therapy
Chest PT for atelectasis
15. incentive spirometer
Please provide patient with an incentive spirometer, to be used
during the day to be used 4 times/hour or per physical therapy
and pulmonary clinic
16. Potassium Chloride 10 mEq Tablet Sustained Release Sig:
Three (3) Tablet Sustained Release PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis: STEMI
Secondary Diagnoses: Obstructive sleep apnea, hypoxia, GI bleed
Discharge Condition:
Improved. Patient was free of chest pain and he was breathing
comfortably with stable oxygen saturation on 3L nasal cannula
during the day and CPAP with 12cm H20 and 12L O2 at night.
Discharge Instructions:
You were admitted with a heart attack, and you received a
cardiac catheterization. The blockage in your artery was not
accessible for repair with a [**Last Name (LF) **], [**First Name3 (LF) **] your heart attack was
managed with medicines. Your blood pressure dropped low and
you started needing a lot of oxygen. You had a CT scan of your
chest that showed no evidence of a blood clot in the lungs.
1. Please take all medications as prescribed. In particular
please do not stop taking aspirin or plavix without talking to
your cardiologist. Because of your heart attack you should not
take pseudoephedrine.
2. Please attend all follow-up appointments as listed below.
You have a sleep study scheduled for [**9-25**]; please make sure you
go to this.
3. You will have a heart monitor delivered to your house. You
can expect a call to help you know how to use this.
4. You should get a call letting you know when to come for a
"cardiac MR", a radiology study that will help get a better
picture of your heart. If you have not heard from the doctor
about this in 2 weeks, please call Dr.[**Name (NI) 1565**] office at
[**Telephone/Fax (1) 285**] for assistance.
5. You will get a new CPAP machine and oxygen delivered on the
day you get home.
6. Please call your doctor or return to the hospital if you
develop:
** chest pain, shortness of breath, lightheadedness/dizziness,
palpitations, bloody vomit, blood in your stools, or other
symptoms that worry you
Followup Instructions:
1. Please see your primary doctor, Dr. [**Last Name (STitle) 5292**] in 2 weeks.
[**Telephone/Fax (1) 5294**]
2. Sleep clinic. Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 20111**] & DR. [**Last Name (STitle) **]
Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2168-9-20**] 10:45
3. Sleep study scheduled for [**2168-9-25**], Sunday at 9:30pm. You
will receive a packet in the mail with directions. Please call
[**Telephone/Fax (1) 38237**] if you have questions or you need to reschedule.
4. You will need to follow up in cardiology clinic with Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**10-10**] at 9:20 at [**Hospital1 18**] [**Hospital Ward Name 23**] 7
5. Please follow up with your lung doctor Dr. [**Last Name (STitle) 22882**] at [**Hospital 61**] [**Location (un) 620**] Monday [**9-26**] at 1:15.
6. Electrophysiology: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D.
Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2168-12-13**] 1:00.
Completed by:[**2168-9-15**]
ICD9 Codes: 4280, 5789, 4271, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1490
} | Medical Text: Admission Date: [**2131-12-29**] Discharge Date: [**2132-1-7**]
Service: GENERAL SURGERY
CHIEF COMPLAINT: Pneumoperitoneum.
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 92834**] is an 84 year-old
female transferred to [**Hospital1 69**]
from [**Hospital 1281**] Hospital. Ms. [**Known lastname 92834**] has a past medical
history significant for coronary artery disease status post
stent, congestive heart failure, hypertension. She was
evaluated at [**Hospital 1281**] Hospital for fatigue, heme positive stool.
Her hematocrit was found to be 17 and an
esophagogastroduodenoscopy was negative. She then underwent
a bowel prep and then colonoscopy at [**Hospital 1281**] Hospital. They
found a right arterial venous malformation. That
malformation was fulgurated on [**12-27**], which was two days
prior to presentation to [**Hospital1 188**]. The patient then developed increased temperatures,
abdominal distention. This prompted the physicians taking
care of her to order a KUB. This KUB showed free air. She
then received a CT, which showed free air, pelvic fluid and
stranding. This CT accompanied her to [**Hospital1 190**] and was seen by us. The patient had been
started on antibiotics and transferred to [**Hospital1 346**] for further evaluation and
treatment.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post stenting.
2. Congestive heart failure.
3. Aortic stenosis.
4. Hypertension.
5. Colon cancer.
6. Left colectomy.
7. Left lumpectomy secondary to breast cancer.
8. Bilateral carotid end arteriectomies.
MEDICATIONS: 1. Lipitor. 2. Zestril. 3. Lasix. 4.
Aspirin. 5. Tamoxifen. 6. Aricept. 7. K-ciel. 8.
Protonix. 9. Meclozine.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: In general, she is awake, alert and in
no acute distress. Vital signs temperature 101.8. Heart
rate 124. Blood pressure 158/70. Respirations 28. Her
lungs are clear to auscultation bilaterally. Her heart is
regular rate and rhythm. She has a 3 out of 6 systolic
ejection murmur. Her abdomen is dissented, tympanic. It is
diffusely tender. She has right lower quadrant rebound
tenderness. She also has guarding. Extremities they are
warm and well perfuse.
PERTINENT IMAGING: CT of abdomen and pelvis from [**Hospital 1281**]
Hospital shows positive free air, pelvic stranding and fluid.
HOSPITAL COURSE: Ms. [**Known lastname 92834**] was admitted to the hospital
the night of [**12-29**] with an apparent cecal perforation
from her colonoscopy. She was made NPO, given intravenous
fluids and antibiotics and laboratories were checked. It was
soon apparent after she was admitted that she would need a
repair of her cecal perforation. Therefore she went to the
Operating Room. In the Operating Room she underwent an
exploratory laparotomy, a colorrhaphy, and an abdominal
irrigation. In the Operating Room there was seen gross fecal
soilage of her abdominal cavity. The patient tolerated the
procedure well. Please refer to the official operative note
for all the details.
Immediately postoperatively the patient was admitted to the
PACU and was followed by the Intensive Care Unit team mostly
due to the patient's critical aortic stenosis. The patient
received a Swan-Ganz catheter for monitoring and adequate
fluid resuscitation. Her postoperative antibiotics included
Ampicillin, Levofloxacin and Flagyl. There were some
difficulties in correctly placing her Swan secondary to her
anatomy, but after multiple manipulations the Swan was placed
correctly. Of note the patient also had some postoperative
psychosis, which from past medical records the patient was
found to have a history of. Therefore she was put on
scheduled Haldol intravenous. This was soon discontinued
after a couple of days when the patient slowly returned to
baseline in mental status. Also immediately postoperatively,
the patient was started on total parenteral nutrition
secondary to the patient's deconditioned state.
The patient did well in the Intensive Care Unit. The only
issue being her high blood pressure and heart rate and the
patient was switched to intravenous hypertension medications
as the patient was not tolerating po. By postoperative day
four the patient was able to be transferred to the floor. At
this point she was also having return of her bowel function
and was started on clears, however, the total parenteral
nutrition was continued. By postoperative day five the
patient was continued to have high blood pressures and heart
rate. The patient was able to be switched to po hypertension
medications to which she had much better blood pressure
control. She was also being diuresed with intravenous Lasix
with good response and over the next few days the patient was
slowly weaned off of her total parenteral nutrition,
restarted on a po diet and restarted on all of her home
medications.
The patient was discharged of all of her antibiotics, which
were Ampicillin, Levofloxacin and Flagyl on postoperative day
seven after a seven day course. She had been afebrile and
her white count had returned to [**Location 213**]. Physical therapy and
occupational therapy consults had been obtained during the
[**Hospital 228**] hospital stay. They felt due to her deconditioned
status that the patient would need an acute rehab stay
immediately upon discharge from the hospital. This was also
reinforced as the patient did have a fall the day before
discharge in the bathroom while nursing was waiting outside.
CONDITION ON DISCHARGE: The patient is stable tolerating a
po diet and po medications, ambulating well with assistance,
however, unstable without assistance. The patient was
somewhat incontinent of urine.
DISCHARGE STATUS: To rehab facility [**Hospital1 **],
staples still in place to be discontinued in one week.
DISCHARGE DIAGNOSIS:
Status post exploratory laparotomy, colorrhaphy for cecal
perforation secondary to colonoscopy.
DISCHARGE MEDICATIONS: 1. Lasix 40 mg po q day. 2.
Protonix 40 po q day. 3. Tamoxifen 10 mg po b.i.d. 4.
Atenolol 75 mg po q.d. 5. Donepazil 5 mg po q.h.s. 6.
Isosorbide dinitrate 10 mg po q day. 7. Lisinopril 40 mg po
q day prn. 8. Heparin subQ 5000 units b.i.d. until fully
functional. 9. Albuterol inhalers prn. 10. Percocet one
to two tabs po q 4 to 6 hours prn pain.
FOLLOW UP: 1. The patient is to follow up with Dr. [**First Name8 (NamePattern2) 333**]
[**Last Name (NamePattern1) **] in one to two weeks. 2. The patient is to follow
up with her primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 48579**] in one to
two weeks.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.
[**MD Number(1) 6066**]
Dictated By:[**Doctor Last Name 46822**]
MEDQUIST36
D: [**2132-1-7**] 09:18
T: [**2132-1-7**] 09:26
JOB#: [**Job Number 38781**]
ICD9 Codes: 4280, 4241, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1491
} | Medical Text: Admission Date: [**2163-3-29**] Discharge Date: [**2163-4-4**]
Date of Birth: [**2142-4-11**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10293**]
Chief Complaint:
20 year old male s/p unintentional APAP overdose.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
20 year old male transferred from [**Hospital1 112**] for liver transplant
evaluation after percocet overdose. On Sunday [**3-27**] had a
stressful day and pt took approximately 20 percocet (5/325)
throughout the day after a series of family arguments. Denies
trying to hurt himself. Parents confirm to suicidal attempts in
the past. Pt felt that he had a hangover on Monday secondary to
"percocet withdrawal" and took an additional 5 percocet. Pt was
admitted to the SICU and followed by Liver, Transplant,
Toxicology, and [**Month/Year (2) **]. He was started on NAC q4hr with gradual
decline in LFT's and INR. His recovery was c/b hypertension,
for which he was started on clonidine. Pt was transferred to
the floor on [**4-1**].
Past Medical History:
Bipolar D/o (s/p suicide attempts in the past)
ADHD
S/p head injury [**2160**]: s/p MVA with large L3 transverse process
fx, small right frontal epidural hemorrhage-- with
post-traumatic seizures (was previously on dilantin, now dc'd)
Social History:
Father is HCP, student in [**Name (NI) 108**], Biology major, parents and
brother live in [**Name (NI) 86**], single without children, lived in a
group home for 3 years as a teenager, drinks alcohol 1 night a
week, denies illict drug use, pt in [**Location (un) 86**] for neuro eval
Family History:
no liver disease
Physical Exam:
VS. 96, 154/90, 67, 20, 97%RA
Gen. comfortable, appears combative at times, using swears
words, then appreciative at other times
Heent. MMM
Chest. CTA ant
Cor. RR, nl s1 s2
Abd. +BS, soft, slight tenderness to palpation, improved
overall, no rebound or guarding.
Ext. no edema
Pertinent Results:
[**2163-3-29**] 11:53PM BLOOD WBC-6.4 RBC-4.71 Hgb-14.0 Hct-41.6 MCV-88
MCH-29.8 MCHC-33.7 RDW-14.2 Plt Ct-50*#
[**2163-3-29**] 11:53PM BLOOD Plt Smr-VERY LOW Plt Ct-50*#
[**2163-3-29**] 11:53PM BLOOD PT-23.7* PTT-28.9 INR(PT)-3.6
[**2163-3-29**] 11:53PM BLOOD Glucose-125* UreaN-13 Creat-1.1 Na-137
K-4.7 Cl-98 HCO3-30* AnGap-14
[**2163-3-30**] 03:36AM BLOOD ALT-[**Numeric Identifier 37727**]* AST-9060* LD(LDH)-5544*
AlkPhos-75 Amylase-49 TotBili-5.0*
[**2163-3-29**] 11:53PM BLOOD Lipase-32
[**2163-3-29**] 11:53PM BLOOD Albumin-3.4 Calcium-8.0* Phos-1.0*#
Mg-1.5*
[**2163-3-30**] 03:36AM BLOOD Hapto-275*
[**2163-3-30**] 04:49PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HAV
Ab-NEGATIVE
[**2163-3-30**] 12:11PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2163-3-30**] 04:49PM BLOOD HIV Ab-NEGATIVE
[**2163-3-30**] 03:36AM BLOOD Phenyto-<0.6* Valproa-<3.0*
[**2163-3-29**] 11:53PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2163-3-29**] 11:53PM BLOOD HCV Ab-NEGATIVE
[**2163-3-30**] 10:53AM BLOOD Type-[**Last Name (un) **] pO2-45* pCO2-44 pH-7.44
calHCO3-31* Base XS-4
CT Abd:
LLL PNA
There is a confluent air space opacity within the left lower
lobe consistent with pneumonia. The right lung is grossly clear.
There are no pleural effusions. The liver, gallbladder, spleen,
pancreas, adrenal glands, and right kidney appear grossly
normal. There are at least two (2) tiny low attenuation foci
arising from the left kidney which are too small to characterize
further. Stomach and visualized loops of small and large bowel
are unremarkable. No pathologically enlarged retroperitoneal or
mesenteric lymph nodes are present. There is no free fluid.
Head CT: There is no intracranial hemorrhage.
C-spine CT: There is no evidence of fracture or dislocation.
There are numerous cervical lymh nodes seen and thickening of
the adenoidal/nasopharyngeal soft tissues. Clinical correlation
recommended.
Brief Hospital Course:
[**Known firstname 20069**] [**Known lastname 37728**] ia a 20 yo male with h/o bipolar disease,
ADHD, h/o seizures p/w acute hepatitis due to unintentional
percocet overdose.
Acute Hepatitis due to APAP overdose: He was initially admitted
to the SICU where he was evaluated by the liver transplant team.
Luckily, his ALT/AST trended down with 17 doses of
N-Acetylcysteine from a peak of 22,000/14,00 respectively, and
an INR peak of 6.6. With his improvement, he was transferred to
the floor on [**4-1**], with continued improvement of his LFT's. An
abd CT was not surprising, showing expected signs of
inflammation around the liver. Pt's abdominal pain was
improving on discharge.
Hypertension: in setting of acute hepatitis. Pt was treated
with clonidine in house with. Anticipate resolution with
resolution of acute process.
?Bipolar Disease/ADHD: Followed by psychiatry in house. They
recommend not medically treating his reported diagnoses given pt
could not provide names of any psychiatrists, and the psychiatry
team questioned the pt's diagnoses. Pt will follow up with
outpatient psychiatry, and was given the number of a psychiatry
practice near his home.
LLL PNA: Likely due to aspiration while pt was acutely sick. Pt
spiked to 101.9, with evidence of LLL PNA on abd CT. He was
started on Levo/Flagyl [**4-2**] for 1 week. He remained comfortable
on room air and afebrile.
? H/O Seizures d/t subdural hemorrhage in setting of CVA in
[**2160**]: Pt reported being on dilantin and depakote for
seizures/mood stabalization. However, I spoke with both his PCP
and primary neurologist who have no record of him being on
either medication, and no record of him ever having a seizure.
Further, he had an EEG for headaches on [**2163-4-22**] that was normal.
Pt's dilantin and depakote levels on admission were below
assay. Pt was not place on either dilantin or depakote. He
remained seizure free in house and head CT showed no evidence of
subdural hematoma as present three years ago after his car
accident. He will follow up with outpatient neurology.
Drug seeking behavior: Pt was clearly pain med seeking, being
verbally abusive to staff. His episode of falling off the
toilet [**4-2**] was likely due to opioid overuse, with no subsequent
evidence of trauma on exam or CT. With some struggle, we have
negotiated switching him from IV to PO dilaudid. He will be
d/c'd off dilaudid, with a few oxycodones for breaktrough pain.
Comm: PCP [**Name9 (PRE) **] [**Name (NI) **] [**Telephone/Fax (1) 8539**], Neuro [**Doctor Last Name 10653**]
[**Telephone/Fax (1) 37729**] in [**Location (un) **].
Dispo: Pt was discharge home with PCP, [**Name10 (NameIs) **], GI, and neuro
followup plans.
Medications on Admission:
Per patient:
Dilantin (for seizure prophylaxis)
Depakote
Dexedrine
Percocet prn
Wellbutrin
Xanax
Neurontin
--doses unknown
Discharge Medications:
1. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 5 days.
Disp:*15 Tablet(s)* Refills:*0*
3. Oxycodone HCl 5 mg Tablet Sig: One (1) Tablet PO every [**5-4**]
hours for 3 days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Acute Hepatitis d/t Tylenol Overdose
2. Hypertension
3. Drug seeking behavior
4. ?Bipolar Disease
5. LLL Pneumonia
Discharge Condition:
Pt was in good condition, afebrile, on room air, with stable
vital signs.
Discharge Instructions:
Follow up with Dr. [**Last Name (STitle) **] on Friday. Please call your other
doctors at the [**Name5 (PTitle) 37730**] provided so that you may follow up with
them.
Do not take any medications with Tylenol, including Percocet,
until directed otherwise by your doctor.
Followup Instructions:
See you primary care doctor, Dr. [**First Name (STitle) **] [**Name (STitle) **] [**Telephone/Fax (1) 8539**]
(phone), on Friday at 1pm (appointment made).
Call Dr.[**Name (NI) 37731**] office at [**Telephone/Fax (1) 37732**] for a follow up GI
visit in 2 weeks.
Call your neurologist, Dr. [**Last Name (STitle) 10653**] [**Telephone/Fax (1) 37729**], for an
appointment next week.
Call [**Hospital 86**] Health Care at [**Telephone/Fax (1) 37733**] for a follow up
psychiatric appointment in 2 weeks.
ICD9 Codes: 486, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1492
} | Medical Text: Admission Date: [**2156-6-16**] Discharge Date: [**2156-6-22**]
Date of Birth: [**2092-9-8**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 10593**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
63 year old male with h/o severe COPD who is being transferred
from [**Hospital1 2177**] after a prolonged admission for hypercapneic
respiratory failure from COPD complicated by pneumothorax and
bleb rupture. He is being transferred for consideration of
intrabronchial valve.
He was admitted to [**Hospital1 2177**] [**2156-5-19**] with hypercapneic respiratory
failure felt to be due to COPD. He has known COPD and was
reportedly not compliant with his medications and still smoking.
At baseline he reportedly has DOE and cannot climb a flight of
stairs and is dyspneic with shaving. He presented with
productive cough and dyspnea. His DNR/DNI status was reversed in
the ED at [**Hospital1 2177**] and he was intubated (initial ABG 7.13/96/234).
CXR showed left basilar PTX and urgent chest tube was placed by
CT surgery. CT chest showed large bulla in [**1-12**] of RLL of lung.
He was extubated on HD2. Course complicated by extensive SC
emphysema felt to be related to bleb rupture. A SC incision into
the left chest wall ("blow hole") was done by CT surgery which
resulted in slow improvement in his SC emphysema. He had
persistent air leak and small left sided PTX was seen on daily
films. Pleurodesis was performed [**2156-6-2**]. He continued to have
persistent air leaks and 2nd chest tube was placed on [**6-10**]. He
is on -40 wall suction on 1st chest tube, and -20 on 2nd chest
tube. He is now being transferred for placement of
intrabronchial valve by IP service.
During his course at [**Hospital1 2177**], he completed a course of steroids and
azithromycin for COPD exacerbation. On [**6-15**], he desatted to the
80's requiring non-rebreather with resolution of his symptoms.
CXR showed RLL infiltrate and he was started on vanco/cefepime
for HCAP, although f/u xray showed chronic changes and
antibiotics were stopped. He also developed diffuse abdominal
pain on [**5-10**] with emesis. CT showed SBO but he refused NG
tube per the discharge summary (per the patient, he agreed and
the team couldn't get it in and he refused to let them try
again). He was made NPO and started on IV fluids. He passed
flatus x 1 on [**6-14**] but has not yet had a bowel movement (last BM
[**6-9**]). Cause of SBO was felt unclear. Vitals on transfer 97.7 80
(100s-110s when moves) 106/57 [**12-24**] 95%4L.
Currently, he reports pain at the site of his chest tubes and
pain in his epigastrium. Denies any SOB, but has productive, wet
cough. States his breathing is okay as long as he has his "best
friend," referring to his nasal cannula. Denies CP. States he is
still passing flatus, but has not had BM. Cannot recall any of
the events leading up to the hospitalization and is not sure why
he was transferred here. He does know that he does not want
anyone to attempt to place another NG tube. Denies recent
fevers. Denies current nausea or vomiting.
Past Medical History:
Severe COPD, not on home O2 as still smoking
Malnutrition/FTT
Chronic hyponatremia
H/o PTX in setting of PNA many years ago
EtOH abuse, remote
Possible h/o cirrhosis per patient
Gastric ulcer
H/o cleft palate surgery in youth with subsequent difficulty
speaking
Social History:
Lived in [**Location 686**] in senior housing by himself prior to
hospitalization. Smokes 1ppd, history of alcohol abuse but quit
[**2137**], no IVDU. Worked in movie theaters and unloading trucks in
past.
Family History:
Brother had CABG, father died of MI, mother died of old age.
Physical Exam:
Admission Physical Exam
Vitals: 96.0 104/58 79 24 100%6L
GENERAL: Pleasant, but very cachectic male in NAD. Has
dysarthria that he reports is his baseline.
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. MMM. OP clear.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or gallops.
LUNGS: Diminished breath sounds throughout L>R with coarse
expiratory wheezing. Right base also with rhonchi. Two chest
tubes in place.
ABDOMEN: Diminished bowel sounds but present, soft and only
mildly tender to palpation over epigastrium, not distended or
tympanic. No HSM palpable. Has diffuse subcutaneous emphysema
across abdomen
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses.
NEURO: A&Ox3. Appropriate.
PSYCH: Listens and responds to questions appropriately, pleasant
Discharge exam: Deceased
Pertinent Results:
Admission labs:
[**2156-6-17**] 02:12AM BLOOD WBC-5.1 RBC-3.13* Hgb-10.2* Hct-31.6*
MCV-101* MCH-32.6* MCHC-32.4 RDW-12.2 Plt Ct-212
[**2156-6-17**] 02:12AM BLOOD PT-12.6* PTT-27.4 INR(PT)-1.2*
[**2156-6-17**] 02:12AM BLOOD Glucose-86 UreaN-5* Creat-0.4* Na-139
K-3.8 Cl-99 HCO3-36* AnGap-8
[**2156-6-17**] 02:12AM BLOOD Calcium-8.5 Phos-2.0* Mg-1.9
[**2156-6-17**] 02:12AM BLOOD ALT-9 AST-19 AlkPhos-55 TotBili-0.4
[**2156-6-17**] 08:03AM BLOOD Type-ART pO2-168* pCO2-72* pH-7.31*
calTCO2-38* Base XS-7 Intubat-NOT INTUBA
[**2156-6-17**] 08:03AM BLOOD Lactate-0.9
Discharge labs: Deceased
Imaging:
-CXR ([**2156-6-17**]): The lung volumes are increased. At the right
apex, there are severe emphysematous and bullous parenchymal
alterations. Identical lesions are seen in the lateral aspects
of the left lung and at the bases of the right lung. At the
bases of the right lung, a small pleural effusion is visible.
On the left, two chest tubes are seen. According to the lateral
radiograph, they appear to be correctly positioned. One of the
tubes, however, has its sidehole very close to the chest wall
and, as a consequence, could be advanced. The presence of a
small basal pneumothorax cannot be excluded with certainty.
There are extensive bilateral parenchymal opacities in the
middle and lower lung zones. The multiple air bronchograms with
irregular border suggest that these changes have a chronic
component. The size of the cardiac silhouette is normal. Also
normal are the hilar and mediastinal contours.
Given that this is the admission radiograph and that the
morphologic feature is complex, CT is recommended to obtain a
better assessment of the complex morphology and a valid baseline
for further followups.
-CT head ([**2156-6-19**]):
1. Thin 2.5 mm subdural hematoma at the right frontal lobe
without evidence of fracture or mass effect.
2. Left sphenoid bone lytic lesion. DDx includes hemangioma,
fibrous
dysplasia, but also metastasis or chondrosarcoma. Further workup
with MRI
might be considered.
3. Small amount of fluid in the left mastoid air cells.
-Right shoulder plain film ([**2156-6-19**]): There are no signs for
acute fractures or dislocations. There is normal osseous
mineralization. There are mild degenerative changes of the
glenohumeral joint. The visualized right lung apex is clear.
-Pelvis ([**2156-6-19**]): Single view of the pelvis demonstrates no
displaced fractures or dislocations. There are degenerative
changes of the right hip with spurring in the superolateral
acetabula. There are mild degenerative changes of the lower
lumbar spine. The sacroiliac joints are within normal limits.
There are vascular calcifications.
Brief Hospital Course:
MR. [**Known lastname 106556**] is a 63 yo M with endstage COPD who was admitted to
[**Hospital1 18**] from [**Hospital1 2177**] for evaluation for a bronchial valve to help
treat his bullous emphysema which had resulted in pneumothoraces
whose goals of care were shifted to comfort measures only during
this hospitalization, and he expired on [**2156-6-22**].
#Bullous Emphysema- The patient has long standing COPD, not on
home o2, as he continued to smoke and it has been complicated by
bleb rupture with pneumothoraces. On admission to the outside
hospital he was in hypercarbic respiratory distress and required
intubation (temporarily reversed his DNI status at that time).
He was ultimately extubated and required bipap while there. He
completed a course of antibiotics for COPD exacerbation at the
OSH. Patient was transferred to [**Hospital1 18**] for further evaluation by
interventional pulmonary. On admission here he was originally
on 6L of NC and was stable. He acutely became tachypneic,
dyspneic and complaining of not being able to breath and was
transferred to the ICU. In the ICU he was placed on a shovel
mask, received morphine and had an NG tube placed. His CXR
showed bullae in the left and right lung. IP evaluated the
patient and switched his Chest tubes to water seal on admission
to the ICU and then pulled them on HD#3. Ultimately, IP felt
there was no intervention that would be of benefit to the
patient.
He complained of multiple episodes of air hunger and was
treated with escalating doses of morphine. He was transferred to
the floor where his respiratory status continued to deteriorate.
After discussion with the patient and his family/HCP, he was
transitioned to [**Name (NI) 3225**] with inpatient hospice, as discussed below.
He expired on [**2156-6-22**] with his family at the bedside.
#Goals of care- the patient was originally DNR/DNI on admission
to the outside hospital however on admission to their ED he
changed this to DNR but okay to intubate. On admission to the
ICU here, he expressed his wishes to be DNR/DNI and that he did
not wish to have any further interventions and was looking for
hospice. Palliative care was consulted and helped to arrange
inpatient hospice. As his respiratory status continued to
decline, he was made full [**Date Range 3225**] and was transitioned to inpatient
hospice care.
#Small bowel obstruction- The patient had a known SBO at the OSH
and had refused NG tube placement there as well as on admission
here. When he was transferred to the ICU he agreed to a NG tube
placement and reported feeling better. There was audible air
that came out of the NG tube on placement. The plan was to get a
CT abd/pelvis to further evaluate however given that he was
unable to lie flat this was not performed and was not pursued
given his change in GOC. The patient pulled the NGT on HD3
while he was delirious and it was not replaced.
#Fall abd subdural hemorrhage- Early on HD4, the patient tried
to leave his room while he was delirious and had a fall with
head strike. Her reported right shoulder and arm pain after the
fall, no fracture on right shoulder plain film and no fracture
on pelvic fx. Head CT showed a 2.5mm frontal subdural hematoma.
He did not have any major apparent neurological sequelae of
this subdural (pupils remained reactive and equal, moving all
extremities) and no repeat imaging was obtained after his GOC
were changed to [**Date Range 3225**].
Medications on Admission:
1000 mL NS Continuous at 75 ml/hr
Albuterol 0.083% Neb Soln 1 NEB IH Q6H
Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN SOB/wheeze
Acetaminophen 650 mg PO/NG Q6H:PRN pain, fever
Famotidine 20 mg IV Q12H
Heparin 5000 UNIT SC TID
Ipratropium Bromide Neb 1 NEB IH Q6H
Lidocaine 5% Patch 1 PTCH TD DAILY
MethylPREDNISolone Sodium Succ 125 mg IV Q8H
Morphine Sulfate 2-4 mg IV Q4H:PRN air hunger Hold for sedation
Morphine Sulfate 4 mg IV ONCE Duration: 1 Doses
Ondansetron 4-8 mg IV Q8H:PRN nausea
Discharge Medications:
Expired
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
ICD9 Codes: 2761, 2930, 3051 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1493
} | Medical Text: Admission Date: [**2184-1-29**] Discharge Date: [**2184-2-10**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
Found down
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
History was obtained from a friend who talks with her a few
times a week, but the last time he saw her was 4 years ago
(history was not obtained from her neighbor who found her), and
also from ED records.
.
84 F with unknown medical history, was found down tonight on her
kitchen floor by her neighbor. [**Name (NI) **] neighbor noticed that she had
been SOB and panting over the past few days, and he kept telling
her she had to go to a physician, [**Name10 (NameIs) 6643**] she refused. He was
walking by her [**Last Name (un) **] this afternoon and heard moaning. He
unlocked the door to her [**Last Name (un) **] and found her lying on the
kitchen floor, no blood or apparent trauma. She states that she
fell off the couch due to sudden weakness, no CP, no abd pain.
+back pain due to position in bed. Neighbor called 911 and
patient was brought to [**Hospital1 18**] ED.
.
In the ED, SBP was 60s, received 2L with BP still in 70s,
received 2 more L with little SBP improvement. Sats started
dropping to 85, so she was intubated for airway protection and
had LIJ central line placed. Norepinephrine was started and SBP
improved to 110s. T102 rectally. NGT put out 250 ml coffee
ground fluid, received 1 U RBC. UO 230 ml after 4 L IVF.
.
UA was positive, CXR shows LLL infiltrate. WBC 21, Bands 5. Hct
35.5. Lactate 4.1. INR 1.9. CK 1677, MB 21, Trop 0.03. CT chest
shows LLL infiltrate, aorta is mildly dilated but nonaneurysmal
with no dissection, large goiter, RML centrilobular nodules
suggestive of atypical Mycobacterial infection, large hiatal
hernia with intrathoracic stomach.
.
At baseline, the patient is independent, lives alone, walks with
a cane, pays a woman who does her shopping for her.
Past Medical History:
Goiter on R side of neck
L hip replacement
Hypertension
Social History:
Has no close relatives, is a private person. Never been married,
has no children. Used to work at [**Location 17448**] in unknown job.
Likes brandy before bed but unknown if has ETOH problem, doesn't
smoke, no illicit drugs. Lives alone in [**Last Name (un) **] [**Location (un) **]. Has a siamese cat, Frank, for the last 10 years.
Family History:
Unknown
Physical Exam:
VS: 100.8 / 116/65 / 103
99% on AC 550 pulling in 600 / 15 breathing 7 over vent at RR 22
/ 5 / 0.5
.
GEN: Sedated, arousable to voice and holding hand, looks
comfortable
HEENT: JVD 7 cm, no LAD, intubated, PERRL. 6x6 cm goiter, soft
and mobile in R central neck.
LUNGS: Coarse breath sounds, clear anteriorly
CHEST: Petechiae on upper chest, upper arms, in axillary areas
bl
HEART: 2/6 systolic flow murmur, no r/g
ABD: Soft, +BS, surgical scar RUQ, ND, NT
EXTR: No c/c/e, 2+ DP bl
NEURO: Withdraws from painful stimuli
SKIN: Petechiae as noted on chest/back
Pertinent Results:
CT chest:
IMPRESSION:
1. Within the limitations of a non-IV contrast examination, the
aorta is mildly dilated but non-aneurysmal with no secondary
evidence of dissection.
2. There is a large goiter. Correlate with physical exam and
thyroid
biochemical profile. If indicated, consider thyroid ultrasound
for further evaluation.
3. Likely small focus of evolving pneumonia or aspiration in the
lateral basal segment of the left lower lobe.
4. Centrilobular nodules in the right middle lobe suggestive of
atypical Mycobacterium infection (indolent and chronic).
5. Large hiatal hernia with resultant intrathoracic stomach.
.
CT C spine:
FINDINGS: There is no fracture. There is exaggeration of the
lordotic
curvature otherwise no malalignment noted. There is disc space
narrowing at C5-C6 and C6-C7 with small marginal osteophytes.
The _____ osteophytes favor the right lateral recess resulting
in bony neural foraminal encroachment. Endotracheal and
nasogastric tubes are evident. There is a large heterogeneous
thyroid, likely goiter. Otherwise, the prevertebral and other
soft tissues of the neck are unremarkable.
IMPRESSION: Degenerative disc disease as detailed above. No
acute traumatic findings.
.
CXR:
FINDINGS: There has been interval withdrawal of a left internal
jugular central venous catheter with tip now in the left
brachiocephalic vein. The remainder of the lines and tubes are
in unchanged position. Again seen is a large hiatal hernia with
an intrathoracic stomach. There is mild airspace opacity
adjacent to the left heart border. The remainder of the
examination remains unchanged.
IMPRESSION:
1. Interval withdrawal of left internal jugular central venous
catheter with
2. Mild airspace opacity adjacent to the left heart border.
.
[**2184-1-30**] Abdominal U/S:
.
[**2184-1-30**] CT abdomen/pelvia:
[**2184-1-29**] 03:10PM PLT SMR-LOW PLT COUNT-92*
[**2184-1-29**] 03:10PM NEUTS-94* BANDS-5 LYMPHS-1* MONOS-0 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2184-1-29**] 03:10PM WBC-21.3* RBC-4.07* HGB-12.3 HCT-35.5* MCV-87
MCH-30.3 MCHC-34.8 RDW-15.6*
[**2184-1-29**] 03:10PM ETHANOL-NEG
[**2184-1-29**] 03:10PM CK-MB-21* MB INDX-1.3
[**2184-1-29**] 03:10PM cTropnT-0.03*
[**2184-1-29**] 03:10PM CK(CPK)-1677*
[**2184-1-30**] 12:25AM BLOOD CK-MB-32* MB Indx-0.9 cTropnT-0.05*
[**2184-1-30**] 11:33AM BLOOD CK-MB-16* MB Indx-0.8 cTropnT-0.03*
[**2184-1-30**] 12:25AM BLOOD ALT-65* AST-165* LD(LDH)-542*
CK(CPK)-3747* AlkPhos-221* Amylase-33 TotBili-0.9
[**2184-1-30**] 06:09AM BLOOD CK(CPK)-2938* TotBili-0.6
[**2184-1-30**] 11:33AM BLOOD ALT-63* AST-139* CK(CPK)-1894*
AlkPhos-132* TotBili-0.5
[**2184-1-29**] 03:10PM BLOOD Glucose-78 UreaN-47* Creat-2.3* Na-137
K-3.8 Cl-99 HCO3-19* AnGap-23*
[**2184-1-30**] 06:09AM BLOOD FDP-[**Telephone/Fax (1) 14007**]*
[**2184-1-30**] 11:33AM BLOOD Fibrino-353 D-Dimer-[**Numeric Identifier 961**]*
[**2184-1-30**] 12:25AM BLOOD Fibrino-261
[**2184-1-29**] 05:10PM BLOOD PT-19.5* PTT-40.3* INR(PT)-1.9*
[**2184-1-30**] 12:25AM BLOOD PT-16.9* PTT-35.7* INR(PT)-1.6*
[**2184-1-30**] 11:33AM BLOOD PT-15.6* PTT-35.2* INR(PT)-1.4*
.
CT abdomen/pelvis IMPRESSION:
1. Left lower lobe consolidation, probably representing
pneumonia. Small bilateral pleural effusions.
2. Very large hiatal hernia containing contrast. NG tube in
place.
3. Stranding in the mesentery and perirenal spaces, consistent
with history of recent percussive resuscitation.
4. Bilateral staghorn calculi.
5. Enlargement of left adrenal gland, which is not specific for
adenoma as there is no definite mass. Dedicated imaging with
adrenal CT or MRI is recommended for further evaluation.
.
ABDOMINAL ULTRASOUND: The gallbladder is unremarkable without
evidence of stones or wall edema. The common bile duct is not
dilated. The liver is coarsened in echotexture. There are
multiple echogenic portal triads. There are no focal lesions.
The portal vein is patent with appropriate directional flow. The
right kidney measures 13.5 cm. The left kidney measures 12.6 cm.
There are no stones or hydronephrosis bilaterally. The spleen
and visualized portions of the pancreas are unremarkable
Brief Hospital Course:
84 F found down, temperature of 102 and significant leukocytosis
admitted with severe sepsis from GU source.
.
# Severe sepsis:
Initially required levophed in order to maintain MAPs. There
was question.- On Ceftriaxone and Azithro for CAP and UTI,
Flagyl for possible aspiration pna, start [**1-29**]. No growth from
cultures (urine or blood). Eventually found to have staghorn
calculus in kidneys and believed most likely to be urinary
source of infection. Later also question of aspiration
pneumonia. Received 10 day course of flagyl and finishing 14
day course CAP/urinary antibiotic (one more day of
levofloxacin). Initially had element of DIC as well, resolved.
Patient transferred to floor with stable blood pressure.
.
# Respiratory insufficiency:
Was intubated for airway protection after sats dropped to 85%
after receiving 2 L NS. Hypoxemia may have been from element
pulmonary fluid overload, although also treated for aspiration
pneumonia.
.
# UTI: Urine cultures remained no growth but received broad
spectrum coverage. Has staghorn calculi which puts her at
increased risk of recurrence. Has follow up appointment with
urology to address.
.
# Leukocytosis: Patient had wbc count peak at [**Numeric Identifier 7670**], down to
[**Numeric Identifier 20476**] on day of discharge. Given flagyl empirically for c diff,
although stools negative here. [**Month (only) 116**] have been all reactive to
infection but will follow up with hematology as an outpatient.
.
# UGIB:
Coffee ground fluid from NGT. Received 1 U RBC in ED. Has a
large hiatal hernia with resultant intrathoracic stomach. [**Month (only) 116**]
predispose to UGIB and gastritis. Cont PPI. H. pylori serology
was negative.
.
# Goiter on R side of neck: TSH and rest of TFTs wnl in
12/[**2183**]. Mild airway involvement. Should get ultrasound as
outpatient and endocrine follow up arranged. Repeat TFTs in 6
weeks.
.
# Adrenal gland: Enlargement of left adrenal gland, which is not
specific for adenoma as there is no definite mass. Dedicated
imaging with adrenal CT or MRI is
recommended for further evaluation as an outpatient.
.
# Anxiety: Patient reports longstanding anxiety. Started on
SSRI and given lorazepam prn, as well as trazodone to help with
sleep. Reports some increased symptom control with combination.
Should be reviewed in outpatient setting.
.
# Dispo: Patient deconditioned after MICU admission. Will be
discharged to [**Hospital 100**] Rehab today for STR with plan for eventual
discharge home.
Medications on Admission:
Given lorazepam previously by PCP.
Discharge Medications:
1. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 days.
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Severe sepsis from urinary tract infection
Staghorn calculi
Leukocytosis, most likely from infection
Acute renal failure (pre renal and infection)
Goiter
Gastritis
Anxiety/Depression
Discharge Condition:
Good
Discharge Instructions:
Please take your medications as prescribed.
You will need to follow up with multiple physicians after
discharge. Please see the appointments below.
You have been found to have a large stone in your kidneys that
needs to be reevaluated by the urologists after discharge.
You also have been found to have a goiter that needs to be
followed up as an outpatient. Your primary care doctor (Dr.
[**First Name (STitle) **] will arrange this.
Your white blood cell count got very high here. Most likely
this was from infection and has now resolved, but you will need
to follow up with hematology as an outpatient as well.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2184-2-18**] 1:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9
Date/Time:[**2184-2-18**] 1:30
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1239**], [**Name Initial (NameIs) **].O. Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2184-2-24**] 11:30 (general medicine/geriatrics)
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 986**] (urology) [**2184-2-25**] @ 10:15am phone:([**Telephone/Fax (1) 93948**]
ICD9 Codes: 0389, 5990, 5849, 5070, 5789 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1494
} | Medical Text: Admission Date: [**2113-3-12**] Discharge Date: [**2113-3-19**]
Date of Birth: [**2036-4-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Amoxicillin / Tape / Lipitor
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Fatigue/Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2113-3-14**] Coronary artery bypass graft x 1, aortic valve
replacement with [**Street Address(2) 6158**]. [**Male First Name (un) 923**] porcine valve
[**2113-3-14**] Right axillary 8 mm Dacron conduit.
History of Present Illness:
76 year old female with history of paroxysmal SVT including
paroxysmal atrial fibrillation and flutter, high degree AVB s/p
dual chamber pacemaker and coronary artery disease with prior
LAD stenting who has been followed by serial echaocardiograms
for worsening aortic insufficiency. Over the past year, she has
noticed a significant decline in her exercise tolerance. She has
gone from being able to walk 30minutes on a treadmill to now
experiencing significant dyspnea climbing stairs or walking up a
[**Doctor Last Name **]. She underewent a cardiac catheterization in [**2112-10-2**]
which revealed recurrent left anterior descending artery disease
and mild right coronary artery disease. Given the progression of
her symptoms and her worsening aortic insufficiency, she has
been referred for surgical evaluation.
Past Medical History:
-history of paroxysmal SVT including paroxysmal atrial
fibrillation/flutter (27% of the time, up from 14% on recent
Holter)
-Coronary Artery Disease s/p prior LAD stenting [**6-2**]
-Hypertension
-Hyperlipidemia
-Hypothyroidism
-glaucoma s/p laser therapy
-Hx of Meniere's (not currently a problem)
-Breast CA [**2070**] s/p left radical mastectomy and chest radiation
with persistent left arm lymphedema and recurrent cellulitis in
left arm
-Tracheobronchomalacia (Mild) and Pulmonary nodules on right
(mild)
-moderate aortic stenosis and mitral regurgitation, moderate
pulmonary hypertension
-Anemia
-Hiatal hernia
-Glaucoma s/p laser therapy
-Susceptible to pneumonia
Past Surgical History:
-s/p dual chamber pacemaker for high degree AVB [**2104**], generator
change [**10-10**]
-s/p left radical mastectomy [**2070**] with radiation
-s/p thyroidectomy for benign thyroid nodule
-s/p bilateral cataract surgery
-s/p left eye [**Last Name (un) **] surgery
-s/p cataract surgery
Social History:
Lives in [**Location **] alone, goes to [**State 108**] in the winter.
-Tobacco history: Denies
-ETOH: Denies
-Illicit drugs: Denies
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Mother had
heart surgery in her 80's.
Physical Exam:
Pulse: 70 Resp: 16 O2 sat: 100%
B/P Right: 123/59 Left: - mastectomy side
Height: 5'5" Weight: 161 lbs
General: Well-devloped, well-nourished elderly female in no
acute
distress
Skin: Dry [X] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR, High picthed III/VI SEM radiating to left carotid
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema: Left arm lymph
edema noted. No peripheral edema of LE's.
Varicosities: some bilateral, GSV appeared suitable on previous
exam in [**Month (only) 956**].
Neuro: Grossly intact [X]
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Transmitted vs bruit bilaterally
Pertinent Results:
[**3-14**] Echo: PRE-BYPASS: The left atrium is moderately dilated.
Moderate to severe spontaneous echo contrast is seen in the body
of the left atrium. No spontaneous echo contrast is seen in the
body of the right atrium. A left-to-right shunt across the
interatrial septum is seen at rest. A small secundum atrial
septal defect is present. Left ventricular wall thicknesses and
cavity size are normal. Right ventricular chamber size and free
wall motion are normal. There are simple atheroma in the aortic
root. There are simple atheroma in the ascending aorta. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets are severely thickened/deformed. There is severe
aortic valve stenosis (valve area 0.8-1.0cm2). Moderate to
severe (3+) aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. There is moderate thickening
of the mitral valve chordae. There is severe thickening of the
mitral valve chordae. There is mild valvular mitral stenosis
(area 1.5-2.0cm2). Moderate (2+) mitral regurgitation is seen.
There is no pericardial effusion. POST CPB: 1. Preserved
[**Hospital1 **]-ventricular systolic function. 2. Bioprosthetic valve in
aortc position. Well seated, stable and has good leaflet
excursion. 3. No AI, Peak gradient = 18 mm Hg. 4. MR is now
trace to mild. 5. Intact aorta and no other change.
[**2113-3-19**] 05:25AM BLOOD WBC-6.7 RBC-3.13* Hgb-9.1* Hct-27.3*
MCV-87 MCH-29.1 MCHC-33.4 RDW-15.4 Plt Ct-243
[**2113-3-19**] 05:25AM BLOOD PT-19.2* PTT-28.7 INR(PT)-1.8*
[**2113-3-18**] 04:40AM BLOOD Plt Ct-187#
[**2113-3-19**] 05:25AM BLOOD Plt Ct-243
[**2113-3-18**] 04:40AM BLOOD PT-17.2* INR(PT)-1.5*
[**2113-3-18**] 04:40AM BLOOD Glucose-112* UreaN-15 Creat-0.7 Na-138
K-3.9 Cl-104 HCO3-27 AnGap-11
[**2113-3-18**] 04:40AM BLOOD WBC-7.7 RBC-3.16* Hgb-9.2* Hct-27.3*
MCV-87 MCH-29.1 MCHC-33.6 RDW-15.5 Plt Ct-187#
Brief Hospital Course:
Ms. [**Known lastname 50183**] was admitted to the [**Hospital1 18**] on [**2113-3-12**] for surgical
management of her cardiac disease. She was placed on heparin as
she had been off Coumadin in preparation for surgery. She was
worked-up in the usual preoperative manner. On [**2113-3-14**], she was
taken to the operating room where she underwent right axillary
artery cannulation with and aortic valve replacement and
coronary artery bypass grafting to one vessel. Please see
operative note for details. Postoperatively she was taken to the
intensive care unit for monitoring. Over the next 24 hours, she
awoke neurologically intact and was extubated. She was weaned
from all vasoactive medications. The EP service interrogated
her pacemaker without changing any settings. She was later
transferred to the step down unit for further recovery. She was
gently diuresed towards her preoperative weight. Chest tubes and
pacing wires were removed per cardiac surgery protocol. Coumadin
was resumed for her chronic atrial fibrillation and she is to
have an INR drawn on [**3-20**] with results called to the [**Hospital 197**]
Clinic. She was receiving her home dose of 3 mg po daily. The
physical therapy service worked with her daily to increase
strength and endurance. On post operative day 5 she was
tolerating a full oral diet, ambulating without difficulty and
her incisions were healing well. It was felt that she was safe
for discharge home with visiting nurse services at this time.
Medications on Admission:
Coumadin 4mg Fridays and 3mg all other days ([**Hospital 197**] clinic
with
Dr. [**Last Name (STitle) **]- LAST DOSE [**2113-3-9**]
Proair HFA 90mcg 1-2puffs every 4 hours prn
Cephalexin 2grams 1 hour prior to dental work and 1gram 6 hours
after.
Lasix 40mg daily
Synthroid 112mcg daily
Mastectomy bra
Metoprolol succinate 100mg daily
Ramipril 10mg daily
Zocor 40mg daily
Aspirin 81mg daily
Calcium 500 + D 500mg (1250mg)-200U twice daily
Systane eye drops
Fibercon 625mg daily
Discharge Medications:
1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 0.5 Tablet
PO BID (2 times a day).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
11. Ramipril 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*0*
12. Combivent 18-103 mcg/Actuation Aerosol Sig: 1-2 puffs
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
Disp:*1 1* Refills:*0*
13. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
Disp:*10 Tablet(s)* Refills:*0*
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*0*
15. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: Take
as directed daily for INR goal 2.0-2.5.
Disp:*30 Tablet(s)* Refills:*0*
16. Multivitamin with Iron-Mineral Tablet Sig: One (1)
Tablet PO once a day: Take at a separtate time from Synthroid.
Disp:*30 Tablet(s)* Refills:*1*
17. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed
for constipation.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary artery disease s/p coronary artery bypass graft x 1
Aortic insufficiency s/p aortic valve replacement
Past medical history:
-history of paroxysmal SVT including paroxysmal atrial
fibrillation/flutter (27% of the time, up from 14% on recent
Holter)
-Coronary Artery Disease s/p prior LAD stenting [**6-2**]
-Hypertension
-Hyperlipidemia
-Hypothyroidism
-glaucoma s/p laser therapy
-Hx of Meniere's (not currently a problem)
-Breast CA [**2070**] s/p left radical mastectomy and chest radiation
with persistent left arm lymphedema and recurrent cellulitis in
left arm
-Tracheobronchomalacia (Mild) and Pulmonary nodules on right
(mild)
-moderate aortic stenosis and mitral regurgitation, moderate
pulmonary hypertension
-Anemia
-Hiatal hernia
-Glaucoma s/p laser therapy
-Susceptible to pneumonia
Past Surgical History:
-s/p dual chamber pacemaker for high degree AVB [**2104**], generator
change [**10-10**]
-s/p left radical mastectomy [**2070**] with radiation
-s/p thyroidectomy for benign thyroid nodule
-s/p bilateral cataract surgery
-s/p left eye [**Last Name (un) **] surgery
-s/p cataract surgery
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**12-3**] weeks ([**Telephone/Fax (1) 1300**]
Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in [**12-3**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Coumadin management postop with Dr. [**Last Name (STitle) **]. Goal INR 2.0-2.5.
Please have blood drawn (INR) on [**2113-3-20**] with results called to
[**Hospital 197**] Clinic.
Completed by:[**2113-3-19**]
ICD9 Codes: 4241, 4168, 4019, 2724, 4240, 4280 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1495
} | Medical Text: Admission Date: [**2143-5-28**] Discharge Date: [**2143-6-5**]
Date of Birth: [**2071-2-1**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 1402**]
Chief Complaint:
"Cardiogenic Shock, CHF, Critical AS"
Major Surgical or Invasive Procedure:
Pulmonary Vein Isolation
Thrombin injection of the left femoral pseudoaneurysm
History of Present Illness:
Mr. [**Known lastname 37217**] [**Last Name (Titles) 1834**] pulmonary vein isolation on [**2143-4-11**] due
to
increasing burden of atrial fibrillation. Afib and left sided
atrial tachycardia were noted at the time of the study. During
the ablation, the patient went into heart block. External pacing
was without effect and he received CPR for several minutes
without any drop in BP or saturation during the episode. He also
reverted to atrial flutter with a SBP in the 80's during the
procedure and was externally cardioverted with 100 J with
reversion of sinus rhythm briefly. The procedure was terminated
prior to completion of the procedure for the above reasons. He
was transferred to the CCU over night for monitoring and
eventually was discharged to home with a KOH monitor after
uptitration of Amiodarone. After his discharge, he was
evaluated in the holding area on [**2143-4-15**] for mild CHF that was
felt to be due to his ablation and conversion to sinus rhythm.
He was treated with increasing doses of Lasix. His Amiodarone
dosing was also cut back. He was re-evaluated on [**2143-4-25**] for
complaints of left groin pain with bruising. Ultrasound revealed
a small hematoma but no vascular injury.
Mr. [**Known lastname 37217**] reports that for the past several weeks he has been
week his heart rate was noted to be in the 130's. He reports
that there has been quite a bit of manipulation of his beta
blocker dosing in the recent weeks, as he was bradycardic when
in sinus and tachycardic when in fib. He is now being referred
back for repeat PVI.
Of note, the patient apparently slipped on the stairs on
Saturday and hit both his face and his left leg. He reports that
his head was minimally injured and that he did not have any type
of hematoma. His leg on the other hand is bothering him quite a
bit with significant discomfort in the left lateral thigh. His
friend who is a doctor thinks that he most likely sprained the
quadricep. He has discomfort with walking but other wise is
doing all right.
.
He was taken to the OR to map fluter and re-isolate PV. He
receive 100 of Fentanyl, 100 of Rocuronium, 5 of Neostigmine,
150 mcg of Propofol, 3.4 mg of Phenylephrine and 79.16 mL of
Desflurane. He received 1200 cc of LR and put out 1600 cc urine.
He had a successful a-tach ablation. post-proc he was
hypotensive to 70's (dry and got a lot of lasix for high LAP).
In PACU, briefly on dopa/neo, then on 5 of Dopa with sBP 150 at
the time of sign out. A Stat echo: no effusion. Patient is
bradycardic at baseline.
.
In the CCU, he is still on Dopa and c/o back pain.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
(Patient denies this as per pre-procedure interview dated
[**2143-4-9**] but in old notes)
2. CARDIAC HISTORY:
- Paroxysmal atrial fibrillation, on Amiodarone, Coumadin and
Toprol s/p cardioversion x2 ([**2141-3-31**])
- Coronary Artery Disease
- PERCUTANEOUS CORONARY INTERVENTIONS: Initial stenting done in
[**2131**], clean cath in [**2139**], repeat cardiac catheterization in [**Month (only) **]
[**2141**] for chest discomfort in the setting of AFib, which
demonstrated mild in-stent restenosis to 30% in the LAD stent.
- PACING/ICD: None
- CABG: None
3. OTHER PAST MEDICAL HISTORY:
- GERD
- Left hernia repair, excision of inclusion cyst from chest wall
([**8-/2142**])
- Ptosis surgery
- Bilateral cataract surgery
Social History:
Married with 3 children and stays with wife. ADL independent.
Works as a lawyer.
- Tobacco history: Remote.
- ETOH: One drink 5x/week.
- Illicit drugs: None.
Family History:
Father (51), uncle (51) and grandfather (51) all had MIs at ages
provided. Sister with DM, valve disease and heart failure at age
50.
Otherwise, no family history of arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
CCU ADMISSION PHYSICAL EXAMINATION:
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
NEURO: PERRL, EOMI. Facial asymmetry on inspection with
decreased nasolabial fold and facial drooping on left.
NECK: Supple with JVP of 3 cm.
CARDIAC: PMI located in 6th intercostal space, 1cm lateral to
the midclavicular line, thrusting in nature. Regular rhythm,
normal S1, S2. No mrg. No thrills, lifts. No S3 or S4. No
midline sternotomy scar.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
was unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
DISCHARGE PHYSICAL EXAM
vitals: 97.8, HR 69-90, RR 16-18, BP 97-115/58-71
GEN: alert, oriented, NAD
HEENT: supple, no JVD
CV: irreg irreg rhythm. No M/R/G
RESP: CTAB post
ABD: soft, NT, ND, pos BS, pt is constipated
EXT: Left groin area and thigh diffusely swollen with mild
ecchymosis (resolving) and tenderness at the puncture site.
Right groin with puncture site but no swelling or hematoma. Feet
warm. pulses palp.
Skin: diffuse macular rash on back, thought [**1-2**] hospital sheets,
mildly itchy.
Pertinent Results:
Labs on admission:
[**2143-5-28**] GLUCOSE-184* UREA N-22* CREAT-0.9 SODIUM-134
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-25 ANION GAP-14
[**2143-5-28**] WBC-5.7 RBC-3.26* HGB-11.0* HCT-32.0* MCV-98 MCH-33.7*
MCHC-34.4 RDW-13.9
[**2143-5-28**] PLT COUNT-265#
[**2143-5-28**] PT-32.1* INR(PT)-3.2*
Labs on discharge:
[**2143-6-5**] WBC-7.3 RBC-2.65* Hgb-8.5* Hct-25.5* MCV-96 MCH-32.2*
MCHC-33.5 RDW-15.0 Plt Ct-445*
[**2143-6-5**] Glucose-183* UreaN-18 Creat-0.7 Na-133 K-4.5 Cl-98
HCO3-26 AnGap-14
[**2143-6-4**] Calcium-8.3* Phos-3.0 Mg-2.2
ECHO ([**5-28**]): The left atrium is moderately dilated. The left
ventricular cavity size is normal. Overall left ventricular
systolic function appears grossly preserved. Cannot exclude
inferolateral hypokinesis. 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 are mildly thickened. Trace aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. At least mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is a
trivial/physiologic pericardial effusion.
ECHO ([**5-30**]): Compared with the findings of the prior study
(images reviewed) of [**2143-5-28**], atrial fibrillation now
present; left ventricular ejection fraction somewhat reduced.
Renal ultrasound ([**5-29**]) - to evaluate cyst seen on prior MRI
([**5-24**])
Rim calcified benign-appearing right upper pole cyst. This
should be followed for expected stability by repeat US in one
year.
CT chest/abdomen/pelvis with contrast ([**5-30**])
1. Bilateral groin hematomas involving the obturator internus
muscles, larger on the left. Closely associated with the right
groin hematoma, is a 9-mm round focus of enhancement which may
represent a pseudoaneurysm, possibly involving a branch of the
superficial femoral artery. No definite active extravasation is
seen.
2. Asymmetric enlargement of the left lower extremity with loss
of normal fat planes could be due to fluid tracking into the
thigh musculature.
3. Hyperdense right renal lesion with amorphous calcifications
should be
further evaluated with ultrasound.
R. femoral ultrasound:([**5-30**])
1.3 x 0.7 cm pseudoaneurysm arising from the right deep femoral
artery.
Results were discussed in person with the patient's nurse [**First Name (Titles) 1023**] [**Last Name (Titles) **]d him to the ultrasound suite on [**2143-5-30**] at the time
of the examination.
(Please refer also to separately reported left groin ultrasound
performed on the same date as regards a concurrent left sided
pseudoaneurysm).
L. femoral ultrasound ([**5-30**])
1.4 x 2.3 cm pseudoaneurysm off a left common femoral artery
branch.
L. and R. femoral ultrasound ([**6-2**])
1. Persistent left-sided pseudoaneurysm arising from a branch of
the left
common femoral artery.
2. Right groin pseudoaneurysm could not be demonstrated, though
this could be partially technical.
pseudoaneurysm injection([**6-4**])
1. Successful treatment of a left inguinal pseudoaneurysm with
300 units of topical thrombin. Pseudoaneurysm appear to arise
from a small branch of the profunda femoral artery.
2. No evidence of a pseudoaneurysm or AV fistula involving the
right inguinal region.
Brief Hospital Course:
72 yo M with hx of Afib and complaints of fatigue s/p pulmonary
vein isolation ([**4-10**]) that was c/b transient CHB who
re-presented for left aflutter mapping and PVI that was c/b
hypotension requiring pressor support and bilateral hematomas
with L. femoral pseudoaneurysm requring thrombin injection.
.
ACTIVE ISSUES:
# Paroxysmal Atrial Fibrillation s/p Pulmonary vein isolation-
Paroxsymal atrial fibrillation throughout hospital stay.
Amiodarone was increased to 400 mg daily and Metoprolol
increased to 150 mg daily. Warfarin was held in the setting of
groin hematoma and drop in HCT. When HCT stabilized, pt was
continued on home coumadin 5 mg for anticoagulation. INR should
be checked on [**6-7**].
.
# Bilateral groin hematomas: The evening of procedure, bilateral
hematomas were present over groin site. Anticoagulation was
stopped. HCT was 22 and pt was transfused with PRBC. CT
chest/abd/pelvis showed evidence of bilateral hematomas with no
evidence of retroperitoneal bleed. Bilateral groin ultrasounds
were done which showed pseudoanerysm of L common femoral artery
branch and a small pseudoaneurysm off R. deep femoral artery.
Given that HCTs remained stable, he was restarted on his home
dose of Warfarin. On [**5-31**] patient complained of increased pain in
L. groin requiring morphine for pain control. Repeat ultrasound
and HCT showed no change. Vascular was consulted and recommended
pressure dressings and thrombin injection of L. pseudoaneurysm
which was completed on [**6-4**] without complication. Given anterior
thigh pain and difficulty with ambulation, PT determined that
acute rehab would be beneficial upon discharge.
.
# Hypotension: Patient was initially admitted with hypotension
which was likely multifactorial and related to hypovolemia and
anesthesia given in pulmonary vein thrombosis. Has baseline SBP
of 90's. Pt was given IV fluid boluses and dopamine for fluid
support. He was blood and urine cultures were sent to rule out
sepsis as cause of hypotenion in the setting of fever. Blood cx
negative, urine cx with 3000 gram positive cocci (likely
contaminant) and negative CXRs. The pt was successfully weaned
off the dopamine drip within 24 hours. His blood pressures
remained stable throughout admission.
.
# Coronary Artery Disease - Pt had one episode of chest pain on
[**5-30**]. No EKG changes were seen. Enzymes showed troponin 0.62, MB
3. Elevated troponin is related to recent pulmonary vein
isolation proceedure and not acute myocardial infarction.
Enzymes trended down. Patient was continued on ASA 81 daily,
Plavix 75 rousouvastatin, and nitro as needed for chest pain.
.
CHRONIC ISSUES:
.
# HTN: Pt was hypotensive upon admission to the CCU and home
antihypertensives were held. As pressures stabilized, he was
started on metoprolol and titrated up to dose of 150 mg daily.
.
# DM: Held pioglitazone, metformin and glucophage while
inpatient and blood sugars covered with humalog sliding scale.
PO medications were restarted at discharge.
.
# DYSLIPIDEMIA:
- Continued Rosuvastatin
.
# GERD:
- Continued Omeprazole
.
TRANSITIONAL ISSUES:
Pt has significant deconditioning that necessitates acute rehab.
His L groin pseudoaneurym is s/p thrombin injection. Will need
to follow serial exams. No restriction on activity. Pt will f/u
with vascular as an outpatient.
For his A fib, his INR should be checked on [**6-7**], along with CBC
and Chem 7. His metoprolol will need to be titrated to HR
70-80s.
Medications on Admission:
AMIODARONE - 200 mg Tablet qd
FUROSEMIDE - 40 mg Tablet qd
LISINOPRIL - 10 mg Tablet qHS
LORAZEPAM - 2 mg Tablet - Tablet(s) by mouth q hs
METFORMIN - 1,000 mg Tablet [**Hospital1 **]
METOPROLOL SUCCINATE - 25 mg qd
OMEPRAZOLE - 20 mg Capsule [**Hospital1 **]
PIOGLITAZONE [ACTOS] 30 mg Tablet
ROSUVASTATIN [CRESTOR] - 10 mg qam
SILDENAFIL [VIAGRA] - 50 mg prn
WARFARIN - 5 mg Tablet - 1-1.5 Tablet
ASPIRIN - 162 mg qpm
Discharge Medications:
1. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. lorazepam 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for anxiety/insomnia.
4. metformin 1,000 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. pioglitazone 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day: on
six days a week, then 7.5 mg on Wednesdays.
9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
10. Outpatient Lab Work
Please check INR, chem 7 and CBC on Friday [**2143-6-7**]
11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
12. senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day): hold for diarrhea.
13. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
TID (3 times a day) as needed for itching.
14. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO three
times a day.
15. oxycodone 5 mg Capsule Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
16. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO once a day.
17. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]
Discharge Diagnosis:
primary diagnoses:
Atrial fibrillation status post pulmonary vein isolation
hypotension
groin hematoma
femoral artery pseudoaneurysm
secondary diagnoses:
hypertension
type 2 diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 37217**],
It was a pleasure caring for you while you were in the hospital.
You were admitted after your pulmonary vein isolation procedure
because your blood pressures were low requiring medication
support. Your blood pressures improved. You also developed
bilateral hematomas (blood collections) in your groin. You had
ultrasounds showing pseudoaneurysms on the left and a thrombin
injection was done to fix this issue. Right now you are in
atrial fibrillation but we hope that you will convert to a
normal rhythm soon.
We have made the following changes to your medication regimen:
1. Increase the amiodarone to 400 mg daily
2. Increase the metoprolol to 150 mg daily
3. Increase aspirin to 325 mg daily
4. Start tylenol three times a day to treat your left leg pain
5. Start oxycodone as needed to treat left leg pain
6. Start Miralax, senna and dulcolax as needed to treat
constipation
Followup Instructions:
Departent: Cardiology
When: Wednesday [**6-12**] at 10:30am with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP[**MD Number(3) **]: [**Hospital Ward Name 23**] 7, Clnical Center, [**Hospital Ward Name 516**]
.
Department: VASCULAR SURGERY
When: TUESDAY [**2143-6-18**] at 1:30 PM
With: VASCULAR LAB [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: VASCULAR SURGERY
When: TUESDAY [**2143-6-18**] at 2:30 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2143-6-6**]
ICD9 Codes: 4254, 4019, 2724, 2859 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1496
} | Medical Text: Admission Date: [**2156-9-15**] Discharge Date: [**2156-9-25**]
Date of Birth: [**2091-11-24**] Sex: M
Service: CARDTHOR SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 64 year old
white male with a history of hypertension, hyperlipidemia,
chronic obstructive pulmonary disease and diabetes mellitus
who presented to an outside hospital on the day prior to
admission with chest pain and EKG changes. He reportedly had
chest pain on and off for the previous two weeks. He
recently underwent a stress echocardiogram without ischemic
changes, but which showed aortic stenosis. His pain
increased one to two days prior to admission with associated
gastrointestinal symptoms. In the Emergency Room at the
outside hospital, his EKG showed 1 to [**Street Address(2) 2915**]
depressions in leads I and V2 through V6, AVL and ST
elevations in leads III and AVF. His troponin on admission
to that hospital was 0.3 with a CK of 98.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Asthma.
3. Chronic obstructive pulmonary disease.
4. Diabetes mellitus type 2.
5. Elevated cholesterol.
6. Rosacea.
7. Status post a left carotid endarterectomy in [**2155-11-19**].
8. Colitis.
9. Diverticulitis.
10. Positive for transient ischemic attack with no residual.
11. Question of nonsustaining ventricular tachycardia on
Holter Monitor.
SOCIAL HISTORY: He is a retired fire fighter. He lives
with his wife. [**Name (NI) **] is a remote smoker, having smoked with a
40 pack year history.
ALLERGIES: He has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Serevent two puffs twice a day.
2. Pulmicort three puffs twice a day.
3. Norvasc 5 mg q. day.
4. Enteric-coated aspirin 325 mg q. day.
5. Asacol 800 mg three times a day.
6. Zantac 150 mg twice a day.
7. Lipitor 10 mg twice a day.
8. Folate 1 mg q. day.
9. Minocycline 50 mg twice a day.
REVIEW OF SYSTEMS: His review of systems shows he has
positive weight loss which was intended; he had been dieting.
He has no palpitations, no syncope. He states that he has
easy bleeding. He currently has an upper respiratory
infection which is resolving. His dental situation is that
he had seen his dentist over the summer; he has broken teeth
on the right but no treatment was undertaken. He has basal
cell carcinoma of his legs, arm and head that have been
resected. Positive osteoarthritis; positive dyspnea on
exertion from his chronic obstructive pulmonary disease. He
does have a history of rectal bleeding, of hemorrhoids.
PHYSICAL EXAMINATION: His physical examination shows his
heart rate to be 58 and in sinus rhythm; blood pressure
154/77; respiratory rate is 14 with an O2 saturation of 99%
on three liters of nasal cannula. He is in general a
pleasant male who is awake and alert and lying on the
stretcher in no apparent distress. His lungs have an
increased A/P diameter. His breath sounds are clear but
diminished bilaterally; there is no wheezing or rhonchi. His
heart is regular rate and rhythm without rub. There is a
positive III/VI harsh systolic murmur. His abdomen is
positive bowel sounds, soft, nontender, nondistended. Liver
is palpable to 2 centimeters below the costal margin. There
are no masses and no splenomegaly, no bruit. Extremities:
Show bilateral lower extremity edema with stasis changes,
left anterior shin dark. He has no edema and no evidence of
varicosities. He has no clubbing or cyanosis. The skin
examination shows multiple well healed surgical scars. His
neurological examination shows strength to be equal on
bilateral upper and lower extremities. His pulse examination
shows his carotids to be without bruit on the right and with
a bruit on the left. His radial artery pulses are two plus
bilaterally; femoral arteries are two plus bilaterally;
popliteal pulses are one plus bilaterally and dorsalis pedis
and posterior tibialis are two plus bilaterally.
LABORATORY: White blood cell count of 8.4, hematocrit of
36.6, platelet count 228,000. Sodium 137, potassium 3.8,
chloride 104, carbon dioxide 27, BUN 17, creatinine 0.8 and a
blood glucose of 113. His liver enzymes were all within
normal limits.
HOSPITAL COURSE: On [**2156-9-16**], the patient underwent
a cardiac catheterization which showed an ejection fraction
of 60%; no mitral regurgitation. His left main coronary
artery was short with moderate calcifications; left anterior
descending artery has proximal moderate calcifications with a
70% tubular lesion at the ostium. The first diagonal has a
90% lesion at the origin; left circumflex has a 70% lesion at
the origin and 90% lesion at the bifurcation of the obtuse
marginal 1. The distal left patent ductus arteriosus with
competitive flow. His right coronary artery is co-dominant
with an 80% lesion at the origin.
A consultation was then put in to Cardiac Surgery for a
possible coronary artery bypass graft and a question of an
aortic valve replacement.
On [**2156-9-17**], the patient underwent coronary artery
bypass graft times four with left internal mammary artery to
left anterior descending artery; saphenous vein graft to left
patent ductus arteriosus; saphenous vein graft to the right
patent ductus arteriosus and a saphenous vein graft to the
obtuse marginal. He also had an aortic valve replacement
with a #23 millimeter pericardial DE valve.
This surgery was performed under general endotracheal
anesthesia with cardiopulmonary bypass time of 174 minutes
and a cross clamp time of 140 minutes. The surgery was
performed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 54443**] and [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **], PA-C and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], N.P. as assistants.
The patient tolerated the procedure well and was transferred
to the Surgical Cardiac Recovery Unit with atrial pacing
wires, two ventricular pacing wires, two mediastinal and one
left pleural chest tube. He was on a Neo-Synephrine drip and
a Propofol drip and paced at 74 beats per minute.
Intraoperatively, the patient had been coagulopathic and had
received 4 units of packed red blood cells and 6 units of
fresh frozen plasma, two units of platelets and protamine.
When he arrived in the Intensive Care Unit, he did receive
more fresh frozen plasma to help control bleeding.
By the morning of postoperative day number one, he was awake,
but agitated. His ventilator was weaned to extubate. He was
extubated on postoperative day number one, but throughout the
day continued to have increasing secretions and was
re-intubated. He subsequently underwent bronchoscopy at the
bedside on postoperative day number two, where it was noted
that he had thick secretions in both the right and left main
stem bronchi. He was then kept intubated for the following
couple of days, again bronched for copious secretions.
On postoperative day number four, he was extubated without
incident. During this time that he was intubated, his chest
tubes were discontinued without incident. On postoperative
day number five, he remained in the unit and had intermittent
periods of confusion and delirium. He did remain this way
until the following day, but he was thought to be ready for
discharge to the floor.
He was transferred to the Surgical Floor on postoperative day
number six, and continued to be pleasantly confused. He did
have a Code Purple called on postoperative day number six in
the evening as the patient attempted to leave the floor. He
was then started on Haldol and was more cooperative by the
morning. Throughout this time, he continued to work with
Physical Therapy and by postoperative day number seven, they
felt that he could be cleared for discharge to home.
By postoperative day number seven, his confusion was present
at times and he still does have hallucinations but he has
been stable and it is felt that he will be ready to be
discharged to home on postoperative day number eight.
PHYSICAL EXAMINATION: His discharge examination shows his
vital signs to be stable with a heart rate of 71, blood
pressure of 138/71; respiratory rate 20; O2 saturation of 99%
on room air. His lungs were clear to auscultation
bilaterally. His heart was regular rate and rhythm. He has
positive bowel sounds, soft, nontender, nondistended. His
extremities show one plus pitting edema bilaterally. His
incision was clean, dry and intact; sternum is stable.
LABORATORY: On discharge is white blood cell count of 7.3,
hematocrit of 26.7, platelet count of 346,000. Sodium of
139, potassium 3.8, chloride 103, carbon dioxide 26, BUN 29,
creatinine 1.1 and blood glucose of 81.
DISCHARGE MEDICATIONS:
1. Lipitor 10 mg p.o. q. day.
2. Protonix 40 mg p.o. q. day.
3. Lopressor 25 mg p.o. twice a day.
4. Lasix 40 mg p.o. twice a day.
5. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. twice a day.
6. Enteric-coated aspirin 325 mg p.o. q. day.
7. Albuterol MDI two puffs q. four hours p.r.n.
8. Advair two puffs twice a day.
9. Asacol 800 mg p.o. three times a day.
10. Minocycline 50 mg p.o. twice a day.
DISCHARGE INSTRUCTIONS:
1. He is to follow-up with Dr. [**First Name (STitle) **] in one to two weeks.
2. He is to follow-up with Dr. [**First Name (STitle) **] in two to four weeks.
3. He is to follow-up with Dr. [**Last Name (STitle) 70**] in six weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], P.A.-C.
MEDQUIST36
D: [**2156-9-24**] 16:37
T: [**2156-9-24**] 17:44
JOB#: [**Job Number 54444**]
ICD9 Codes: 4241, 496, 4111, 4019, 2724 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1497
} | Medical Text: Admission Date: [**2166-11-8**] Discharge Date: [**2166-11-12**]
Date of Birth: [**2091-11-12**] Sex: F
Service: MEDICINE
Allergies:
Keflex / Augmentin / Amoxicillin
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is a 74 yo F with PMH of DM, COPD, and hx of foot osteo s/p
multiple debridements and surgeries admitted with respiratory
distress. The pt was found at home today in bed in respiratory
distress by her family. EMS was called and she was found to have
a O2 sat 60% and appeared to be cyanotic. She was given sl NTG
and nebulizer and started on Bipap in the field. On arrival to
[**Hospital1 18**] ED Vitals T 102.2 HR 114 BP 156/60 RR 24 100% 40 FIO2. ECG
with sinus tachycardia. CXR negative for evidence of PNA. She
was started on Vancomycin and Levofloxacin for fever and was
given solu-medrol 125 X1.
.
On arrival to the MICU, the patient was in no acute distress.
Answering questions appropriately. She denies shortness of
breath or chest pain. She was alert and oriented to place and
time. Her family reports that she has increased her tobacco
usage over the past week secondary to R hip pain. She was found
by her husband and daughter to be gagging, with minimal
respiratory effort and appeared to have a blue-tinged color.
Past Medical History:
COPD/Asthma
Hypertension
Diabetes Type II
Peripheral neuropathy
History of MRSA osteomyelitis right foot
MRSA bacteremia [**6-18**]
.
[**Doctor First Name **]: Bilateral cataracts, debridement of right foot
osteomyelitis x3
Social History:
Lives with husband, smokes 2 ppd x 50 years, has recently been
under stress and admits to increasing her smoking to 3 ppd. Occ
ETOH, lives in [**Location 686**].
Family History:
Noncontributory.
Physical Exam:
ADMISSION EXAM:
VS: T:98.7 R:18 Sat:95% on Bipap 10/8 BP:162/59 HR:89
GEN: NAD, well nourished
HEENT: PERRLA, NCAT
Neck: no LAD
CV: s1/s2 no murmur, pulses present
PULM: wheezes and rhonchi throughout
ABD: soft NTND BS +
EXT: no edema, TTP of R hip bursal sac, no pain on ROM
Pertinent Results:
ADMISSION LABS:
.
BLOOD:
[**2166-11-8**] 04:07PM GLUCOSE-284* UREA N-30* CREAT-1.3* SODIUM-136
POTASSIUM-4.7 CHLORIDE-97 TOTAL CO2-29 ANION GAP-15
[**2166-11-8**] 04:07PM CALCIUM-9.0 PHOSPHATE-4.2 MAGNESIUM-1.7
[**2166-11-8**] 04:07PM WBC-12.9* RBC-4.91 HGB-15.1 HCT-44.7 MCV-91
MCH-30.7 MCHC-33.8 RDW-13.5
[**2166-11-8**] 04:07PM PLT COUNT-219
[**2166-11-8**] 01:11PM cTropnT-0.03*
[**2166-11-8**] 01:11PM CK-MB-9
[**2166-11-8**] 01:11PM CK(CPK)-120
.
URINE:
[**2166-11-8**] 01:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2166-11-8**] 01:30PM URINE RBC-[**4-16**]* WBC-[**7-22**]* BACTERIA-MANY
YEAST-NONE EPI-0
.
.
DISCHARGE LABS:
CBC:13.3/15.5/45.1/287
Chem 7: 142/3.7/102/30/54/1.2/123
IMAGING:
PROCEDURE: CTA chest with and without contrast on [**2166-11-10**].
.
COMPARISON: [**2165-6-3**].
.
TECHNIQUE: Pre- and post-contrast examination of the thorax with
contiguous
axial images from the thoracic inlet to the subdiaphragmatic
area, coupled
with sagittal/oblique and coronal reformatted images.
.
HISTORY: 74-year-old woman with hypoxemia and tachycardia,
please evaluate
for PE.
.
FINDINGS:
.
The pulmonary arteries are well visualized up to the first
segmental level
showing no PE. Beyond that the opacification is faint and so no
peripheral PE can be excluded. The aorta is unremarkable in
size, showing no evidence of dissection or aneurysmal
dilatation.
.
Stable coronary calcifications are again seen. The heart size is
within
normal limits. Mitral annular valve calcification is stable.
There is no pleural or pericardial effusion.
.
The lungs have relatively cleared as previously there was
diffuse tree-in-[**Male First Name (un) 239**] nodularity, indicative of an infectious
process. However, there are persistent prominent lymph nodes in
the mediastinum and hilar areas stable to slightly increased in
size on today's examination. For example, the subcarinal lymph
node which is 9.3 mm is stable in size while the 5.4-mm left
prevascular lymph node was previously 4.6 mm in size.
.
Mitral annular valve calcification is stable.
.
New minimal bibasilar atelectasis is seen in both lung fields.
.
The bony structures do not show any lesion suspicious for
malignancy, however, there are significant disc osteophyte
complexes seen at multiple thoracic vertebral body levels better
appreciated in the sagittal reformatted images.
.
In the abdomen, stable subcentimeter right adrenal adenoma is
noted. No other abnormalities are seen.
.
IMPRESSION:
1. Negative examination for PE in the major and first segmental
branches.
2. Almost complete resolution of the infectious process seen in
both lungs.
3. Persistent but slightly increased bilateral lymphadenopathy.
4. Stable pulmonary artery calcifications.
5. Stable right adrenal adenoma.
.
.
CHEST XRAY [**2166-11-9**]:
HISTORY: 74-year-old female with shortness of breath.
.
COMPARISON: None available.
.
PORTABLE UPRIGHT CHEST RADIOGRAPH: The heart size is normal and
the aortic
contour mildly unfolded. The lungs are well expanded, and note
is made of
patchy infiltrate in the left lung base. No evidence of
pneumothorax or large pleural effusion is seen. Degenerative
changes are noted along the visualized thoracic spine.
.
IMPRESSION: Patchy infiltrate in the left lung base could be
consistent with pneumonia.
Brief Hospital Course:
Pt is a 74 yo F with PMH of DM, COPD, and hx of foot osteo
admitted with respiratory distress, found to have UTI and
question of lingular PNA. Initially managed in MICU with
non-invasive ventilation support, steroids, and antitbiotics and
transferred to the floor once no longer requiring ventilation
support. On floor patient was continued on po steroids and
antibiotics for UTI and concern for lingular PNA. Patient
continued to require oxygen therapy and was discharged to rehab
in stable condition with O2, steroid taper and antibiotics.
Patient was also counseled for smoking cessation.
.
RESPIRATORY FAILURE:
Pt found by EMS with 02 sat 60% at home, improved with
initiation of CPAP. Patient initially managed in MICU and then
on floor with po steroids and antibiotics. She continued to
require oxygen, which was a change from her home status so there
was a concern for PE. CTA was done and showed no central PE.
Her lung exam improved as did her symptoms however she continued
to need oxygen and it was determiend she needed home O2 and was
discharge on it.
.
FEVER:
Febrile on initial presentation with a negative workup. No
clear infiltrate on CXR though concern for lingular PNA and was
treated with 7 day course of po levofloxacin.
.
UTI:
Found on screening UA, pan-sensitive E. coli, treated with 7 day
course of levofloxacin.
.
DIABETES:
Continue home regimen of 70/30 28U QAM and 32 U QPM.
Fingersticks elevated with start of steroids, managed with SSI.
.
RIGHT HIP PAIN:
On admission, pt with point tenderness over R hip bursa on
exam, no pain on ROM of hip. Managed with home dose of Ultram.
.
PERIPHERAL NEUROPATHY:
Continued home gabapentin.
.
CODE STATUS:
FULL per patient.
Medications on Admission:
ALBUTEROL - 90 mcg Aerosol PRN
CITALOPRAM - 10 mg Tablet - daily
FEXOFENADINE - 60mg daily
FLUTICASONE-SALMETEROL 250 mcg-50 mcg/Dose daily
GABAPENTIN - 300 mg Capsule QHS
HYDROCHLOROTHIAZIDE - 12.5 mg daily
METOPROLOL SUCCINATE [TOPROL XL] - 100 mg Tablet daily
SIMVASTATIN - 40 mg Tablet QHS
ASPIRIN - 81 mg Tablet daily
Ultram
INSULIN NPH & REGULAR HUMAN [HUMULIN 70/30] - 100 unit/mL
(70-30) Suspension - 28 units QAM, 32 units QPM twice a day
Discharge Medications:
1. Ipratropium Bromide 0.02 % Solution Sig: Two (2) puffs
Inhalation Q6H (every 6 hours).
2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs
Inhalation every four (4) hours: can do nebs instead if needed.
3. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day: hold for sbp < 100.
9. Calcium 500 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: 1.5
Tablet Sustained Release 24 hrs PO once a day: hold for sbp < 95
or HR < 55.
11. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO every
other day for 1 doses: last dose due [**2166-11-14**].
12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day:
hold for sbp < 100.
13. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
14. Ultram 50 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day): stop when patient is ambulatory.
16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
17. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
18. Prednisone 10 mg Tablet Sig: variable Tablet PO once a day:
see instructions and calendar.
19. insulin
insulin 70/30, 28 units every morning and 32 units every evening
with dinner plus attached sliding scale
20. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) patch
Transdermal every twenty-four(24) hours.
21. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO twice a day as
needed for constipation.
22. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2732**] & Retirement Home - [**Location (un) 55**]
Discharge Diagnosis:
Primary: Chronic Obstructive Pulmonary Disease, acute
exacerbation
Secondary:
Asthma
Hypertension
Diabetes, type 2
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted to the hospital for respiratory distress and
low oxygen. Upon admission, you first went to the Medical
Intensive Care Unit where antibiotics and steroids were started.
Once stabilzed, you were transferred to the medical floor. A
CT Angiogram was performed and showed no evidence of pulmonary
embolism. A urinalysis showed a urinary tract infection which
will be covered with your current antibiotic. Physical therapy
was consulted for support and logistics regarding outpatient
disposition.
.
Please continue taking the antibiotic as prescribed.
.
Follow-up with Dr. [**Last Name (STitle) 6680**] as outpatient for COPD/Asthma.
.
Resume your home medication regimen, but please note the
following important changes:
* METOPROLOL (TOPROL XL) increased to 150 mg daily.
* AMLODIPINE started due to high blood pressure.
* HCTZ increased due to high blood pressure.
* Started PREDNISONE taper per attached calendar for COPD flare.
Briefly,
Prednisone 50 mg daily for 2 days, 40 mg daily for 2 days, 30
mg daily for 2 days, 20 mg daily for 2 days, 10 mg daily for 2
days, then stop.
* Start CALCIUM and VITAMIN D for protection of the bones.
* You will need one more dose of LEVOFLOXACIN (which you will
get on Friday) for treatment of pneumonia and urinary tract
infection.
.
Please contact your doctor or return to the Emergency Department
if you develop fevers (>101.5), shaking chills, difficulty
breathing, shortness of breath, or pain on urination.
.
PLEASE STOP SMOKING, as we have discussed. This is the most
important thing you can do for your overall health!
Followup Instructions:
Please follow-up with your primary care physican, Dr. [**Last Name (STitle) 6680**],
on Friday, [**11-28**] at 11:10am.
Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2167-2-17**] 1:00
Provider: [**Name10 (NameIs) 6800**] CLINIC Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2167-2-17**]
1:00
ICD9 Codes: 5990, 4019 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1498
} | Medical Text: Admission Date: [**2133-1-19**] Discharge Date: [**2133-1-25**]
Date of Birth: [**2057-8-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / Bactrim
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
chest/back heaviness-
Major Surgical or Invasive Procedure:
[**2133-1-20**]
1.Coronary artery bypass graft x 3 Left internal mammary artery
grafted to left anterior descending artery, Saphenous vein
grafted to Obtuse Marginal, Saphenous vein grafted to posterior
descending artery.
2.Primary sternal repair using Synthes plating
system times 5.
History of Present Illness:
75F who has c/o chest/back heaviness times several months.
Persantine Stress Test was abnormal and she was referred for
cardiac catheterization. This revealed two vessel coronary
artery disease. Admitted pre-operatively for heparin drip
before high risk CABG.
Past Medical History:
coronary artery disease s/p coronary bypass grafting
Secondary:
Chronic atrial fibrillation on Coumadin, diagnosed [**2123**]
stable primary biliary cirrhosis
Type II diabetes
Hypothyroidism
Polymyalgia rheumatica diagnosed [**3-31**], On Prednisone
Hypercholesterolemia
Osteoarthritis
Vulvar cancer [**2129**] s/p vulvectomy at [**Hospital1 2025**] (no chemo or radiation)
Urinary incontinence s/p vulvectomy
nephrolithiasis
chronic lower extremity edema r/t lymphedema
urosepsis
arthritis left knee- needs replacement
Past Surgical History:
right hip replacement [**2130**]
right knee replacement [**2130**]
Back surgery x 4
Appendectomy
Tonsillectomy
Social History:
Race: Caucasian
Last Dental Exam: edentulous
Lives with: husband
Occupation: retired director of nursing at [**Hospital1 18**]
Tobacco: quit 35yrs ago
ETOH: 1 drink/day
Family History:
sister died last year at age 71. S/P CABG at age 39, repeat age
49, peripheral bypass.
Father had an MI at age 50, died at age 76 from ruptured AAA
Physical Exam:
Pulse: 69 a-fib Resp: 16 O2 sat:
B/P Right: 130/54 Left:
Height: 5'[**31**]" Weight: 310lb
General: NAD, obese female
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x] pupils fixed (bilat. cataracts)
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x- chronic afib] Murmur
Abdomen: Obese, Soft [x] non-distended [x] non-tender [x] bowel
sounds + [x]
Extremities: Warm [x], well-perfused [x]
Edema: 2+ pitting edema
Varicosities: moderate varicosities and spider veins
Neuro: Grossly intact x
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: doppler Left: doppler
PT [**Name (NI) 167**]: doppler Left: doppler
Radial Right: 2+ Left: 2+
Carotid Bruit NO bruits
Pertinent Results:
Pre-op labs
[**2133-1-19**] 07:16PM PT-14.3* PTT-23.1 INR(PT)-1.2*
[**2133-1-19**] 07:16PM PLT COUNT-184
[**2133-1-19**] 07:16PM WBC-7.7 RBC-3.82* HGB-11.2* HCT-34.1* MCV-89
MCH-29.5 MCHC-33.0 RDW-14.3
[**2133-1-19**] 07:16PM %HbA1c-6.9* eAG-151*
[**2133-1-19**] 07:16PM ALBUMIN-3.8 MAGNESIUM-2.0
[**2133-1-19**] 07:16PM LIPASE-25
[**2133-1-19**] 07:16PM ALT(SGPT)-11 AST(SGOT)-17 LD(LDH)-199 ALK
PHOS-103 AMYLASE-50 TOT BILI-0.3
[**2133-1-19**] 07:16PM GLUCOSE-253* UREA N-26* CREAT-1.1 SODIUM-139
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-27 ANION GAP-13
[**2133-1-19**] 09:54PM URINE RBC-1 WBC-63* BACTERIA-FEW YEAST-NONE
EPI-5
[**2133-1-19**] 09:54PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-150 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2133-1-19**] 09:54PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.014
Discharge labs:
[**2133-1-23**] 04:22AM BLOOD WBC-7.3 RBC-3.03* Hgb-9.2* Hct-27.3*
MCV-90 MCH-30.5 MCHC-33.8 RDW-15.5 Plt Ct-107*
[**2133-1-23**] 04:22AM BLOOD Plt Ct-107*
[**2133-1-23**] 04:22AM BLOOD PT-14.3* INR(PT)-1.2*
[**2133-1-23**] 04:22AM BLOOD Glucose-167* UreaN-31* Creat-1.7* Na-139
K-4.8 Cl-104 HCO3-28 AnGap-12
[**2133-1-23**] 04:22AM BLOOD Mg-2.3
[**2133-1-22**] 01:59AM BLOOD WBC-11.9* RBC-2.82* Hgb-8.6* Hct-24.9*
MCV-88 MCH-30.7 MCHC-34.7 RDW-15.3 Plt Ct-105*
[**2133-1-23**] 04:22AM BLOOD WBC-7.3 RBC-3.03* Hgb-9.2* Hct-27.3*
MCV-90 MCH-30.5 MCHC-33.8 RDW-15.5 Plt Ct-107*
[**2133-1-24**] 05:45AM BLOOD WBC-6.3 RBC-2.91* Hgb-8.8* Hct-26.4*
MCV-91 MCH-30.3 MCHC-33.4 RDW-15.2 Plt Ct-129*
[**2133-1-25**] 06:07AM BLOOD Hct-26.5*
[**2133-1-24**] 05:45AM BLOOD PT-15.6* INR(PT)-1.4*
[**2133-1-24**] 05:45AM BLOOD Plt Ct-129*
[**2133-1-25**] 06:07AM BLOOD PT-15.3* INR(PT)-1.3*
[**2133-1-23**] 04:22AM BLOOD Glucose-167* UreaN-31* Creat-1.7* Na-139
K-4.8 Cl-104 HCO3-28 AnGap-12
[**2133-1-24**] 05:45AM BLOOD Glucose-156* UreaN-32* Creat-1.4* Na-140
K-3.6 Cl-102 HCO3-32 AnGap-10
[**2133-1-25**] 06:07AM BLOOD Glucose-140* UreaN-30* Creat-1.3* Na-137
K-4.1 Cl-97 HCO3-34* AnGap-10
Radiology Report CHEST (PORTABLE AP) Study Date of [**2133-1-22**] 8:46
AM
Final Report: In comparison with study of [**1-21**], the left chest
tube has been removed and there is no pneumothorax. Right
central catheter has been
exchanged for a sheath in the internal jugular vein. Remainder
of the
examination is unchanged.
[**2133-1-20**] Carotid US
On the right systolic/end diastolic velocities of the ICA
proximal, mid and distal respectively are 52/22, 68/22, 91/28, ,
cm/sec. CCA peak systolic velocity is cm/sec. ECA peak systolic
velocity is 67 cm/sec. The ICA/CCA ratio is 1.9. These findings
are consistent with <40% stenosis.
-On the left systolic/end diastolic velocities of the ICA
proximal, mid and distal respectively are 65/20, 71/30, 64/26,
cm/sec. CCA peak systolic
velocity is 53 cm/sec. ECA peak systolic velocity is 73 cm/sec.
The ICA/CCA ratio is 1.3. These findings are consistent with
<40% stenosis.
-There is antegrade right vertebral artery flow.
There is antegrade left vertebral artery flow.
-Impression: Right ICA stenosis <40%. Left ICA stenosis <40%.
Blunted RCCA waveform may indicate more proximal CCA or
innominate stenosis.
[**2133-1-20**] Vein Mapping
RIGHT: The right greater saphenous is patent throughout its
length with
diameters in the lower leg ranging from 3.6-4.2 mm. The thigh
diameters range from 3.6-6.3 mm.
LEFT: The left greater saphenous is patent throughout with lower
leg
diameters ranging from 3.7-5.2 mm and thigh diameters ranging
from 3.9-6.1 mm.
All veins are thin-walled and compressible.
IMPRESSION: Patent bilateral greater saphenous vein with good
quality and
appropriate diameters for conduit.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.9 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 60% >= 55%
Aorta - Sinus Level: *3.8 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.6 cm <= 3.0 cm
Aorta - Ascending: *3.9 cm <= 3.4 cm
Aorta - Arch: 2.9 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.2 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.3 m/sec <= 2.0 m/sec
Aortic Valve - LVOT diam: 1.8 cm
Findings
Multiplanar reconstructions were generated and confirmed on an
independent workstation.
LEFT ATRIUM: Mild spontaneous echo contrast in the body of the
LA. Mild spontaneous echo contrast in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No spontaneous echo contrast in
the body of the RA. Normal interatrial septum. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%).
RIGHT VENTRICLE: Mildly dilated RV cavity. Normal RV systolic
function.
AORTA: Mildy dilated aortic root. Mildly dilated ascending
aorta. Normal aortic arch diameter. Normal descending aorta
diameter. Focal calcifications in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3).
Filamentous strands on the aortic leaflets c/with Lambl's
excresences (normal variant). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The rhythm appears
to be atrial fibrillation. Results were personally reviewed with
the MD caring for the patient.
Conclusions
Prebypass
Mild spontaneous echo contrast is seen in the body of the left
atrium. Mild spontaneous echo contrast is present in the left
atrial appendage. No spontaneous echo contrast is seen in the
body of the right atrium. 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 normal free
wall contractility. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened. There are filamentous
strands on the aortic leaflets consistent with Lambl's
excresences (normal variant). No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
Postbypass
The patient is A-paced on a phenylephrine infusion. Left
ventricular function continues to be normal (LVEF >60%),
although it is underfilled. Mitral regurgitation is now trace
and there is still no aortic regurgitation. The thoracic aorta
is intact post decannulation.
Brief Hospital Course:
Ms [**Known firstname **] was admitted for surgical management of coronary artery
disease. Pre operatively she had a routine workup that included
Heparinization as a bridge for anticoagulation. She also had
carotid ultrasound and vein mapping. On [**2133-1-20**] she was brought
to the operating for for coronary bypass grafting, please see
the operative report for details. In summary she had:
1.Coronary artery bypass graft x 3 Left internal mammary artery
grafted to left anterior descending artery, Saphenous vein
grafted to Obtuse Marginal, Saphenous vein grafted to posterior
descending artery.
2.Primary sternal repair using Synthes plating system times 5.
Her bypass time was 53 minutes with a crossclamp of 42 minutes.
she tolerated the procedure well and was transferred to the
cardiac surgery ICU in stable condition.
She woke from anesthesia neurologically intact and was
extubated. she remained in the ICU on Neosynephrine to support
her hemodynamically, this was weaned to off over the first 24
hours. On POD2 she was transferred from the CVICU to the
stepdown floor for continued post-operative recovery. The
remainder of her post-operative course was generally uneventful.
All tubes lines and drains were removed per cardiac surgery
protocol. Once on the floor she continued to make slow progress
in advancing her activities of daily living, she remained
hemodynamically stable throughout this period. She had atrial
fibrillation and therefore her Coumadin was resumed.
On POD5 she was transferred to rehabilitation at
[**Hospital1 **]-[**Location (un) 86**] in stable condition.
Medications on Admission:
Medications at home:
Medications - Prescription
ESTRADIOL [ESTRING] - (Prescribed by Other Provider) - Dosage
uncertain
FUROSEMIDE [LASIX] - (Prescribed by Other Provider) - 20 mg
Tablet - 1 Tablet(s) by mouth daily
GABAPENTIN - (Prescribed by Other Provider) - 300 mg Capsule -
1
Capsule(s) by mouth twice a day
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) -
100
unit/mL Cartridge - 24 units HS
LEVOTHYROXINE - (Prescribed by Other Provider) - 137 mcg Tablet
- 1 Tablet(s) by mouth daily
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 50 mg
Tablet - 1 Tablet(s) by mouth twice daily
OXYBUTYNIN CHLORIDE - (Prescribed by Other Provider) - 5 mg
Tablet Extended Rel 24 hr - 2 Tablet(s) by mouth twice a day
PRAVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1
Tablet(s) by mouth at hs
PREDNISONE - (Prescribed by Other Provider; Dose adjustment -
no
new Rx) - 1 mg Tablet - 6 Tablet(s) by mouth once a day
TRAMADOL - (Prescribed by Other Provider) - 50 mg Tablet - [**11-23**]
Tablet(s) by mouth prn
TRIMETHOPRIM - (Prescribed by Other Provider) - 100 mg Tablet -
1 Tablet(s) by mouth daily
URSODIOL [ACTIGALL] - (Dose adjustment - no new Rx) - 300 mg
Capsule - 3 Capsule(s) by mouth twice a day
WARFARIN [COUMADIN] - (Prescribed by Other Provider) - 4 mg
Tablet - 1 Tablet(s) by mouth daily Resume on Friday [**2132-12-26**] and
INR on Tuesday [**2132-12-30**] per usual
Medications - OTC
CYANOCOBALAMIN (VITAMIN B-12) [VITAMIN B-12] - (Prescribed by
Other Provider) - Dosage uncertain
Discharge Medications:
1. metoprolol tartrate 25 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. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever or pain.
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
8. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
9. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. cyanocobalamin (vitamin B-12) 50 mcg Tablet Sig: One (1)
Tablet PO once a day.
11. trimethoprim 100 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
12. vitamin A 10,000 unit Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
13. oxybutynin chloride 5 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
14. prednisone 1 mg Tablet Sig: Six (6) mg PO DAILY (Daily).
15. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
16. ursodiol 300 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
17. levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO once a
day.
18. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
19. warfarin 1 mg Tablet Sig: as directed to keep INR 2-2.5
Tablets PO Once Daily at 4 PM: Target INR 2-2.5
was taking 4mg daily(pre-op).
20. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
21. insulin glargine 100 unit/mL Solution Sig: Twenty Five (25)
units Subcutaneous once a day.
22. insulin regular human 100 unit/mL Solution Sig: sliding
scale Injection Q AC&HS.
23. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
coronary artery disease
Secondary:
Chronic atrial fibrillation on Coumadin, diagnosed [**2123**]
stable primary biliary cirrhosis
Type II diabetes
Hypothyroidism
Polymyalgia rheumatica diagnosed [**3-31**], On Prednisone
Hypercholesterolemia
Osteoarthritis
Vulvar cancer [**2129**] s/p vulvectomy at [**Hospital1 2025**] (no chemo or
radiation)
Urinary incontinence s/p vulvectomy
nephrolithiasis
chronic lower extremity edema r/t lymphedema
urosepsis
arthritis left knee- needs replacement
Past Surgical History:
right hip replacement [**2130**]
right knee replacement [**2130**]
Back surgery x 4
Appendectomy
Tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Activity-OOB to chair with assist
Incisional pain managed with Percocet
Incisions:
Sternal - Keep tegaderm intact until appt with Dr. [**First Name (STitle) **].
healing well, no erythema or drainage. JP drain to bulb suction-
to be removed by Dr. [**First Name (STitle) **] in 1 week.
Bilat LE: [**1-23**]+ bilat pedal edema; with staples no erythema,
serosang drainage d/t edema. leg staples may be removed by Rehab
NP/MD in 2weeks
Discharge Instructions:
**Keep sternal tegaderm dressing on until postop appointment
with Plastic Surgery-Dr. [**First Name (STitle) **]. He will remove dressing and JP
drain in one week- please call to make this appointment.
Please do sponge bath every day. Wash legs daily, but keep
sternum dry. You can wash with 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 AT ALL TIMES 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 [**Last Name (STitle) **]: on [**2-19**] at 1pm [**Telephone/Fax (1) 100534**]
Cardiologist: Dr [**Last Name (STitle) **] on [**3-10**] at 3:40pm
**Please call to schedule the following:
Primary Care Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11198**] in [**2-24**] weeks ([**Telephone/Fax (1) 100531**]
Plastic Surgeon: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in one week - will remove JP
drain and sternal dressing at this appointment. [**Street Address(2) **].,
[**Apartment Address(1) **], [**Location (un) **], [**Numeric Identifier 1415**]
Office Phone: ([**Telephone/Fax (1) 1429**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Please call to schedule appointments with your
Primary Care Dr [**First Name (STitle) **],[**First Name8 (NamePattern2) **] [**Doctor First Name **] [**Telephone/Fax (1) 1408**] in [**11-23**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication: Atrial Fibrillation
Goal INR:2-2.5
First draw : day after discharge
Completed by:[**2133-1-25**]
ICD9 Codes: 2449, 2720 |
{
"dataset_link": "https://huggingface.co/datasets/ricardosantoss/ehrcomplete_icdfiltered",
"dataset_name": "ehrcomplete-icdfiltered",
"id": 1499
} | Medical Text: Admission Date: [**2126-5-23**] Discharge Date: [**2126-5-28**]
Date of Birth: [**2056-8-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2126-5-24**] - CABGx4 (Mammary to left anterior descending artery,
vein to diagonal artery, vein to obtuse marginal artery, vein to
right coronary artery)
[**2126-5-23**] - Cardiac Catheterization
History of Present Illness:
This 69 year old woman has a history of diabetes, hyperlipidemia
and clinical depression. The patient reports that over the past
month she has noticed episodes of mild mid chest pressure,
occurring when under emotional stress or when climbing a flight
of stairs. She has difficulty offering specifics but states that
these episodes typically resolve with rest. She is unclear on
how often they have been occurring.
She recently saw her primary care provider for her yearly
physical. Upon being questioned on whether or not she has been
having any chest discomfort, she described her recent symptoms.
He has since referred her for stress testing has noted below.
Given these finding she was referred for a cardiac
catheterization which was significant for severe three vessel
disease. She is now referred for surgical revacularization.
[**2126-5-17**] ETT: Preliminary reports mention that the patient
exercised 3.5 minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol, 77% max PHR, stopping
due to fatigue. She had no chest pain. Imaging revealed evidence
of septal, anterior and apical defects, mostly fixed. There was
septal hypokinesis confirmed by echo. LVEF 50%.
Past Medical History:
Hyperlipidemia
Diabetes
Depression
s/p left breast cancer treated by lumpectomy, radiation and
chemotherapy
Glaucoma
Frequent diarrhea of unknown etiology
Social History:
She is married with 2 adult children. Lives in [**Location 95107**].
Family History:
Moter with MI in her 70's. Father with CABG in his 80's.
Physical Exam:
153/63 62" 57.2 KG
GEN: Well appearing
SKIN: Unremarkable
NECK: Supple, full range of motion
LUNGS: Clear
HEART: RRR, Nl S1-S2
ABD: Nontender, nondistended, soft, normoactive bowel sounds
EXT: Warm, well perfused, no edema, vein small but no
varicosies, pulses 2+ throughout.
NEURO: Left sided facial droop which has been there for a long
time.
Pertinent Results:
[**2126-5-23**] 02:00PM PT-12.1 PTT-30.7 INR(PT)-1.0
[**2126-5-23**] 02:00PM PLT COUNT-223
[**2126-5-23**] 02:00PM WBC-5.3 RBC-4.02* HGB-11.8* HCT-33.9* MCV-84
MCH-29.2 MCHC-34.7 RDW-13.4
[**2126-5-23**] 02:00PM ALT(SGPT)-9 AST(SGOT)-12 ALK PHOS-64 TOT
BILI-0.3
[**2126-5-23**] 02:00PM GLUCOSE-82 UREA N-12 CREAT-0.6 SODIUM-138
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12
[**2126-5-23**] 08:06PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2126-5-28**] 07:35AM BLOOD WBC-6.5 RBC-3.24* Hgb-9.3* Hct-26.7*
MCV-83 MCH-28.7 MCHC-34.7 RDW-16.2* Plt Ct-242
[**2126-5-28**] 07:35AM BLOOD Plt Ct-242
[**2126-5-28**] 07:35AM BLOOD Glucose-145* UreaN-10 Creat-0.6 Na-140
K-3.8 Cl-103 HCO3-29 AnGap-12
[**2126-5-23**] Carotid series
No evidence of hemodynamically significant stenosis bilaterally
with less than 40% stenosis in the proximal left internal
carotid artery.
[**2126-5-23**] Cardiac Catheterization
1. Selective coronary angiography revealed a right dominant
system with
patent non-obstructive LMCA. The LAD was proximally subtotally
occluded
and gave off a large, patent D1. The left circumflex was not
obstructived. The OM1 has a hazy, eccentric 80% lesion. The
RCA was
diffusely disease with a 80% proximal lesion that caused
catheter
damping.
2. Left ventriculography showed an ejection fraction of 55% and
normal
wall motions. No significant mitral regurgitation was noted.
3. Limited hemodynamic assessment showed mildly elevated left
sided
filling pressures and mildly elevated systemic pressure.
[**2126-5-25**] X-ray
Following line and tube removal, a small left apical
pneumothorax is visualized. Dr. [**Last Name (STitle) 67549**] was left an Alpha
message via the page system and telephone contact was made at
8:37 p.m. on [**2126-5-25**].
[**2126-5-24**] ECHO
Pre-cpb: No spontaneous echo contrast is seen in the left atrial
appendage. Left ventricular wall thicknesses are normal. EF 50 -
55%. The left ventricular cavity size is normal. Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta. There are
three aortic valve leaflets. Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are moderately thickened.
Moderate (2+) mitral regurgitation is seen. There is no
pericardial effusion.
Post- CPB: Preserved biventricular systolic fxn. 1- 2+ MR. 1+
AI. Aorta intact. Other parameters as pre-bypass
Brief Hospital Course:
Mrs. [**Known lastname 3075**] was admitted to the [**Hospital1 18**] on [**2126-5-23**] for a cardiac
catheterization. This revealed severe three vessel coronary
artery disease. Given the severity of her disease, the cardiac
surgical service was consulted for surgical management. Mrs.
[**Known lastname 3075**] was worked-up in the usual preoperative manner including
a carotid duplex ultrasound which revealed no evidence of
hemodynamically significant stenosis bilaterally with less than
40% stenosis in the proximal left internal carotid artery.
On [**2126-5-24**], Mrs. [**Known lastname 3075**] was taken to the operating room where
she underwent coronary artery bypass grafting to four vessels.
Please see operative note for details. Postoperatively she was
taken to the cardiac surgical intensive care unit for
monitoring. By postoperative day one, Mrs. [**Known lastname 3075**] was awake,
neurologically intact and extubated. Beta blockade, a statin and
aspirin were started. She was then transferred to the step down
unit for further recovery. Mrs. [**Known lastname 3075**] was gently diuresed
towards her preoperative weight. The physical therapy service
was consulted for assistance with her postoperative strength and
mobility. Mrs. [**Known lastname 3075**] made steady progress and was discharged
home on postoperative day four. She will follow-up with Dr.
[**Last Name (STitle) **], her cardiologist and her primary care physician as an
outpatient.
Medications on Admission:
Admission Medications:
Nortriptyline 75mg daily at bedtime
Haldol 1mg daily at bedtime
Lipitor 20mg daily every evening
Klonopin 0.5mg daily at bedtime
Aspirin 81mg daily at bedtime
Plavix 75mg daily every evening (recently prescribed)
Atenolol 25mg daily every evening (recent prescribed)
Prandin 0.5mg, two tablets daily at dinner
Metformin 1000mg twice a day
Nitroglycerin SL prn
Lumagen eye drops, one drop OU qhs
Refresh tears prn
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. 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:*4*
3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 5 days: Take twice daily with potassium then stop.
Disp:*10 Tablet(s)* Refills:*0*
4. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 5
days: Take twice daily with lasix then stop.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
8. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
9. Nortriptyline 75 mg Capsule Sig: One (1) Capsule PO at
bedtime.
Disp:*30 Capsule(s)* Refills:*1*
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Repaglinide 0.5 mg Tablet Sig: Two (2) Tablet PO BIDWM (2
times a day (with meals)).
Disp:*60 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary artery disease
Hyperlipidemia
Diabetes
Depression
s/p left breast cancer with lupectomy/chemotherapy/radiation
Glaucoma
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
2) Report any fever greater then 100.5.
3) Report any weight gain of greater then 2 pounds in 24 hours
or 5 pounds in 1 week.
4) No lifting greater then 10 pounds for 10 weeks.
5) No driving for 1 month.
6) You may wash incision and gently pat dry. No swimming or
bathing until wounds have healed. No lotions, creams or powders
to incision.
7) Take lasix 20mg twice daily and potassium 20mEq twice daily
for five days then stop.
8) Please have liver function studies checked upon follow-up
with either cardiologist or primary care physician. [**Name10 (NameIs) **] is to
check your tolerance to lipitor.
9) You may resume your other sleep medications as needed.
10) Please call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] (Surgeon) in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with cardiologist Dr. [**Last Name (STitle) **] in [**11-19**] weeks. ([**Telephone/Fax (1) 29561**]
Follow-up with primary care physician [**Last Name (NamePattern4) **] 2 weeks. ([**Telephone/Fax (1) 16005**]
Call all providers for appointments.
Completed by:[**2126-5-28**]
ICD9 Codes: 2720, 311 |
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